Health Equity Considerations Research Articles

Qualitative Evidence to Inform Municipal Government Actions to Increase Recreation Space Usage and Promote Equitable Participation in Leisure-Time Physical Activity

Municipal recreation infrastructure is critical for enhancing people’s opportuni-ties to be physically active during leisure time and reducing usage inequities. Yet, the literature on municipal equity-sensitive strategies is limited. To address this gap, we combined a socio-ecological framework with equity, diversity, and inclu-sion (EDI) and health equity lenses to examine intersecting social and structural determinants of municipal recreation (indoor and outdoor) infrastructure usage. We used data from 22 focus groups involving youth, adult regular users, and adult non-regular users. The intersecting factors influencing people’s utilization experi-ences were organized at intrapersonal, socio-cultural environment, organization, and built and natural environment levels. Policy and practice implications for mu-nicipal governments vis-à-vis EDI and health equity considerations are discussed. Recommendations include public transportation improvement, design of strategic communication plans, and linking activities with opportunities for socialization, among others.

Changes in systems thinking and health equity considerations across four communities participating in Catalyzing Communities.

Childhood obesity is a persistent public health concern, and community-based interventions have become crucial for addressing it by engaging local communities and implementing comprehensive evidence-based strategies. The Catalyzing Communities intervention takes a "whole-of-community"approach to involve leaders from diverse sectors in thinking systematically about child healthy weights and implementing evidence-based solutions. Using systems thinking and the Getting to Equity framework to guide interview analysis, this study examines changes in participants' use of systems thinking concepts and health equity in 43 participants across four U.S. communities involved in the Catalyzing Communities intervention. Our findings reveal significant shifts in systems thinking concepts, as participants develop a deeper understanding of childhood obesity as a complex adaptive system, and system insights, as participants increasingly recognize the interconnections and leverage points within the system driving childhood obesity. Participants also experienced increases in health equity thinking and action, particularly when discussing social and structural determinants of health, commitment to targeted actions, and a focus on addressing barriers and enhancing resources. The intersection between systems insights and health equity action, such as explaining leverage points and interventions to reduce deterrents to health behaviors, suggests the need for systems thinking activities to be integrated into health equity planning. Future research is needed to develop measures to connect systems thinking concepts to health equity, and the impact of these to community-level policy, systems, and environmental changes in public health.

9255 Use of Race and Ethnicity in Endocrine Clinical Practice Guidelines

Abstract Disclosure: D. Segura Torres: None. K. Raygoza: None. M. Garcia: None. J.P. Brito: None. M.E. McDonnell: None. M. Corrigan: None. C.R. McCartney: None. R. Dhaliwal: None. N.M. Singh Ospina: None. Clinical practice guidelines (CPG) improve healthcare quality by guiding decision making. Recent trends in CPG development emphasize incorporating race/ethnicity terms and health equity considerations. However, the appropriateness of how race/ethnicity is utilized remains uncertain. Objective This study seeks to evaluate the use of race/ethnicity in published Endocrine Society (ES) CPG and elucidate the context in which race and ethnicity terms are used. Methods: We identified 30 active clinical practice guidelines from ES up to January 2023. Two reviewers independently and in duplicate: a) located statements addressing race/ethnicity using an electronic search with 24 keywords, b) determined the statements' location within guidelines, and c) classified them based on content using frameworks by Cerdena and Gilliam. Disagreements were resolved by consensus. Exclusions were made for statements not addressing race and ethnicity terms in the appropriate context (e.g., “minority” of the panel disagreed), as well as for those in references or duplicates. Results: We reviewed 30 clinical practice guidelines, with 19 of them containing statements related to race or ethnicity. After applying exclusion criteria, we identified a final analytic sample of 114 statements. The majority of these statements were found in the body of the clinical guidelines (79%), followed by the evidence-to-decision framework (14%), and clinical recommendations (7%).The predominant classification were statements in which there was biologization of race/ethnicity 55% (n=63). Discussions on racial/ethnic disparities accounted for 23% (n=26) of the statements, with 31% (n=8) of these including explicit considerations of social context. Additionally, there were descriptions of race-specific treatment or diagnosis/screening in 14% (n=16) and 9% (n=10) of the statements, respectively.Less commonly statements of race/ethnicity reflected the consideration of ancestry as a code for race/ethnicity (n=7, 6%), identified ancestry as a risk factor for disease (n=19, 6%), highlighted racial/ethnic groups as understudied n=6, 5%), normalized findings to the majority group (White centeredness) (n=7, 6%), and other categories (7%). None of the statements employed race/ethnicity terms to emphasize cultural humility or the value of inclusivity in guideline committees. Conclusion: We systematically analyzed how race and ethnicity terms are used in ES CPGs. Our findings align with prior assessments made in non-ES CPG, highlighting the prevalent biologization of race and ethnicity constructs. Addressing this trend and incorporating socio-structural context considerations could bolster the impact of clinical guidelines in promoting health equity. Presentation: 6/1/2024

Centering Racial Health Equity in Systematic Reviews Paper 2: Themes from Semi-structured Interviews

ObjectiveIn the context of profound and persistent racial health inequities, we sought to understand how to define racial health equity in the context of systematic reviews and how to staff, conduct, disseminate, sustain, and evaluate systematic reviews that address racial health equity. Study Design and SettingThe study consisted of virtual, semi-structured interviews followed by structured coding and qualitative analyses using NVivo. ResultsTwenty-nine individuals, primarily US-based, including patients, community representatives, systematic reviewers, clinicians, guideline developers, primary researchers, and funders, participated in this study. These interest holders brought up systems of power, injustice, social determinants of health, and intersectionality when conceptualizing racial health equity. They also emphasized including community members with lived experience in review teams. They suggested making changes to systematic review scope, methods, and eligible evidence (such as adapting review methods to include racial health equity considerations in prioritizing topics for reviews, formulating key questions and searches, and specifying outcomes) and broadening evidence to include designs that address implementation and access. Interest holders noted that sustained efforts to center racial health equity in systematic reviews require resources, time, training, and demonstrating value to funders. ConclusionInterest holders identified changes to the funding, staffing, conduct, dissemination, and implementation of systematic reviews to center racial health equity. Action on these steps requires clear standards for success, an evidence base to support transformative changes, and consensus among interest holders on the way forward.

Quality Indicators for Transition from Pediatric to Adult Care for Youth With Chronic Conditions: Proposal for an Online Modified Delphi Study.

The transition from pediatric to adult care poses a significant health system-level challenge impeding the delivery of quality health services for youth with chronic health conditions. In Canada and globally, the transition to adult care is regarded as a top priority in adolescent health in need of readily applicable, adaptable, and relevant national metrics to evaluate and benchmark transition success across disease populations and clinical care settings. Unfortunately, existing literature fails to account for the lack of engagement from youth and caregivers in developing indicators, and its applicability across chronic conditions, primary care involvement, and health equity considerations. Our proposed study aims to establish a consensus-driven set of quality indicators for the transition to adult care that are universally applicable across physical, developmental, and mental health conditions, clinical care settings, and health jurisdictions. Using an integrated knowledge translation (iKT) approach, a panel comprising youth, caregivers, interdisciplinary health care providers, and health system leaders will be established to collaborate with our research team to ensure that the study methodology, materials, and knowledge dissemination are suitable and reflect the perspectives of youth and their families. We will then conduct an iterative 3-round Online Modified Delphi (OMD) study (n=160) to (1) compare and contrast the perspectives of youth, caregivers, health care providers, and health system leaders on quality indicators for transition; and (2) prioritize a key set of quality indicators for transition applicable across disease populations that are the most important, useful, and feasible in the Canadian context. Using the RAND/UCLA Appropriateness Method (RAM) multistage analytic approach, data from each panel and stakeholder group will be examined separately and compared to establish a key set of indicators endorsed by both panels. The study is funded by the Canadian Institutes of Health Research and Physicians Services Incorporated. This study will produce quality indicators to evaluate and inform action equitably to improve transition from pediatric to adult care for youth and their families in Canada. PRR1-10.2196/60860.

A review of health equity considerations in Cochrane reviews of lifestyle interventions for cardiovascular health in adults

ObjectiveCardiovascular disease (CVD) is the leading cause of global disease burden and rising healthcare costs. Systematic reviews (SRs) rigorously evaluate evidence on health interventions' effects and guide personal, clinical, and policy decision-making. Health equity is the absence of avoidable and unfair differences in health between groups within a population. Assessing equity in lifestyle interventions for cardiovascular health is important due to persisting health inequities in CVD burden and access to interventions. We aim to explore how health equity considerations are addressed in Cochrane SRs of lifestyle interventions for cardiovascular health. Study Design and SettingThis is a methodological review of Cochrane SRs of lifestyle interventions for cardiovascular health using the PROGRESS-Plus framework. PROGRESS-Plus stands for Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status, and Social capital, while “Plus” stands for additional factors associated with discrimination and exclusion such as age, disability, and comorbidity. Using predefined selection criteria, two authors independently screened all Cochrane reviews published in the Cochrane Database of Systematic Reviews between August 2017 and December 2022. PROGRESS-Plus factors in the SRs were sought in the Summary of Findings (SoF) table, Methods/Inclusion criteria, Methods/Subgroup analyses, Results/Included studies, Results/Subgroup analyses, and Discussion/Overall completeness and applicability of evidence. ResultsWe included 36 SRs published by 10 Cochrane groups, addressing 11 health conditions with mostly dietary and exercise interventions. The most common PROGRESS-Plus factors assessed were gender/sex, age, and comorbidity. PROGRESS-Plus factors were most addressed in the inclusion criteria (64%), the discussion (75%), and the included studies (92%) sections of the SRs. Only 33% of SoF tables referenced PROGRESS-Plus. Sixty-nine percent of the included SRs planned for subgroup analyses across one or more PROGRESS-Plus factors, but only 43% of SRs conducted subgroup analyses, suggesting limited reporting of PROGRESS-Plus factors in primary studies. ConclusionsEquity factors are not sufficiently addressed in Cochrane reviews of lifestyle interventions for cardiovascular health. Low reporting of PROGRESS-Plus factors in implications for practice and research sections of Cochrane SRs limit equity focused guidance for current clinical practice, public health interventions and future research.

Health Equity Considerations in Cost-Effectiveness Analysis: Insights from an Umbrella Review.

Cost-effectiveness analyses (CEA) are important in healthcare decision-making and resource allocation; however, expanding the scope of CEAs beyond the traditional clinicoeconomic concepts to also include value elements such as health equity has attracted much interest in recent years. This umbrella review aimed to synthesize evidence on how equity concepts have been considered in modified types of CEAs. Publicly available articles in MEDLINE were searched on January 25, 2024, to identify systematic reviews (SLRs) published in English since 2013 that incorporate health equity considerations in CEAs. Title/abstract, full-text article screening and data extraction were conducted by a single reviewer and validated by a second reviewer. Results were qualitatively synthesized to identify common themes. Eight SLRs were included. Distributional CEAs (DCEA), equity-based weighting, extended CEA (ECEA), mathematical programming and multi-criteria decision analysis (MCDA) were the most discussed approaches. A lack of consensus on the best approach for incorporating health equity into CEAs was highlighted, as these approaches are not currently consistently used in decision-making. Important limitations included scarcity of robust data to inform health equity indices, bias associated with commonly used health outcome metrics and the challenge of accounting for additional contextual factors such as fairness and opportunity costs. Proposals to expand CEAs to address equity issues come with challenges due to data unavailability, methods complexity, and decision-makers unfamiliarity with these approaches. Our review indicates that extended and distributional CEAs can support decision-making by capturing the impact of inequity on the clinical and cost-effectiveness assessment of treatments, although future modeling should account for additional contextual factors such as fairness and opportunity costs. Recommendations for actions moving forward include standardization of data collection for outcomes related to equity and familiarity with methodologies to account for the complexities of integrating health equity considerations in CEAs.

A review of local global health education in post-graduate medical education

Background Global health (GH) education is offered in post-graduate medical education (PGME) programs and local experiences are desired by trainees and educators. This scoping review aimed to map the literature on local GH education in PGME, to describe curricular components, factors facilitating successes, and challenges to implementation using a validated education intervention checklist and inclusion of seven components of local GH programming. Methods A decolonization conceptual framework informed a 5-step scoping review. In May 2022, eight databases and MedEdPORTAL were searched using key words describing local GH education curricula. Results Sixty-eight full-text articles described local GH education programs in residencies (n = 52; 76.4%) and fellowships (n = 10; 14.7%) spanning multiple specialties, predominantly in North America (90%). Successful programs included faculty mentoring, community-based partnerships, and a multidisciplinary component. Scheduling challenges, cultural and linguistic differences, and trainee workload contributed to implementation difficulties. Only four programs included all seven local GH health equity/decolonization components. Conclusions Local GH curricula vary widely in clinical experiences, didactic sessions, and inclusion of mentorship and partnerships. Local populations within the communities of these training programs could benefit from standardized inclusion of components for local global health education with careful consideration of health equity.

Advancing youth transportation safety in North Carolina through addressing alcohol-related motor vehicle collisions

The aim of this work is to analyze trends in youth transportation fatalities and injuries in North Carolina (NC), assess the implementation of ignition interlock devices (IIDs) in the United States and abroad, discuss policy implications for IIDs, and highlight health equity considerations related to motor vehicle collisions (MVCs). MVCs cause the highest number of unintentional injury-related deaths for children and teenagers in NC, and policymakers should pay special attention to MVCs related to alcohol consumption. IIDs are effective in reducing collision rates and recidivism for driving under the influence of alcohol (DUI). Ignition interlock device requirements have been increasingly implemented globally over the past three decades. However, the adoption of stricter IID policies after first-time DUI offenses in NC and across the U.S. is a prudent public health measure to enhance transportation safety for both adults and children. Evidence-based interventions such as IIDs must also strive to address inequities in transportation safety, and the framing of proposed policies should reflect the tenets of cultural humility.

Health equity in multi-cancer early detection (MCEDs): A literature review and content analysis.

10549 Background: Multi-cancer early detection tests (MCEDs) are an emerging screening technology to identify biomarkers of up to 50 different types of cancer using a single blood sample. While there is potential for MCEDs to advance health equity in cancer screening, considerations for how to do so are not established. We sought to identify emerging health equity themes related to MCEDs, and to explore where along the MCED evaluation process they have been considered. Methods: We conducted a targeted review of white and grey literature to identify references discussing health equity and MCEDs. We searched PubMed and Google Scholar from 2015-2024, using key search terms including “MCEDs,” “health equity,” and “diversity, equity and inclusion.” We used thematic analysis to identify health-equity related themes raised across included records. We then used content analysis to describe where these themes arose along the phases of cancer screening evaluation described by the CanTest Framework (product design, test performance, clinical feasibility, clinical effectiveness, and screening implementation). Results: We identified 22 records for inclusion, which varied in their content and depth when exploring health equity considerations for MCEDs. Thematic analysis of the records revealed five overarching health equity themes: access, acceptability, affordability, bias, and disparities. Acceptability, which included topics such as patient preference and measuring benefit/harms, and disparities, such as racial/ethnic differences in cancer deaths, were the most discussed themes (55% of records; Table). Bias, including provider discrimination, was the least discussed theme (32% of records). Content analysis revealed that health equity themes mostly arose across cancer screening evaluation phases of clinical feasibility, effectiveness, and implementation (82%, 73%, 64% of records respectively). No records explored health equity themes of acceptability, access, or bias in the product design phase (0%). Conclusions: Current literature considering health equity for MCEDs consistently address equity aspects related to clinical feasibility, clinical effectiveness, and implementation, but generally fails to consider health equity in early phase evaluation. Increasing consideration of health equity across all phases of the screening lifecycle is crucial if MCEDs are to advance health equity.[Table: see text]

Understanding Health Equity in Patient-Reported Outcomes

Patient-reported outcomes (PROs) are measures of patients' health that are conveyed directly by individual patients. These measures serve as instruments to evaluate the impact of interventions on any aspect of patients' health, from specific symptoms to broader quality of life indicators. However, their effectiveness relies on capturing relevant factors accurately. Whereas they are commonly used in clinical trials, PROs extend their influence across health care settings, informing clinicians, health care payers, regulators, and administrators to guide quality improvement and reimbursement decisions. Neglecting health equity considerations in PRO development and implementation widens health disparities, leading to biased interpretations, medical mismanagement, and poor health outcomes among marginalized groups. To foster equitable health care, efforts must focus on considering the values of underrepresented populations in PRO design, addressing barriers to completion, enhancing representation in research, providing cultural competency training for clinicians, and allocating research funding to support health equity research. By addressing these issues, advances can be made toward fostering inclusive, equitable health care for all individuals.

Health technology assessment of video otoscopy for the diagnosis of otitis media in children in comparison to conventional otoscopy in primary healthcare settings in India

ObjectiveThis Health Technology Assessment (HTA) was undertaken to assess the clinical-effectiveness, cost-effectiveness, and operational feasibility of using otoscopes in primary healthcare settings in India, for diagnosing otitis media in children. MethodsWe undertook a three-step process sequentially determining (i) clinical effectiveness of video as well as conventional otoscopy (compared to otic microscope as the reference standard); (ii)cost-effectiveness analysis of the video otoscope; and (iii)operational feasibility and health equity considerations. The systematic review for clinical effectiveness involved literature search across five databases, screening and inclusion of relevant studies, and data synthesis. Cost-effectiveness analysis was performed using data from published literature, specialist interviews, and cost assumptions if neither was available. The Progress Plus tool was used to explore health equity and operational feasibility was taken into account. ResultsThe systematic review on clinical effectiveness include three relevant studies from a total of 1361 identified. The pooled sensitivity and specificity of video otoscope were 0.70 (95%CI 0.60, 0.84) and 0.92 (CI95% 0.89, 0.95) to be 0.88 (95% CI, 0.84 to 0.91). The cost-effectiveness analysis identified the incremental cost-effectiveness ratio (compared to conventional otoscope) as INR 1008.4 per QALY, with an overall gain of 413 QALYs per year. This was well below the willingness-to-pay threshold for India. There was potential of enhancing health equity and no insurmountable operational barriers, to the use of video otoscope in primary healthcare settings. ConclusionThis HTA concluded that video otoscope is clinically effective, cost-effective, and operationally feasible in Indian primary health settings, for diagnosing otitis media in children.

Reporting of health equity considerations in vaccine trials for COVID-19: a methodological review

Background and ObjectivesAn emerging body of randomized controlled trials (RCTs) on COVID-19 vaccines has served as the evidence base for public health decision-making. While it is recommended that RCTs report results by health equity stratifiers to reduce bias in health care and gaps in research, it is unknown whether this was done in COVID-19 vaccine trials. To critically examine the use of health equity stratifiers in COVID-19 vaccine trials. Study Design and SettingWe conducted a methodological review of published COVID-19 vaccine trials available in the COVID-19 living Network Meta-Analysis systematic review database through February 8, 2023. Based on the PROGRESS-Plus framework, we examined the following health equity stratifiers: place of residence, race/ethnicity, occupation, gender/sex, religion, education, socio-economic status, social capital, age, disability, features of relationships, and temporary situations. We assessed each study in duplicate according to three criteria for comprehensive health-equity reporting: 1) describing participants, 2) reporting equity-relevant results, and 3) discussing equity-relevant implications of trial findings. ResultsWe reviewed 144 trial manuscripts. The most frequently used PROGRESS-Plus stratifiers to describe participants were age (100%), place of residence (100%), gender/sex (99%), and race/ethnicity (64%). Age was most often used to disaggregate or adjust results (67%), followed by gender or sex (35%). Discussions of equity-relevant implications often indicated limited generalizability of results concerning age (40% of studies). Half (47%) of the studies considered at least one health equity stratifier for all three criteria. No trials included stratifiers related to religion, socioeconomic status, sexual orientation, or features of relationships. ConclusionCOVID-19 vaccine trials provided a limited description of health equity stratifiers as defined by PROGRESS-Plus and infrequently disaggregated results or discussed the study implications as they related to health equity. Considering the health disparities exacerbated during the pandemic, increased uptake of PROGRESS-Plus in RCTs would support a more nuanced understanding of health disparities and better inform actions to improve health equity.

PROTOCOL: Effects of social prescribing for older adults: An evidence and gap map.

Objectives This is the protocol for an evidence and gap map. The objectives are as follows: The aim of this evidence and gap map is to map the available evidence on the effectiveness of social prescribing interventions addressing a non-medical, health-related social need for older adults in any setting. Specific objectives are as follows: 1.To identify existing evidence from primary studies and systematic reviews on the effects of community-based interventions that address non-medical, health-related social needs of older adults to improve their health and wellbeing.2.To identify research evidence gaps for new high-quality primary studies and systematic reviews.3.To highlight evidence of health equity considerations from included primary studies and systematic reviews.

HPR15 Review and Evaluation of Health Equity Considerations in Health Technology Assessments in Cystic Fibrosis

HPR15 Review and Evaluation of Health Equity Considerations in Health Technology Assessments in Cystic Fibrosis

Operationalizing the GRADE-equity criterion to inform guideline recommendations: application to a medical cannabis guideline

ObjectivesIncorporating health equity considerations into guideline development often requires information beyond that gathered through traditional evidence synthesis methodology. This article outlines an operationalization plan for the Grading of Recommendations Assessment, Development, and Evaluation (GRADE)-equity criterion to gather and assess evidence from primary studies within systematic reviews, enhancing guideline recommendations to promote equity. We demonstrate its use in a clinical guideline on medical cannabis for chronic pain. Study Design and SettingWe reviewed GRADE guidance and resources recommended by team members regarding the use of evidence for equity considerations, drafted an operationalization plan, and iteratively refined it through team discussion and feedback and piloted it on a medicinal cannabis guideline. ResultsWe propose a seven-step approach: 1) identify disadvantaged populations, 2) examine available data for specific populations, 3) evaluate population baseline risk for primary outcomes, 4) assess representation of these populations in primary studies, 5) appraise analyses, 6) note barriers to implementation of effective interventions for these populations, and 7) suggest supportive strategies to facilitate implementation of effective interventions. ConclusionOur approach assists guideline developers in recognizing equity considerations, particularly in resource-constrained settings. Its application across various guideline topics can verify its feasibility and necessary adjustments.

Translating and disseminating a localised economic model to support implementation of the 'Ending the HIV Epidemic' initiative to public health policymakers.

Despite significant progress in HIV treatment and prevention, the US remains far from its goal of 'Ending the HIV Epidemic' by 2030. Economic models using local data can synthesise the evidence to help policymakers allocate HIV resources efficiently, but persistent research-to-practice gaps remain. Little is known about how to facilitate the use of economic modelling data among local public health policymakers in real-world settings. To explore the dissemination of results from a locally-calibrated economic model for HIV prevention and treatment and identify the factors influencing potential uptake of the model for public health decision making at the local level. Four virtual focus groups with 26 local health department policymakers in Baltimore, Miami, Seattle, and New York City were held between July 2020 and May 2021. Qualitative content analysis of transcripts identified key themes around using the localised economic model in policy decisions. Participants were interested in using local data in their decisions to allocate resources for HIV prevention/treatment. Six themes emerged: 1) importance of understanding local policy context; 2) health equity considerations; 3) using evidence to support current priorities; 4) difficulty of changing strategies, even incrementally; 5) bang for the incremental buck (efficiency) vs. previous impact; and 6) community values. To optimise acceptance and use of results from economic models, researchers should engage with local community members and public health decision makers early to understand budgetary and community priorities. Participants prioritised evidence that supports their existing strategies, considers budgets and funding streams, and improves health equity; however, real-world budget constraints and conflicting interests serve as barriers to implementing model recommendations and reaching national goals.

Quasi-experimental evaluations of health-related policies in Europe: a scoping review

Abstract Background Quasi-experimental methods (QEM) are study designs increasingly used in public health to evaluate the impact of health-focused policies. We sought to examine the scope, methodological characteristics as well as health equity considerations of policy evaluations using QEM that assess health and social outcomes in Europe. Methods We conducted a scoping review as outlined in our pre-registered protocol (https://osf.io/n5rvg). We searched Medline, EMBASE, and EconLit databases in December 2022 and included studies labelled as interrupted time series, difference-in-difference (DID), controlled before and after, regression discontinuity, and synthetic control studies; that focused on policies implemented at regional, national, and supranational level in the WHO European region. Among all identified records, we drew a random sample of 350 records for title and abstract screening and subsequent full-text screening, data extraction and analysis. Results Database searches rendered 2102 records. Of the random sample of 350 records, we identified 59 records as eligible for inclusion. Most studies evaluated health and social policies implemented on a national level in EU member states and the UK. Common policy topics were related to tobacco control, healthcare co-payments, and employment. DID was the most common study design label. Few studies were based on pre-registered protocols. There was substantial variability in the number and types of additional analyses conducted to assess the appropriateness of assumptions and the robustness of results. With respect to health equity (HE), 16 included studies had a strong HE focus by examining disadvantaged populations, and in 23 and 18 studies, respectively, HE was discussed and HE-related recommendations were made. Discussion QEM were frequently used to undertake policy evaluations and studies showed great diversity in scope and methodology. Health equity was considered in a surprisingly low number of studies. Key messages • We identified a large number of policy evaluations employing quasi-experimental methods. • Studies were heterogeneous in scope and methodological rigour and few considered health equity.

Equity-Focused Health Technology Assessment at CADTH


 The introduction of equity-focused methodologies into health technology assessment (HTA) can facilitate a systemic and comprehensive focus on health equity and enable the delivery of more equitable health outcomes.
 CADTH has introduced several approaches and methodologies to centre equity considerations in its assessments of health technologies, including in topic identification and scoping, literature searches and information retrieval, health technology reviews, and the Early Scientific Advice program, supported by attention to equity in patient engagement, accessible publishing practices, and tracking outcomes.
 CADTH’s initiatives to incorporate health equity considerations continue to evolve, and CADTH is involved in the ongoing trialling and adaptation of tools, methodologies, processes, and sources to address health inequities through the processes of HTA.

Sample Size Requirements to Test Subgroup-Specific Treatment Effects in Cluster-Randomized Trials

Cluster-randomized trials (CRTs) often allocate intact clusters of participants to treatment or control conditions and are increasingly used to evaluate healthcare delivery interventions. While previous studies have developed sample size methods for testing confirmatory hypotheses of treatment effect heterogeneity in CRTs (i.e., targeting the difference between subgroup-specific treatment effects), sample size methods for testing the subgroup-specific treatment effects themselves have not received adequate attention—despite a rising interest in health equity considerations in CRTs. In this article, we develop formal methods for sample size and power analyses for testing subgroup-specific treatment effects in parallel-arm CRTs with a continuous outcome and a binary subgroup variable. We point out that the variances of the subgroup-specific treatment effect estimators and their covariance are given by weighted averages of the variance of the overall average treatment effect estimator and the variance of the heterogeneous treatment effect estimator. This analytical insight facilitates an explicit characterization of the requirements for both the omnibus test and the intersection–union test to achieve the desired level of power. Generalizations to allow for subgroup-specific variance structures are also discussed. We report on a simulation study to validate the proposed sample size methods and demonstrate that the empirical power corresponds well with the predicted power for both tests. The design and setting of the Umea Dementia and Exercise (UMDEX) CRT in older adults are used to illustrate our sample size methods.