Surgery - PowerPoint Presentation

Slide1

Surgery & “Hospital equity Reports”: Leading the Curve in Healthcare Equality .

John R. Stone, MD,

PhD

Center for Health Policy and Medicine

johnstone@creighton.

edu

– Oc

tober

2009Slide2

John StoneConflicts of Interest & DisclosuresNo known conflicts of interest

Nothing to disclose

No investments in health-related companies or ventures

No drug or device industry gifts or remuneration

No industry relationshipsSlide3

Alternative TitleMeeting the quality challenge regardingRaceEthnicityLanguageSES (Socioeconomic status)Slide4

Learning ObjectivesRegarding healthcare equality: Explain why hospitals and departments should collaborate in developing “equity reports.”

Explain key strategies.

Explain core challenges.Slide5

Policy & ProcedureMGH Policy: “In order to assess and address racial and ethnic disparities on an ongoing basis, all relevant performance improvement data should be collected and stratified by race and ethnicity.”“Each department’s strategy for meeting this requirement is now discussed at annual meetings between senior hospital leadership and department chairs.”

Weinick

2008Slide6

Developing, Coordinating, Communicating“UW [U of Wisc-Madison] Health has taken a unique approach in creating visibility for efforts related to inequalities within the hospital system, and to coordinating these efforts internally and externally with a variety of different racial and ethnic groups in the community.” (

Weinick

2008)Slide7

2008 National Healthcare Disparities Report (NHDR)Disparities persist in health care quality and access

Released May 6, 2009

Agency for Healthcare Research and Quality (AHRQ). National Healthcare Disparities Report.

http://

www.ahrq.gov/qual/qrdr08.htm

nhdr08.ppt

. (Accessed 23Oct2009)Slide8

NHQR/NHDR Content and OrganizationEffectiveness Cancer Diabetes

End Stage Renal Disease (ESRD)

Heart Disease

HIV and AIDS

Maternal and Child Health

Mental Health and Substance Abuse

Nursing Home, Home Health,

and Hospice Care

Patient Safety

Timeliness

Patient Centeredness

Access to Health Care

Priority Populations

*Also includes a chapter on Efficiency

NHQR*

NHDR

Agency for Healthcare Research and Quality (AHRQ). National Healthcare Disparities Report.

http://

www.ahrq.gov/qual/qrdr08.htm

.

nhdr08.ppt

. (Accessed 23Oct2009)Slide9

Health Care Quality Disparities in health care quality are staying the same or increasing

n=number of core measures

Agency for Healthcare Research and Quality (AHRQ). National Healthcare Disparities Report.

http://

www.ahrq.gov/qual/qrdr08.htm

nhdr08.ppt

. (Accessed 23Oct2009)Slide10

Disparities in QualityFor Blacks, Asians, American Indians/Alaska Natives, Hispanics, and poor people, disparities stayed the same or increased in at least 60% of quality measures For Blacks and Asians, disparities decreased in fewer than 20% of quality measures

For AI/ANs, Hispanics, and poor populations, disparities decreased in approximately one-third of quality measures

Agency for Healthcare Research and Quality (AHRQ). National Healthcare Disparities Report.

http://

www.ahrq.gov/qual/qrdr08.htm

nhdr08.ppt

. (Accessed 23Oct2009)Slide11

AHRQ: SurgeryBetter: 20002005: “appropriate timing of antibiotics”- % “AI/AN adult surgery patients: 52.0% to 80.8% (comparable to Whites)Good: 1999-2005: Breast Ca I-

Iib

: Ax node

diss

/sentinel node

bx

: rates

75.3



86.5, no inequality

Agency for Healthcare Research and Quality (AHRQ). National Healthcare Disparities Report.

http://www.ahrq.gov/qual/nhdr08/nhdr08.pdf

. (Accessed 23Oct2009)Slide12

Agency for Healthcare Research and Quality (AHRQ). National Healthcare Disparities Report.

http://www.ahrq.gov/qual/nhdr08/nhdr08.pdf

. (Accessed 23Oct2009)Slide13

Agency for Healthcare Research and Quality (AHRQ). National Healthcare Disparities Report.

http://www.ahrq.gov/qual/nhdr08/nhdr08.pdf

. (Accessed 23Oct2009)

Figure 2.36. Composite measure: Adult surgery patients who received appropriate timing of antibiotics, by race/ethnicity, 2006

Antibiotics 2006 by R/E (timing)

Vs

White

Vs

WhiteSlide14

Agency for Healthcare Research and Quality (AHRQ). National Healthcare Disparities Report.

http://www.ahrq.gov/qual/nhdr08/nhdr08.pdf

. (Accessed 23Oct2009)

Composite measure: Medicare surgery patients with postoperative complications, by race, 2004-2006.Slide15

 Alderman AK, Hawley ST, Janz NK, et al. Racial and ethnic disparities in the use of postmastectomy breast reconstruction: Results from a population-based study. J Clin

Oncol

. 2009; JID: 8309333;

aheadofprint

. (data rounded)

Postmastectomy

Breast Reconstruction

W

AA

L-High

L-Low

Reconstruction % (p

<.001)

41

34

41

14

Differences “

may be related to limited information about the procedure and less access to plastic surgeons.”Slide16

Surgery to Med OncColon CancerSignificant B/W inequalityWorst age 66-70

B

:

65.7

%

,

W

:

86.3%

,

Diff

20.6%, 95% CI = 10.7% to 30.4%,

P <.001

)

Only 50% explainable

What role for surgery?

Baldwin LM, Dobie SA, Billingsley K, et al. Explaining black-white differences in receipt of recommended colon cancer treatment. J

Natl

Cancer Inst. 2005; 97(16):1211-1220.Slide17

Time to CareED to SurgeryExample: AppendicitisIf nonwhite & no private insurance ED LOS

(P < .001)

Time to Surgeon’s

Dx

(P = .0o2)

Small study/single large

Acad

MC

Need more studies.

Bickell

NA, Hwang U, Anderson RM, Rojas M,

Barsky

CL. What affects time to care in emergency room appendicitis patients? Med Care. 2008; 46(4):417-422Slide18

Breas

t Ca

Breslin

TM, Morris AM,

Gu

N, et al. Hospital factors and racial disparities in mortality after surgery for breast and colon cancer. J

Clin

Oncol

. 2009; 27(24):3945-3950

Breast/Colon Ca – Post Hosp Mortality Inequality: 5 year

Breast/Colon Ca – Post Hosp Mortality Inequality: 5 yearSlide19

Colon Ca

Breslin

TM, Morris AM,

Gu

N, et al. Hospital factors and racial disparities in mortality after surgery for breast and colon cancer. J

Clin

Oncol

. 2009; 27(24):3945-3950

Breast/Colon Ca – Post Hosp Mortality Inequality: 5 yearSlide20

Breast/Colon Ca – Post Hosp Mortality Inequality: 5 year

Hospital:

matters

Reasons

uncertain-Possibilities

Resources



processes of care

Multidisciplinary

teams

Imaging capability

Evidence-based adjuvant therapy

Insufficient resources to surgery

vs

ED, trauma care, ID

Breslin

TM, Morris AM,

Gu

N, et al. Hospital factors and racial disparities in mortality after surgery for breast and colon cancer. J

Clin

Oncol. 2009; 27(24):3945-3950Slide21

Breast Ca CareSurgery & SystemFreedman RA, Winer EP.

Reducing disparities in breast cancer care: A daunting but essential responsibility.

J

Natl

Cancer Inst. 2008; 100(23):1661-1663JID: 7503089; CON: J

Natl

Cancer Inst. 2008 Dec 3;100(23):

1717-23.

Bickell

NA,

Shastri

K,

Fei

K, et al.

A tracking and feedback registry to reduce racial disparities in breast cancer care.

J

Natl

Cancer Inst (2008) (23):100–1723, 1717.Slide22

Healthcare Inequalities/DisparitiesRace & ethnicity:In the USA, solid evidence documents widespread inequality/disparity of healthcare.Yes

NoSlide23

Physician Views: Healthcare Inequalities/DisparitiesA significant majority of USA physicians believe that healthcare disparities are a significant problem in the nation.Yes

NoSlide24

Beliefs: Healthcare Equality“Just as many people assumed that they “knew” a hospital provided good quality care before quality measurement became common

, many

now assume that their hospital

provides equal

quality of care to all of its patients, regardless

of their

race, ethnicity, language, or socioeconomic status

.”

Weinick

2008Slide25

Reasons: Equity ReportsPromote equal and excellent servicesHonor respectAssure justiceProvide humanistic careImprove relationships with Omaha communities

Increase appeal of CUMCSlide26

CUMC*“Through our Commitment to Quality we will work to:”

“Provide exceptional clinical care to every patient we serve”

*

http://www.creightonhospital.com/en-us/cwsapps/qcommitment.aspx

(Accessed 27Sep2009) Slide27

CUMC & Healthcare EqualityCUMC provides care of equal quality regardless of race, ethnicity, language, and SES (socioeconomic status)Yes

No

UncertainSlide28

Intention and CarePhysicians almost uniformly intend that they personally provide equal and excellent medical care to all patients (regardless of race, ethnicity, and other comparable factors).

Yes

NoSlide29

Intention and CarePhysicians almost uniformly intend that their institution provide equal and excellent medical care to all patients (regardless of race, ethnicity, and other comparable factors).

Yes

NoSlide30

CUMC and Equal CareCUMC assesses whether patients are treated equally regardless of race and ethnicity.YesNoSlide31

Intention and OutcomesRegarding race and ethnicity, outcome studies are unnecessary for confidence that race and ethnicity in themselves do not influence quality of care.

Yes

NoSlide32

Healthcare Equality: Evidence“Given the pervasiveness of racial and ethnic inequalities nationwide, hospitals cannot assume that they provide equitable care without

first examining their data

.”

Weinick

2008Slide33

Influences on Quality of CareRace & EthnicityHospitalRegionSpecific Providers within hospitals

Hospital resources

Access to specialists

Focus on quality

Weinick

2008Slide34

Hospital Equity ReportsWhy & WhatHealthcare inequalities: R, E, SES, LangAssessIdentify

Monitor

(

Weinick

2008)Slide35

Hospital Equity ReportsRationale Healthcare inequalities: R/E/LPersist after adjustmentAccess

Insurance

SES

Weinick

2008Slide36

Equity in HealthcareNeeds equally metMinimized healthcare factors that could produce unequal outcomesCore element of quality (IOM)Weinick 2008Slide37

Equity ReportBenefitsWho served  needs

Who needs better care



Capacity to intervene



= care

Track progress

Enhanced community relationshipsSlide38

Healthcare Equality: StrategiesAssessPlanEducate and trainAssessPlan

Educate and train

Ongoing

Iterative

Weinick

2008Slide39

Healthcare Equality: StrategiesLeadership investmentProfessional involvementNurses Physicians

Social workers

Pharmacists

….

Community involvement

Horizontal & collaborative

Weinick

2008Slide40

Healthcare Equality: ChallengesExpertiseWillResourcesRisk

See

Weinick

2008 on many related points.Slide41

Leadership and ChangeWho: the leadershipElements of leading changeUrgencyCoalition

Vision

Communicating

Empowering action

Short

-term

wins

Building on wins

Institutionalizing

new approaches

.

Weinick

2008Slide42

Policy & ProcedureMGH Policy: “In order to assess and address racial and ethnic disparities on an ongoing basis, all relevant performance improvement data should be collected and stratified by race and ethnicity.”“Each department’s strategy for meeting this requirement is now discussed at annual meetings between senior hospital leadership and department chairs.”

Weinick

2008Slide43

Developing, Coordinating, Communicating“UW [U of Wisc-Madison] Health has taken a unique approach in creating visibility for efforts related to inequalities within the hospital system, and to coordinating these efforts internally and externally with a variety of different racial and ethnic groups in the community.” (

Weinick

2008)Slide44

Key Questions*: Hospital EquityWhat existing quality measures can be readily adapted according to RELS?Can patient satisfaction data be sorted by RELS?

*

Weinick

2008Slide45

Equity Implications“Achieving equity and addressing disparities has implications for quality, cost, risk management, accreditation, and community benefit.”Betancourt 2009, p. 6.Slide46

Leadership, Systems, Equity*Multidisciplinary committee: system repsRELS data collectionPlanDevelop supporting policiesIdentify quality measures (“Disparities dashboard”)

Assess, disseminate, revise

*Betancourt 2009Slide47

Evidence ReviewsUS Healthcare Inequality2002: IOM-Institute of Medicine, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care”

2003-

2008:

AHRQ-Agency for Healthcare Research and Quality, “National Healthcare Disparities Report (NHDR)”

IOM:

http://www.nap.edu/catalog.php?record_id=10260

(Accessed 27Sep2009)

AHRQ-Agency for Healthcare Research and Quality. “National Healthcare Disparities Report 2008.” (NHDR)

p

. 62.

http://www.ahrq.gov/qual/qrdr08.htm

(Accessed 27Sep2009)Slide48

References & ResourcesHealthcare EquityBetancourt 2009: Betancourt JR, Green AR, King RR, et al. Improving Quality and Achieving Equity: A Guide for Hospital Leaders. The Disparities Solutions Center at Massachusetts General Hospital. (

http://www2.massgeneral.org/disparitiessolutions/resources.html

, Accessed 26Sep2009)

Cummings LC, Bennett BA,

Boutwell

AE, Martinez EL. Assuring HealthCare Quality: A Healthcare Equity Blueprint. National Public Health and Hospital Institute National Association of Public Hospitals and Health Systems. Washington DC, 2008.

http://www2.massgeneral.org/disparitiessolutions/resources.html

. (Accessed 26Sept2009)

Weinick2008

: Robin

M.Weinick

, Katherine Flaherty, and

Steffanie

J.Bristol

. Creating Equity Reports

: A

Guide for Hospitals. The Disparities Solutions Center, Massachusetts General Hospital,2008. (

http://www2.massgeneral.org/disparitiessolutions/resources.html

. (Accessed 26Sept2009)