Innovative approaches to improving health equity
“Is it working the same for all people?” That’s the question Dr. Tara Kiran asks herself often as a physician and a researcher on quality of care. On many days, the answer is no.
“When we do research, we often want to understand what the quality of care is on average. But we also know when we only look at averages, we might be missing part of the story,” explains Dr. Kiran.
“When we take an equity lens, we are taking a deeper dive to understand the perspectives and quality of care for a particular group.”
But to take a “deeper dive” and better understand different patient groups, physicians need more detailed information about their patients’ lives and the socioeconomic factors that could be affecting their health.
So, in 2013, Dr. Kiran and the St. Michael’s Hospital Academic Family Health Team (SMHAFHT) adopted a survey collection tool — developed in partnership with several other Toronto health organizations — to collect patient data.
Dr. Kiran says to date almost 20,000 patients have completed the survey, answering questions about their race, ethnicity, sexual orientation, gender, housing, income and disabilities. The health team have been able to integrate this information into patients’ electronic medical records.
“It’s not perfect, but it’s a start,” she says.
Dr. Kiran will be sharing more about this survey and other innovative approaches to reducing health inequalities as part of a panel discussion at the CMA Health Summit in August.
As the director of quality improvement program for the SMHAFHT, Dr. Kiran says having more detailed patient data, as well as collecting feedback from patients on their care, has been key to ensuring more equitable treatment.
When the team wanted to improve cancer screening rates, for example, they started by mailing reminder letters to every patient. Dr. Kiran says although overall screening rates did improve, a closer analysis revealed that patients who lived in lower income neighborhoods were less likely to get screening than patients in higher income neighborhoods, and this difference in screening rates did not change after the reminder letters were sent.
Dr. Kiran says to improve the screening rates for people in lower income neighborhoods, her team needed to develop a more targeted approach. Since they already knew that phone calls are more effective — but more expensive — than letters, they decided to create a targeted phone campaign as a way of “maximizing equity.”
Dr. Kiran says this approach requires a shift in thinking; while equality is when you do the same for everyone, equity is about doing different things for different people, to get similar results.
“We have to think critically about where different patients are at and acknowledge that one solution may not be the right solution for everybody,” says Dr. Kiran.
To ensure they are getting a broad picture of different patient needs, Dr. Kiran and her team have made deliberate efforts to consult diverse groups. For a recent patient engagement day, they had 350 patients “volunteer” for about 35 spots. Rather than select patients at random, her team asked a series of demographic questions about housing status, age and gender to choose the participants, to insure they were consulting a range of patients, with a range of backgrounds.
Dr. Kiran says the next frontier in ensuring equity is looking past sociodemographic data and trying to determine patients’ “social needs.”
In Boston and in California, there are now family practices trying to gauge social needs by asking patients “Do you have a job?” and if the answer is no, the next question they ask is “Would you like help with finding employment?”
Dr. Kiran says this approach is more action based; it not only identifies socioeconomic details about patients’ lives, it goes one step further and helps link patients to services that can improve their lives.
Kiran says some of this work is also happening in Canada; in Ontario, there is a pilot project underway where health providers are asking patients the question “Do you have trouble making ends meet?” and then intervening with a poverty tool developed by Dr. Gary Bloch and the Ontario College of Family Physicians and collaborating with agencies such as Ontario 211 to help match patients with resources.
As a physician who is concerned about the health impacts of social inequality, Dr. Kiran says she’s encouraged by the range of projects underway. But when it comes to her own work she often returns to the same basic question.
“When you are improving the quality of care overall, is it just some groups that improve, and others stay the same? And how do you reach the ones that are staying the same?”