HDG #011: How can you quantify health equity?
Read time: 4 minutes
Greetings, Gurus! Today, we're continuing our conversations about measuring program success, but this week we’re focused specifically on what areas make sense to quantifiably focus on for health equity programs.
Health equity programs aren't your everyday healthcare improvement initiatives. It’s not just about providing food in the community or increasing access to care (though that is important, too!). It's about improving equitable access to effective healthcare and enhancing health outcomes that are particularly impacted by disparities.
But here’s the tricky part: how do we quantify the success of these programs? Many of the “outcomes” can seem ambiguous—how do you quantify that every person, regardless of their background, has an equal shot at achieving the best health possible?
Another sticky wicket: it depends on what area or domain that you’re focusing on. Is it community health? Access? Health and disease outcomes? Other quality measures? Affordability? As I have talked about before, literally everything in healthcare ties back to health equity in some way.
Luckily, much thought leadership is being published on this very topic. Using ideas from multiple credible resources, here are 20 ideas you can consider when assessing health equity quantitatively. Of course, this list is NOT all-inclusive and some of them are proxy indicators, but I like them because they are a little broader than “just” the Social Determinants of Health (SDOH) and high-level community indicators box:
Health outcomes equity gap: this refers to quantifying discrepancies in health outcomes (like diabetes control or maternal mortality) between diverse demographic groups, as outlined in Health Affairs' typology for health equity measures. “It involves taking existing measures and stratifying them by REL, SOGI, disability status, rurality, and other variables.”
Access to healthcare services: As underlined by Healthy People 2020, access to services - proximity to healthcare facilities and appointment availability - is a crucial factor. This is perhaps one of the most common domains cited with regard to health equity.
Measuring patient population diversity: Understanding how/if your patient population reflects the diversity of your community helps you understand if you’re reaching your target audience. It also helps you understand if your targeted outreach to certain communities or subpopulations is effective.
Staff diversity: CDC emphasizes that your staff should represent the community they serve. This could be extrapolated to educators, etc.
Utilization of preventive services: NCQA states uniform preventive service usage across demographic groups is key to measuring health equity.
Cultural competency training: Health Affairs suggests counting the staff members undergoing cultural competency training and observing its impact on patient outcomes.
Patient satisfaction surveys: Disaggregate patient feedback by race, ethnicity, gender, socioeconomic status, etc., to measure equitable satisfaction.
Health literacy rates: Institute for Healthcare Improvement (IHI) advocates that your health education materials should be universally understandable.
Language services utilization: Measure the demand and quality of language interpretation services, as suggested by Health Affairs.
Screening rates: Track uniformity in disease screening across diverse groups.
Referral rates: The National Academies of Sciences, Engineering, and Medicine/Institute of Medicine’s Board on Population Health points out that consistency of specialist referrals across diverse patient groups is a strong indicator of health equity.
Insurance coverage rates & cost burden: HHS recommends ensuring uniform accessibility of insurance services across all demographic groups. We can also then analyze the percentage of income spent on healthcare across different groups, another economic health equity indicator as per HHS. This comes from a 90-page report that RAND Health Care published for HHS about “Developing Health Equity Measures” which has a ton of good info.
Telehealth access: Equitable access to telehealth services in today's digital age is critical. You might also look to understand differences in who is utilizing (or not utilizing) telehealth or digital health services—rural vs. urban, age groups, demographics, etc.
Emergency Room (ER) visit rates: Increased ER visits by certain groups, as cited by Health Affairs, could be an indicator of barriers to regular care. The same could be considered by analyzing urgent care visits. Diagnoses help to tip us off if patients are using these settings of care for preventative care, chronic conditions, less emergent types of ailments, or exacerbations of diseases brought on by poor preventative care (asthma attacks, etc.).
Discharge rates: Disparities in discharge rates can reveal differences in how people are experiencing the healthcare system, or how outcomes are impacting different groups of folks.
Post-hospitalization follow-up rates: A study on health equity in England suggests that equal follow-up care rates across diverse groups are a crucial indicator of health equity.
Representation in clinical trials: NCQA mentions ensuring adequate representation of diverse groups in clinical trials, and this can be extended to sample populations within analyses, program enrollment, focused initiatives, etc.
Rate of reported discrimination: Monitor the frequency of discrimination incidents reported by patients and stratify by demographics, as suggested by IHI. Pull out sentiments, keywords, themes, and etc. Use this to help understand how to deliver more culturally-appropriate care.
Community engagement: CDC endorses tracking the number and diversity of community members engaged in health programs, surveys, participation, feedback and etc.
Community-level indicators: for those working at the community level on social determinants of health that impact equity (like poverty, racism, health, education, etc.), Healthy People 2030 breaks social determinants of health into 5 main categories, each with a corresponding “scorecard” of objectives to improve equity in each domain. For instance, here is their list of Economic Stability objectives:
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While some of this might seem daunting, remember that you won’t be tackling all of these at once. This list is to provide ideas to help you shape what you focus on and how you might measure it. It is also provided as an example of different areas that you might not have previously considered for equity initiatives.
Start by quantifying these to establish a baseline and provide a starting point to chart progress. As you implement your initiatives, regularly measure and analyze these metrics to discern if you're indeed making an impact. Are the gaps closing or becoming more uniform? Are the right needles moving? These are the kind of questions that will help you quantify progress. However, true analysis goes beyond merely observing numbers. It's about understanding the stories behind these trends and the real-world implications of each data point. It's about constantly questioning, learning, and adapting your strategies to ensure that your efforts lead to sustained change. After all, at the heart of health equity is humanity, and that's what really counts.
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Actionable Idea of the Week:
As you're thinking about what it really means to advance health equity, keep these ideas in mind. Really think about the outcome of a new initiative—what area does it (or should it) touch upon? How can you use data to analyze the existing baseline or existing disparities, and then design a program that is more targeted? How would you measure progress?
The areas I mentioned above can be further broken out into metrics and KPIs for innovative new programs. Having measurable goals will enable us to track our progress towards this more mindfully, show success, and procure more resources/buy-in so that we can help more people.
The ultimate goal is a world where health equity is a standard, and where equitable practices, program design, care delivery, outcomes, and access are the norm. These can help get us there.
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Agree or disagree? What other health equity metrics is your organization using? What would you add? Reply and let me know. I’d love to chat with you about it.
See you next week!
-Stefany
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