Equity – a blog
Ontario’s Ministry of Health and Long-Term Care (MOHLTC) has identified equity as a key component of quality care. The Ministry has developed a Health Equity Impact Assessment (HEIA) to support improved health equity, including the reduction of avoidable health disparities between population groups. HEIA also supports improved targeting of healthcare investments—the right care, at the right place, at the right time. And that is what this blog covers. Join us in the conversation.

Getting serious about reducing inequities in health and healthcare

Equity is a well recognized attribute of high performing health systems. Few would disagree that health equity is a laudable objective. Yet, there is no organized strategy to reduce health inequities in Canada and little progress has been made towards achieving this goal.  The biggest obstacles to reducing the many sizable and modifiable health inequities found in POWER Study analyses (www.powerstudy.ca) may very well be nihilism, inertia, and insufficient commitment.  These “root causes” help explain the paradox  that Adalsteinn Brown underscored in his blog; Canada has led the world in defining the problem of health inequities and the contribution of the social determinants of health, but has lagged internationally in developing, implementing, and evaluating interventions to close these gaps.

While it is not surprising that the POWER Study found health inequities in Ontario, the magnitude of these inequities and their impact on both individuals and the health system should be of concern to all.  One in four low income Ontarians reported difficulty accessing healthy food. Low income Ontarians are three times as likely as those with higher incomes to report fair or poor overall health and mental health. Low income Ontarians also had much higher rates of disability and mortality. Forty-one percent of men living in neighborhoods with the lowest income quintile die prematurely, or before age 75.  We estimated that if all Ontarians had the same health as Ontarians with higher income, 318,000 fewer people would be in fair or poor health, 231,000 fewer people would be disabled, and 3,373 fewer deaths would occur each year among Ontarians living in metropolitan areas.

It is well-known that the non-medical determinants of health rather than medical care or health behaviour are the primary drivers of health inequities. Some conclude, therefore, that health inequities are “old news” and it is expected that “the poor will be sicker.” Hence, the nihilism and inertia. Others conclude that because social determinants of health influence health status, health behaviours and healthcare are inconsequential. The POWER Study Framework bridges these divergent perspectives by emphasizing the importance of the social determinants of health, while recognizing that the way we organize and deliver healthcare and community services mediates the effects of the social determinants of health (see Figure).  The social determinants of health increase the risk of illness. Once one is sick access to and the quality of health services influence health outcomes. I still vividly remember many patients that I treated in NYC, negatively affected by lack of universal access to healthcare entering our public hospital system way too late. Preventable and tragic cases included late stage breast cancer, a disabling stroke from uncontrolled hypertension in a relatively young man, and a below the knee amputation in a single mother who had diabetes. Access to effective healthcare is an important determinant of health. The POWER Study framework recognizes that healthcare and community services can play an important role in reducing health inequities and complement needed efforts to address the social determinants of health. Coordination and partnership between these sectors, with services tailored to the needs of at risk populations, should be an important component of strategies for achieving health equity.

POWER Study Gender and Equity Health Indicator Framework

In the POWER study we found that many health inequities resulted from chronic diseases and their risk factors. We looked at patterns of potentially avoidable hospitalizations for four common chronic conditions – heart failure, chronic obstructive pulmonary disease (COPD), diabetes and asthma. The graph shows hospitalization rates for heart failure. Heart failure is often preventable, and for those living with heart failure effective chronic disease management in the community can reduce the need for hospitalization. Women and men living in the lowest income neighbourhoods were 53% and 60% more likely respectively to have a hospital admission for heart failure than those living in the highest income neighborhoods. An income gradient was seen for each of these conditions with rates of hospitalization increasing as neighbourhood income quintile decreased. For these four conditions alone, there were 51, 930 hospital admissions in Ontario in one year. If all Ontarians had the same rates of hospitalization as those in the highest income quintile there would be an estimated 15,703 fewer hospital admissions per year for these four conditions alone, a 30% reduction. We also observed significant regional variation in hospital admission rates. Again, an estimated 30% of these hospitalizations could be avoided if all Local Health Integration Networks (LHINs) achieved the same hospitalization rates as the LHINs with the lowest hospitalization rates for these conditions.  Thus, a focus on health equity would not only improve the quality of life of many, but by reducing the burden on the health system would contribute to health system sustainability.

Age standardized hospitalization rates for congestive heart failure (CHF) per 100,000 adults aged 25 or older, by sex and neighbourhood income quintile, in Ontario, 2006/07

A number of important lessons emerged from POWER Study analyses. First, we found that inequities in health were greater than inequities in access to and quality in care, pointing upstream for solutions. Second, the gender differences observed highlight the need for gender sensitive solutions. Third, inequities in access to primary care and chronic disease management were larger than inequities in treatment of acute conditions, highlighting the need to focus on primary care and community services. Fourth, where there was an organized strategy for quality improvement in place informed by performance measurement few inequities were observed. With extensive stakeholder input we have identified a leading set of health equity indicators that can drive change and a ten point health equity roadmap to help us do so. Gender and equity analysis need to be routinely included in health systems performance measurement and reporting. Innovative work is underway by many individuals and organizations across the province aimed at tackling these health inequities. We have the evidence, measures, and tools to move forward. We have the scientific methods to learn what works for which communities as we implement innovative interventions aimed at achieving health equity. What we need is the commitment and the will.

About the Author

Dr. Arlene Bierman is a general internist, geriatrician, and the inaugural holder of Echo’s Ontario Women’s Health Council Chair in Women’s Health; Associate Professor in the Lawrence F. Bloomberg Faculty of Nursing; and of Health Policy, Evaluation, and Management; and Medicine at the University of Toronto; and a Senior Scientist in the Li Ka Shing Knowledge Institute at St. Michael’s Hospital. She is the principal investigator for the POWER study (Project for an Ontario Women’s Health Evidence-Based Report Card www.powerstudy.ca) which through the collaboration of an interdisciplinary group of investigators is providing actionable data to help policymakers and healthcare providers to improve health and reduce health inequities in Ontario (www.powerstudy.ca). Dr. Bierman served on the board of the Health Quality Ontario and chaired its Performance Measurement Advisory Board. She is a member of the Cancer Quality Council of Ontario. Her research is directed at examining the impact of models service delivery and finance on access, quality, and health outcomes among older adults, with a special focus on low literacy and low income populations, and the unique needs of older women.

This entry was posted on Monday, March 12th, 2012 at 11:19 am and is filed under Longwoods Online.