Advancing Health Equity – Data Driven Strategies Reduce Health Inequities

Health equity means that everyone has an equal opportunity to live the healthiest life possible – this requires removing obstacles to health. The U.S. ranks last on nearly all measures of equity, as indicated by its large, disparities in health outcomes. Illness, disability, and death in the United States are more prevalent and more severe for minority groups. Health inequities persist in Minnesota as well, which motivated Allina Health to take targeted actions to reduce inequities.

Allina Health needed actionable data to identify disparities and to reduce these inequities. This came in the form of REAL (race, ethnicity, and language) data, which Allina Health analysts used to visualize how health outcomes vary by demographic characteristics including race, ethnicity, and language. To understand the root causes of specific disparities as well as to identify solutions within their sphere of influence as a healthcare delivery system, Allina Health consulted the literature and also consulted patients, employees and community members. Then Allina Health created appropriate interventions based on this information.

因此，阿利纳卫生中心使人们认识到病人群体在保健方面的不平等，并采取有效办法打破阻碍这些病人获得所需护理的障碍。虽然在实现卫生公平的漫长旅程中还有许多工作要做，但阿利纳卫生已经向前迈出了一些重要步骤。

HEALTH INEQUITIES EXIST ACROSS THE U.S.

根据罗伯特·伍德·约翰逊基金会的说法，“卫生公平意味着每个人都有公平和公正的机会变得更健康。这就需要消除健康方面的障碍，如贫穷、歧视及其后果，包括无力和无法获得同工同酬的好工作、优质教育和住房、安全的环境和医疗保健。”¹

The U.S. ranks last on nearly all measures of equity because of its large income-related differences in health outcomes.²The most common causes of illness, disability, and death in the U.S.—heart disease, cancer, diabetes, and stroke—are more common and more severe for minority groups.

尽管许多组织和项目都在努力改善健康状况，但明尼苏达州的健康不平等现象依然存在。³

• African-American and American Indian babies die in the first year of life at twice the rate of white babies.
  • While infant mortality rates for all groups have declined, the inequity in rates has existed for over 20 years.
• The rate of HIV/AIDS among African-born persons is nearly 16 times higher than among white, non-Hispanic persons.
• American Indian, Hispanic/Latino, and African-American youth have the highest rates of obesity, and African-American and Hispanic/Latino women in Minnesota are more likely to be diagnosed with later-stage breast cancer.

Allina Health, a not-for-profit healthcare system with 12 hospitals and 67 clinic sites and ambulatory care centers, is dedicated to the prevention and treatment of illness, and helping people live healthier lives in communities throughout Minnesota and western Wisconsin.

HEALTH EQUITY PROBLEMS PERSIST IN MINNESOTA

For more than 15 years, Minnesota has tracked disparities in populations of color, American Indians, children, adolescents, immigrants and refugees, and lesbian, gay, bisexual, transgender, and queer (LGBTQ).

2011年，明尼苏达州开始要求医疗服务提供者收集种族、民族和语言(REAL)数据。这些数据显示了不平等。Available literature provided insight into several variables that contribute to these inequities:

• 卫生系统的问题与系统的复杂性有关，它如何不适应少数患者或英语水平有限的人，以及如何不成比例地难以驾驭。
• 与护理提供者相关的护理过程问题，包括刻板印象，种族和民族对决策的影响，以及由于沟通不周造成的临床不确定性。
• Patient-related issues including patient’s mistrust, poor adherence to treatment, and delays in seeking care.

2013年，阿利纳卫生开始对其临床质量结果指标进行分层，揭示了缩小其一些种族/少数民族患者群体之间差距的机会。这些分层数据表明，严重的卫生不平等现象持续存在，促使阿利纳卫生采取有针对性的行动减少不平等现象。

UNDERSTANDING CAUSES OF INEQUITY ENABLED CUSTOMIZED INTERVENTIONS

Using data to identify inequities

To be successful in reducing inequities, Allina Health needed to understand the outcomes its patients were experiencing. For this, it needed data. Using the Health Catalyst^®Analytics Platform, including the Late-Binding™ Data Warehouse and a broad suite of analytics applications, Allina Health studied REAL data, and data regarding country of origin, to begin understanding inequities.

在标准化数据收集、数据类别和用于进行分析的方法之后，Allina Health的数据分析师按种族、民族和语言提供了健康结果的可视化，并将结果与白人、非西班牙裔/拉丁裔进行了比较，English-speaking population (see Figure 1).

分析显示，阿利纳健康有机会减少健康不平等，包括提高结直肠癌筛查(CRC)率。Allina Health制定了一项多层次的工作计划，以提高使用索马里语、苗语、西班牙语、阿拉伯语和俄语的儿童CRC筛查率;以及西班牙裔/拉丁裔、美国印第安人、非裔美国人、夏威夷原住民和其他太平洋岛民。其目标是达到与白人、非西班牙裔/拉丁裔、讲英语的患者相当的筛查率，逐步缩小差距。

Allina Health承认，尽管有真实的数据，但其对患者的需求和对CRC筛查的看法的理解可能是不完整的。真实数据和电子病历中的数据不包括影响健康的其他因素的重要数据，如患者对医疗保健和特定医疗干预的价值观和信念、住房稳定性、财政资源紧张、文化、性别认同、粮食不安全、社会联系和其他健康的社会决定因素。

Using literature and engagement to understand disparities

To develop a complete picture and understand root causes contributing to lower CRC screening rates, Allina Health researched available evidence about how to increase screening rates in minority populations, which increased its understanding of barriers, and activities to remedy those barriers.

Allina Health used focus groups with its certified medical interpreters, to gain additional understanding of various patient populations. Allina Health learned about values, beliefs, and barriers that might impede patients from completing the recommended CRC screening:

• 主题可能会被一些人认为是可耻的或性的。
• Screening may be an unfamiliar concept. In some cultures, the word “screening” simply doesn’t exist. Phrases such as “looking for cancer” may be more effective.
• 对手术过程中不适的担忧，基于患者在未使用止痛药的母国的医疗保健经验。
• 基本需求——食物、住房、账单——可能优先于预防性保健治疗。
• Discomfort with opposite sex providers and interpreters.
• Belief that cancer is God’s will, and that people should not intervene or try to prevent it.

Intervening and monitoring the effectiveness of interventions

With improved understanding of the needs of the various patient populations, Allina Health developed and implemented a work plan to improve CRC screening rates, which includes the following interventions:

• The health system mails patients home testing/screening kits. The health system uses culturally tailored education materials, instructions, and frequently asked question documents, all written in the patient’s primary language.
• Patients who do not complete the CRC screening after the initial offering receive a second kit and a phone call in their own language to remind them to complete the test. To convey the benefit of completing the CRC screening, and to address questions a patient might have about the test.
• 阿利纳卫生雇用的护理指南与患者联系并克服障碍，包括与非医疗卫生相关的社会需求和交通需求，以增加患者对筛查目标和筛查选项的了解。Allina Health利用社区的力量，例如开展结肠直肠癌筛查社交媒体活动，旨在更好地吸引非洲裔和西班牙语患者，为索马里患者制作结肠直肠癌筛查视频，以及一项基于技能的员工志愿者活动，邀请Allina Health的员工在他们的社交网络上谈论为什么以及如何进行结肠直肠癌筛查。社交媒体活动和视频使用循证沟通，以最有效地触及利益群体。阿利纳健康还在其网站上宣传儿童权利普查的重要性，并正在调查报纸、广播和电视的使用情况。
• Through its analytics application, Allina Health is able to monitor the effectiveness of its interventions on the populations at highest risk for the poorest screening rates (see Figure 2).

RESEARCH AND DATA-DRIVEN RESULTS

阿利纳卫生公司以数据为驱动的减少卫生不平等现象的方法通过定制干预措施显示出了有效性。The system increased its understanding of health equity, improved its awareness of where inequities existed, and confirmed an effective approach for reducing them resulting in:

• Three percent relative improvement in colorectal cancer (CRC) screening rates for targeted populations, exceeding national CRC screening rates by more than ten percentage points.
• REAL data embedded in dashboards and workflow to easily identify and address disparities.

“我们已经了解到，平等——每个人都受到同等对待——和公平之间是有区别的;为我们的病人提供成功所需的支持。通过提供额外支持来解决这些障碍，我们能够减少卫生不平等现象。”

– Jana Beckering, RN
Project Manager
Allina Hospitals and Clinics

WHAT’S NEXT

The integration of demographic filters into all of Allina Health dashboards has enabled the organization to identify opportunities to address health inequities in many areas, including:

• Primary care—diabetes, hypertension, asthma, pediatric immunizations, cancer screening, no show-rates, primary care provider assignment.
• Obstetric care—breastfeeding, transfusion, post-partum hemorrhage, pre-term delivery, fetal loss.
• 心理健康抑郁筛查抑郁申报门诊随访
• Emergency care—ED utilization, wait times, use of restraints/seclusions.
• Hospital care—potentially avoidable hospitalizations for diabetes, HF, asthma, COPD, pneumonia and depression, readmissions, high-tech imaging claims.
• Pharmacy utilization.

The organization will continue to build capacity for the organizationto understand the root causes of the inequities and to take action. Allina Health is sharing the learnings from this important work and creating additional organizational capacity to reduce health inequities throughout the organization, integrating health equity data into all its quality improvement efforts.

参考文献

1. 布雷弗曼，P.， Arkin, E.，奥尔良，T.， Proctor, D. & Plough, A.(2017)。什么是卫生公平:一个定义有什么不同?Robert Wood Johnson Foundation.
2. National Quality Forum. (2008).Closing the disparities gap in health quality with performance measurement and public reporting.
3. Minnesota Department of Health, Commissioner’s Office. (2014).Advancing health equity in Minnesota: Report to the legislature.

ABOUT HEALTH CATALYST

Health Catalyst is a next-generation data, analytics, and decision support company committed to being a catalyst for massive, sustained improvements in healthcare outcomes. We are the leaders in a new era of advanced predictive analytics for population health and value-based care. with a suite of machine learning-driven solutions, decades of outcomes-improvement expertise, and an unparalleled ability to integrate data from across the healthcare ecosystem. Our proven data warehousing and analytics platform helps improve quality, add efficiency and lower costs in support of more than 85 million patients and growing, ranging from the largest US health system to forward-thinking physician practices. Our technology and professional services can help you keep patients engaged and healthy in their homes and workplaces, and we can help you optimize care delivery to those patients when it becomes necessary. We are grateful to be recognized by Fortune, Gallup, Glassdoor, Modern Healthcare and a host of others as a Best Place to Work in technology and healthcare.

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