All Quality Improvement Is Health Equity Work: Designing Improvement to Reduce Disparities

Lion, K. Casey; Faro, Elissa Z.; Coker, Tumaini R.

doi:10.1542/peds.2020-045948e

Cited by 38 publications

(26 citation statements)

References 46 publications

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“…A growing literature describes how structural and interpersonal racism can drive differences in how patients receive healthcare,34–37 countering the position that race and ethnicity are only a proxy for other factors. At the same time, more action-oriented frameworks have begun to demonstrate that improvement work focused on disparities can be effective in eliminating or countering the impact of these factors 38–40. The safety outcomes in our study (CLABSI and UE) have been shown to be sensitive to various technical and behavioural variables, including level of sedation and nursing care of the central line.…”

Section: Discussionmentioning

confidence: 73%

Racial and ethnic disparities in common inpatient safety outcomes in a children’s hospital cohort

Lyren,

Haines,

Fanta

et al. 2023

BMJ Qual Saf

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BackgroundEmerging evidence has shown racial and ethnic disparities in rates of harm for hospitalised children. Previous work has also demonstrated how highly heterogeneous approaches to collection of race and ethnicity data pose challenges to population-level analyses. This work aims to both create an approach to aggregating safety data from multiple hospitals by race and ethnicity and apply the approach to the examination of potential disparities in high-frequency harm conditions.MethodsIn this cross-sectional, multicentre study, a cohort of hospitals from the Solutions for Patient Safety network with varying race and ethnicity data collection systems submitted validated central line-associated bloodstream infection (CLABSI) and unplanned extubation (UE) data stratified by patient race and ethnicity categories. Data were submitted using a crosswalk created by the study team that reconciled varying approaches to race and ethnicity data collection by participating hospitals. Harm rates for race and ethnicity categories were compared with reference values reflective of the cohort and broader children’s hospital population.ResultsRacial and ethnic disparities were identified in both harm types. Multiracial Hispanic, Combined Hispanic and Native Hawaiian or other Pacific Islander patients had CLABSI rates of 2.6–3.6 SD above reference values. For Black or African American patients, UE rates were 3.2–4.4 SD higher. Rates of both events in White patients were significantly lower than reference values.ConclusionsThe combination of harm data across hospitals with varying race and ethnicity collection systems was accomplished through iterative development of a race and ethnicity category framework. We identified racial and ethnic disparities in CLABSI and UE that can be addressed in future improvement work by identifying and modifying care delivery factors that contribute to safety disparities.

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Section: Discussionmentioning

confidence: 73%

Racial and ethnic disparities in common inpatient safety outcomes in a children’s hospital cohort

Lyren,

Haines,

Fanta

et al. 2023

BMJ Qual Saf

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“…To conduct quality improvement work that improves equity, teams should stratify outcomes to assess and understand disparities before starting quality improvement interventions . Quality improvement strategies to address disparities due to bias and racism require long-term organizational commitment.…”

Section: Discussionmentioning

confidence: 99%

Identifying and Mitigating Disparities in Central Line–Associated Bloodstream Infections in Minoritized Racial, Ethnic, and Language Groups

et al. 2023

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ImportanceAlthough inequitable care due to racism and bias is well documented in health care, the impact on health care–associated infections is less understood.ObjectiveTo determine whether disparities in first central catheter–associated bloodstream infection (CLABSI) rates existed for pediatric patients of minoritized racial, ethnic, and language groups and to evaluate the outcomes associated with quality improvement initiatives for addressing these disparities.Design, Setting, and ParticipantsThis cohort study retrospectively examined outcomes of 8269 hospitalized patients with central catheters from October 1, 2012, to September 30, 2019, at a freestanding quaternary care children’s hospital. Subsequent quality improvement interventions and follow-up were studied, excluding catheter days occurring after the outcome and episodes with catheters of indeterminate age through September 2022.ExposuresPatient self-reported (or parent/guardian-reported) race, ethnicity, and language for care as collected for hospital demographic purposes.Main Outcomes and MeasuresCentral catheter–associated bloodstream infection events identified by infection prevention surveillance according to National Healthcare Safety Network criteria were reported as events per 1000 central catheter days. Cox proportional hazards regression was used to analyze patient and central catheter characteristics, and interrupted time series was used to analyze quality improvement outcomes.ResultsUnadjusted infection rates were higher for Black patients (2.8 per 1000 central catheter days) and patients who spoke a language other than English (LOE; 2.1 per 1000 central catheter days) compared with the overall population (1.5 per 1000 central catheter days). Proportional hazard regression included 225 674 catheter days with 316 infections and represented 8269 patients. A total of 282 patients (3.4%) experienced a CLABSI (mean [IQR] age, 1.34 [0.07-8.83] years; female, 122 [43.3%]; male, 160 [56.7%]; English-speaking, 236 [83.7%]; LOE, 46 [16.3%]; American Indian or Alaska Native, 3 [1.1%]; Asian, 14 [5.0%]; Black, 26 [9.2%]; Hispanic, 61 [21.6%]; Native Hawaiian or Other Pacific Islander, 4 [1.4%]; White, 139 [49.3%]; ≥2 races, 14 [5.0%]; unknown race and ethnicity or refused to answer, 15 [5.3%]). In the adjusted model, a higher hazard ratio (HR) was observed for Black patients (adjusted HR, 1.8; 95% CI, 1.2-2.6; P = .002) and patients who spoke an LOE (adjusted HR, 1.6; 95% CI, 1.1-2.3; P = .01). Following quality improvement interventions, infection rates in both subgroups showed statistically significant level changes (Black patients: −1.77; 95% CI, −3.39 to −0.15; patients speaking an LOE: −1.25; 95% CI, −2.23 to −0.27).Conclusions and RelevanceThe study’s findings show disparities in CLABSI rates for Black patients and patients who speak an LOE that persisted after adjusting for known risk factors, suggesting that systemic racism and bias may play a role in inequitable hospital care for hospital-acquired infections. Stratifying outcomes to assess for disparities prior to quality improvement efforts may inform targeted interventions to improve equity.

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“…More research is needed to understand and address the drivers of care variation, but in the meantime, clinical groups can invest in monitoring quality metrics stratified by race, ethnicity, and language and engaging in equity-focused quality improvement efforts to address disparities identified locally. 58,59 Second, the new American Academy of Pediatrics guidelines take an important step in advocating for a patient-centered approach, highlighting opportunities for shared decisionmaking. Paradoxically, this could exacerbate disparities if there is bias in when and how clinicians engage in shared decisionmaking.…”

Section: Figure Inclusion and Exclusion Flow Diagrammentioning

confidence: 99%

Race, Ethnicity, Language, and the Treatment of Low-Risk Febrile Infants

Gutman,

Aronson,

Singh

et al. 2024

JAMA Pediatr

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ImportanceFebrile infants at low risk of invasive bacterial infections are unlikely to benefit from lumbar puncture, antibiotics, or hospitalization, yet these are commonly performed. It is not known if there are differences in management by race, ethnicity, or language.ObjectiveTo investigate associations between race, ethnicity, and language and additional interventions (lumbar puncture, empirical antibiotics, and hospitalization) in well-appearing febrile infants at low risk of invasive bacterial infection.Design, Setting, and ParticipantsThis was a multicenter retrospective cross-sectional analysis of infants receiving emergency department care between January 1, 2018, and December 31, 2019. Data were analyzed from December 2022 to July 2023. Pediatric emergency departments were determined through the Pediatric Emergency Medicine Collaborative Research Committee. Well-appearing febrile infants aged 29 to 60 days at low risk of invasive bacterial infection based on blood and urine testing were included. Data were available for 9847 infants, and 4042 were included following exclusions for ill appearance, medical history, and diagnosis of a focal infectious source.ExposuresInfant race and ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White, and other race or ethnicity) and language used for medical care (English and language other than English).Main Outcomes and MeasuresThe primary outcome was receipt of at least 1 of lumbar puncture, empirical antibiotics, or hospitalization. We performed bivariate and multivariable logistic regression with sum contrasts for comparisons. Individual components were assessed as secondary outcomes.ResultsAcross 34 sites, 4042 infants (median [IQR] age, 45 [38-53] days; 1561 [44.4% of the 3516 without missing sex] female; 612 [15.1%] non-Hispanic Black, 1054 [26.1%] Hispanic, 1741 [43.1%] non-Hispanic White, and 352 [9.1%] other race or ethnicity; 3555 [88.0%] English and 463 [12.0%] language other than English) met inclusion criteria. The primary outcome occurred in 969 infants (24%). Race and ethnicity were not associated with the primary composite outcome. Compared to the grand mean, infants of families that use a language other than English had higher odds of the primary outcome (adjusted odds ratio [aOR]; 1.16; 95% CI, 1.01-1.33). In secondary analyses, Hispanic infants, compared to the grand mean, had lower odds of hospital admission (aOR, 0.76; 95% CI, 0.63-0.93). Compared to the grand mean, infants of families that use a language other than English had higher odds of hospital admission (aOR, 1.08; 95% CI, 1.08-1.46).Conclusions and RelevanceAmong low-risk febrile infants, language used for medical care was associated with the use of at least 1 nonindicated intervention, but race and ethnicity were not. Secondary analyses highlight the complex intersectionality of race, ethnicity, language, and health inequity. As inequitable care may be influenced by communication barriers, new guidelines that emphasize patient-centered communication may create disparities if not implemented with specific attention to equity.

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All Quality Improvement Is Health Equity Work: Designing Improvement to Reduce Disparities

Cited by 38 publications

References 46 publications

Racial and ethnic disparities in common inpatient safety outcomes in a children’s hospital cohort

Racial and ethnic disparities in common inpatient safety outcomes in a children’s hospital cohort

Identifying and Mitigating Disparities in Central Line–Associated Bloodstream Infections in Minoritized Racial, Ethnic, and Language Groups

Race, Ethnicity, Language, and the Treatment of Low-Risk Febrile Infants

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