Health equity monitoring for healthcare quality assurance

• Published in: Social science & medicine (1982) 2018-02, Vol.198, p.148-156
• Main Authors: Cookson, R., Asaria, M., Ali, S., Shaw, R., Doran, T., Goldblatt, P.
• Format: Article
• Language: English
• Subjects: Ambulatory Care; Ambulatory care sensitive; Ambulatory health care; Averages; Chronic Disease - therapy; Chronic illnesses; Commissioning; Deprivation; Deprived areas; Emergency admissions; England; Fairness; Health care; Health care industry; Health disparities; Health Equity; Health services; Healthcare Disparities; Hospitalization; Hospitalization - statistics & numerical data; Humans; Inequality; Inpatient care; Neighborhoods; Patient admissions; Patient communication; Patients; Purchasing; Quality Assurance, Health Care; Quality control; Quality indicators; Quality of care; Residence Characteristics - statistics & numerical data; Small-area analysis; Socioeconomic Factors; State Medicine
• ISSN: 0277-9536; 1873-5347
• DOI: 10.1016/j.socscimed.2018.01.004

Population-wide health equity monitoring remains isolated from mainstream healthcare quality assurance. As a result, healthcare organizations remain ill-informed about the health equity impacts of their decisions – despite becoming increasingly well-informed about quality of care for the average patient. We present a new and improved analytical approach to integrating health equity into mainstream healthcare quality assurance, illustrate how this approach has been applied in the English National Health Service, and discuss how it could be applied in other countries. We illustrate the approach using a key quality indicator that is widely used to assess how well healthcare is co-ordinated between primary, community and acute settings: emergency inpatient hospital admissions for ambulatory care sensitive chronic conditions (“potentially avoidable emergency admissions”, for short). Whole-population data for 2015 on potentially avoidable emergency admissions in England were linked with neighborhood deprivation indices. Inequality within the populations served by 209 clinical commissioning groups (CCGs: care purchasing organizations with mean population 272,000) was compared against two benchmarks – national inequality and inequality within ten similar populations – using neighborhood-level models to simulate the gap in indirectly standardized admissions between most and least deprived neighborhoods. The modelled inequality gap for England was 927 potentially avoidable emergency admissions per 100,000 people, implying 263,894 excess hospitalizations associated with inequality. Against this national benchmark, 17% of CCGs had significantly worse-than-benchmark equity, and 23% significantly better. The corresponding figures were 11% and 12% respectively against the similar populations benchmark. Deprivation-related inequality in potentially avoidable emergency admissions varies substantially between English CCGs serving similar populations, beyond expected statistical variation. Administrative data on inequality in healthcare quality within similar populations served by different healthcare organizations can provide useful information for healthcare quality assurance. •Healthcare organizations are ill-informed about the equity impacts of their decisions.•This paper presents a new analytical approach to address this problem.•Inequality in quality in the served population is benchmarked to similar populations.•We illustrate using a widely used quality indicator: avo