A Conceptual Framework for Optimizing the Equity of Hospital-Based Emergency Care: The Structure of Hospital Transfer Networks

• Published in: The Milbank quarterly 2023-03, Vol.101 (1), p.74-125
• Main Authors: HSUAN, CHARLEEN, CARR, BRENDAN G., VANNESS, DAVID, WANG, YINAN, LESLIE, DOUGLAS L., DUNHAM, ELEANOR, ROGOWSKI, JEANNETTE A.
• Format: Article
• Language: English
• Subjects: Built environment; Clinical outcomes; Delivery of Health Care; Discrimination; Emergency medical care; Emergency medical services; Emergency Service, Hospital; Emergency services; Equity; Health; Health disparities; health policy; Health status; Hospital emergency service; Hospitals; Humans; Medicine; Networks; Optimization; Original Scholarship; patient transfer; Patient-centered care; Patients; Population; Population Health; Quality of care; Reimbursement, Incentive; Research methodology; social determinants of health; social inequity; Sociocultural factors; Stabilization; structural racism; Systemic racism; Urban environments
• ISSN: 0887-378X; 1468-0009; 1468-0009
• DOI: 10.1111/1468-0009.12609

Policy Points Current pay‐for‐performance and other payment policies ignore hospital transfers for emergency conditions, which may exacerbate disparities. No conceptual framework currently exists that offers a patient‐centered, population‐based perspective for the structure of hospital transfer networks. The hospital transfer network equity‐quality framework highlights the external and internal factors that determine the structure of hospital transfer networks, including structural inequity and racism. Context Emergency care includes two key components: initial stabilization and transfer to a higher level of care. Significant work has focused on ensuring that local facilities can stabilize patients. However, less is understood about transfers for definitive care. To better understand how transfer network structure impacts population health and equity in emergency care, we proposea conceptual framework, the hospital transfer network equity‐quality model (NET‐EQUITY). NET‐EQUITY can help optimize population outcomes, decrease disparities, and enhance planning by supporting a framework for understanding emergency department transfers. Methods To develop the NET‐EQUITY framework, we synthesized work on health systems and quality of health care (Donabedian, the Institute of Medicine, Ferlie, and Shortell) and the research framework of the National Institute on Minority Health and Health Disparities with legal and empirical research. Findings The central thesis of our framework is that the structure of hospital transfer networks influences patient outcomes, as defined by the Institute of Medicine, which includes equity. The structure of hospital transfer networks is shaped by internal and external factors. The four main external factors are the regulatory, economic environment, provider, and sociocultural and physical/built environment. These environments all implicate issues of equity that are important to understand to foster an equitable population‐based system of emergency care. The framework highlights external and internal factors that determine the structure of hospital transfer networks, including structural racism and inequity. Conclusions The NET‐EQUITY framework provides a patient‐centered, equity‐focused framework for understanding the health of populations and how the structure of hospital transfer networks can influence the quality of care that patients receive.