Post on 14-Jan-2016
description
Achieving Equitable Outcomes:Collecting Socio-Demographic Patient
Data in Health Care Settings
Joseph R. Betancourt, M.D., M.P.H.
Director, The Disparities Solutions CenterSenior Scientist, Institute for Health Policy
Director for Multicultural Education, Massachusetts General Hospital
Associate Professor of Medicine, Harvard Medical School
Outline
Disparities in Health and Health Care
Collecting Patient Demographics
Case Study of Mass General Hospital
– Collecting Race/Ethnicity Data
– Measuring and Monitoring Equity
– Developing Interventions
Diabetes-Related Death Rate, 2010
Deaths per 100,000 population
22.8
50.1
33.6
50.3
18.4
0
10
20
30
40
50
WHITE BLACK HISP/LTN AI/AN ASIAN/PI
What causes these Racial/Ethnic Disparities in Health?
Social Determinants
Access to Care
Health Care?
Racial/Ethnic Disparities inHealth Care
In patients with insurance…– Disparities based on race for:
Influenza vaccination (Gornick et al.)
Lung Ca Surgery (Bach et al.)
Renal Transplantation (Ayanian et al.)
Treatment of chest pain, cardiac catheterization, angioplasty, bypass (Harris et al, Ayanian et al., Peterson et al., Johson et al.)
Referral to cardiology specialist care (Schulman et al.)
Treatment of HIV/AIDS (Shapiro et al.)
Pain management (Todd et al.)
Disparities in Health Care 2002
Racial/Ethnic disparities found across a wide range of health care settings, disease areas, and clinical services, even when various confounders (SES, insurance) controlled for.
Many sources contribute to disparities—no one suspect, no one solution•Provider-Patient Communication
•Stereotyping
•Mistrust
IOM’s Unequal Treatmentwww.nap.edu
Recommendations
Increase awareness of existence of disparities
Address systems of care
– Support race/ethnicity data collection, quality improvement, evidence-based
guidelines, multidisciplinary teams, community outreach
– Improve workforce diversity
– Facilitate interpretation services
Provider education
– Health Disparities, Cultural Competence, Clinical Decisionmaking
Patient education (navigation, activation)
Research
– Promising strategies, Barriers to eliminating disparities
Quality Health Care
Health care should be
– Safe
– Effective
– Patient-centered
– Timely
– Efficient
– Equitable
Case Study:Achieving Equity
Massachusetts General Hospital
MGH Disparities Committee 2003
Underlying Principle
While data specific to disparities at MGH important, not
necessary to begin to take action given IOM Report
documented issue nationally
Charge
Identify and address disparities in health and health care
wherever they may exist at MGH– Subcommittees: Quality, Pt Experience, Education/Awareness
– Present plan and results to Board, Executive Council and other
hospital leadership regularly
Case Study:Achieving Equity at MGH
Data Collection
Data CollectionPerceived Challenges
Collection of information is illegal
Patients won’t want to provide information
Registrars won’t want to collect information (have history
of just deciding patient info)
Process will take too long, impede registration
Adapting IT systems to collect info costly
Uncertain how information will be used
Data Collection: TimelinePrior to 2003
Collected R/E data in 5 basic categories and preferred
language
Registrars asked basic questions
Little training or quality assurance
No preamble to collection of data
No campaign to inform patients of purpose
Information not linked to quality data
Data Collection: Timeline
2003Boston Mayor convenes Hosp CEO’s & Community Leaders
– Agree to effort to address disparities in health and health care– Boston hospitals to be required to collect race/ethnicity
2004Piloted new method of collection
– 3 models among 7000 patients (R/E, subgroup, language, education)– Metrics: Collects key info in timely fashion in way patients could understand
Registrars receive intense training and QA Process – Includes preamble, methods to respond to questions
City releases PR Poster CampaignMGH passes policy that all Quality Data will be stratified by race/ethnicity and language
Data Collection: Timeline2006MA Health Care Reform requires race/ethnicity, language, and highest level of education to be collectedMGH begins preparation of Disparities Dashboard
– Poster campaign series and website unveiled – Disparities questions incorporated in Quality Rounds– Patient Experience Survey Conducted– Multicultural Advisory Board Convened– Patient Satisfaction stratified by race/ethnicity, and language
2007MGH develops first Disparities DashboardDisparities found, interventions developed
2008MGH begins public reporting via web
Case Study:Achieving Equity at MGH
Measuring and Monitoring
Initial Disparities Dashboard Welcome and Purpose
– Definition of DisparitiesFocus on disparities in care
– Purpose of DashboardAnnual ReportEmbedded into Q and S Reporting
– Data and MeasurementHow race/ethnicity data collected
– Process, categoriesData Sources
– IDX, PATCOM, TSI, H-CAHPS survey data, medical record review (Core/NHQM)
Snapshot of diversity of MGH patients– Who they are and where they are seen
Initial Disparities Dashboard Measures
– Clinical quality indicatorsInpatient: National Hospital Core Measures
– AMI, CHF, CAP, SCIP
Outpatient: HEDIS Measures– Mammogram, Pap, CRC Screening
– Diabetes, Coronary Artery Disease
– Physician, Practice Linkage
– Patient Experiences with CarePress-Ganey Inpatient satisfaction by r/eResults of Quality RoundsResults of Minority Survey
– Communication with LEP patients
Disparities Dashboard Evolution (V2, V3) H-CAHPS Inpatient satisfaction by race/ethnicity
All-cause and ACS Admission by race/ethnicity
CHF Readmissions by race/ethnicity
Sentinel Measures– Mental Health
– Pain Mgmt in the ED
– Wait time for Renal Transplantation
– Orbit time for CABG
Patient Experience Summit– Interpreter Pilot Project
Cross-Cultural Communication Training Report
Public Reporting via external MGH Q/S Website
Disparities Dashboard Executive Summary– Green Light: Areas where care is equitable
National Hospital Quality MeasuresHEDIS Outpatient Measures (Main Campus)Pain Mgmt in the ED
– Orange Light: National disparities, areas to be exploredMental Health, Renal TransplantationAll cause and ACS Admissions (so far no disparities)CHF Readmissions (so far no disparities)Patient Experience (H-CAHPS subgroub differences)
– Red Light: Disparities found, action being takenDiabetes at community health centers
– Chelsea (Latino), Revere (Cambodian) Diabetes Project
Colonoscopy screening rates– Chelsea CRC Navigator Program (Latinos)
Case Study:Achieving Equity at MGH
Developing Interventions
The MGH Chelsea Diabetes Program
Chelsea: Large minority and immigrant community (Hispanic/Latino
primarily, but also Bosnian, Somali) about 3 miles from hospital.
MGH Chelsea Healthcare Center provides community based
care
MGH Chelsea Diabetes Program: A quality improvement /
disparities reduction program with 3 primary components:
• Telephone outreach to increase rate of HbA1c testing
• Individual coaching to address patients’ needs and concerns regarding
diabetes self-management to improve HbA1c
• Group education meeting ADA requirements
Diabetes Control Improving for All: Gap between Whites and Latinos Closing
24% 24%
20%
37%
34%
29%
0%
10%
20%
30%
40%
50%
2007 2008 2009
Year
% o
f P
atie
nts
wit
h P
oo
rly
Co
ntr
olle
d D
iab
etes
(H
bA
1c
> 8
) Whites
Latinos
* Chelsea Diabetes Management Program began in first quarter of 2007; in 2008 received Diabetes Coalition of MA Programs of Excellence Award
*
Monitoring Equity: Key Lessons Learned There may be initial resistance and concern
– Appropriate messaging, explanation of disparities, description of “work in progress”, blame-free approach is key
Not always as easy as it seems, but can be done
– Some data systems not easily connected; begin incrementally, build the system step-by-step; perfect not enemy of good
– Address basic methodological issues, don’t get bogged down by them
Need to expand measure set over time, innovate
– Sentinel measures; sub-group analysis of patient experience; errors
Mainstreaming essential
– Policies, champions make for success and culture change; needs to be owned by Quality and Safety; tailor to your needs
Looking towards the FutureBuilding Equitable Systems and Incentives
Race/ethnicity and other data collection is essential
Need to measure and monitor
20/80 Rule: Conditions of Focus
Asthma, Diabetes, CVD, CRC Screen, Mental Health
– South Asians and First Nation populations
Increase Capacity of Health Care Providers
Foster cultural competence of health care providers
Empower Patients
Support coaching and navigation activities
Summary
There is a significant body of evidence that has
identified racial/ethnic disparities in health care
Hospitals can play a major role in their elimination
through quality improvement; monitoring equity is key
Improving equity will improve the care not only of
minorities, but of all patients
Thank You
Joseph R. Betancourt, MD, MPH
jbetancourt@partners.org
www.mghdisparitiessolutions.org