What can the health system do to improve health equity? Cristina Ugolini Julie Kryzanowski

This Session is sponsored by:

Health Care Equity in Saskatoon Health Region

What can the health care system do to improve health equity?

2013 Health Care Quality Summit

Objectives

• Define “health equity”

• Connect “health care quality” to “health equity”

• Understand what the health care system can do to promote health equity

The Social Determinants of Health

PHAC. 2008. The Chief Public Health Officer's Report on the State of Public Health in Canada, 2008. Ottawa, Canada.

Impacts of Poverty on Marginalized Groups

The Social Determinants of Health

PHAC. 2008. The Chief Public Health Officer's Report on the State of Public Health in Canada, 2008. Ottawa, Canada.

Impacts of Poverty on Marginalized Groups

Life Expectancy in Saskatoon Health Region, 1997-2006

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

SHR 78.8 79.0 79.3 79.3 79.4 79.8 79.7 79.8 79.9 79.9

Core Nhd 74.7 75.4 76.4 75.0 75.0 75.0 74.1 74.4 74.3 73.4

70

80

Life

exp

ec

tan

cy a

t b

irth

in y

ea

rs

The Health Gradient

0

1

Health

Advantage

The Health Gradient

0

1

Health

Advantage

The Health Gradient

0

1

Health

Advantage

Health Care Equity

0

1

Health Care

Health Need

Equality vs. Equity

Inequity Equity

Inequality

Equality

Equality vs. Equity

Most common

Inequity Equity

Inequality

Equality

Equality vs. Equity

Undesirable

Most common

Inequity Equity

Inequality

Equality

Equality vs. Equity

Undesirable Unlikely

Most common

Inequity Equity

Inequality

Equality

Equality vs. Equity

Undesirable Unlikely

Most common

Achievable

Inequity Equity

Inequality

Equality

Health Care Equity

Available

Acceptable Accessible

Appropriate

The Plan for Saskatchewan Health Care

The 4 “Betters” and How Equity Runs Through Them

The 4 “Betters”

The 3 Levels of Action

3. Advocate and partner with other sectors to improve social determinants of health

2. Integrate health equity into all parts of the health care system

1. Deliver equitable health care services

Applications within Population and Public Health

Health Equity

Public Health Service Delivery

Supporting Health Equity Assessments

Health System

Performance Monitoring

Developing Tools for

Health Equity

Research & Evaluation

Population Health Equity Surveillance

Community Engagement

& Partnership

Advocacy & Policy

Development

1. Public Health Service Delivery

2002 2003 2004 2005 2006 2007

Affluent 82.05 79.08 80.48 79.61 80.07 84.81

Core 48.40 47.08 47.22 45.02 47.52 49.82

Middle_Income 69.14 68.19 66.68 68.28 70.79 71.27

Rural_or_PO_Box 71.75 74.79 75.32 75.90 74.23 77.48

0 10 20 30 40 50 60 70 80 90

100

% o

f C

lien

ts w

ith

MM

R x

2

Two-year-old immunization coverage for measles, mumps and rubella (MMR) by neighbourhood group, SHR, 2002-2007

Health Care Equity Audit Cycle

Problem

Evidence

Intervention

Evaluation

Health Care Equity Audit Cycle Low

immunization rates in core

neighbourhoods

Best-practise literature review & parent survey

Phone-based reminder system

Increased immunization

rates

2007 2008 2009 2010 2011

measles - Core 51.9 63.8 57.7 60.1 67.4

measles - Non-Core 73.4 75.0 76.4 76.0 74.7

measles - Rural 74.5 81.9 77.4 73.5 77.6

0 10 20 30 40 50 60 70 80 90

% o

f C

lien

ts w

ith

MM

R x

2

Two-year-old immunization coverage for measles, mumps and rubella (MMR) by neighbourhood group, SHR, 2007-2011

Impact of Health Equity Audit Cycle

Other Areas for Health Care Equity Audit

• Diabetes

• Home Care

• Mental Health

• Surgical Procedures

• Renal Services

Problem

Evidence

Intervention

Evaluation

Other Areas for Health Care Equity Audits

Best Practise

Health Care Delivery (SHR Public Health Observatory, 2012)

Culturally safe service provision

Language diversity

Inclusion of skill building in behavioural interventions

Sustainable, long-term programming

Integration and inclusion of social supports in programs

Service provision in home, school, workplace and community

Integration of services in housing initiatives

Multidisciplinary case management for high-risk populations

Integration of community health workers in health program delivery

Standardized provider care systems

2. Health System Performance Monitoring

Ind

ex

Sco

re

DASHBOARD - FACT SHEET

IMMUNIZATION DISPARITY RATIO

MUMPS MEASLES RUBELLA (MMR)

What is being measured?

Equity is defined as providing care on basis of need not

influenced by personal characteristics and circumstance. Immunization disparity can be expressed as a ratio

comparing the top socio-economic quintile to the bottom quintile. In other words, this compares the wealthiest fifth of

our population to the poorest fifth.

The ratio is calculated by dividing the two year-old MMR coverage rate in the top socio-economic quintile by the coverage rate in the bottom quintile. A ratio equal to one indicates equity while measures greater than one indicate inequity.

Socio-economic quintiles are based on the Total Deprivation Index. This includes income, employment, education and

social support indicators. It is calculated at the Dissemination Area level geography for Saskatoon city only,

and cannot be utilized at present for rural SHR.

Immunization rates are calculated for populations in the top

and bottom quintiles - 20% of the population.

Why is it important?

SHR has a mandate to reduce disparities based on the Federal Healthy Living Strategy. Health disparities make it

difficult for individuals and groups to participate fully in society. Health disparities are also huge cost drivers which

are estimated to account for 20% of all healthcare

expenditures.

How are we doing?

The ideal disparity ratio is equal to 1.0, which indicates

equality between the upper and lower quintiles or socio- economic groups of population (i.e. no gap). In SHR the disparity ratio has been decreasing most rapidly since 2007. This signals greater equity in immunization rates.

Our 2011-12 target was 1.16, and our Q4 ratio was 1.25. In January 2012, we initiated a targeted pilot campaign to

address immunization rates in the lowest socioeconomic

neighbourhoods and it has been successful in immunizing some of the hardest to reach families in Saskatoon. In 2012 -13, our Community Program Builders will continue to make personal connections and reminders via home visits and

phone calls with the hardest to reach families and

neighbourhoods.

2.0

Disparity ratio between top quintile and bottom quintile,

MMR coverage rates by fiscal year and quarter 2002 - 2011

with 12 Quarter Trailing Average

1.8

1.6

1.4

1.2

2011-12

1.25

1.0

Target = 1.16

Turning 2 year and Quarter

Healthiest people, healthiest communities, exceptional service.

0 10 20 30 40 50 60 70 80 90

100 M

ar

Ap

r

May

Jun

Jul

Au

g

Sep

Oct

No

v

Dec

Jan

Feb

Mar

Pe

rce

nt

Two-Year-Old MMR Immunization Coverage, SHR

Baseline

Target = 79% Current Month = 85.45%

Date Prepared: March 4, 2013

Report Contact: Dr. Cory Neudorf, Suzanne Mahaffey

Source:sims_extracts_frozen_stats.mdb

Refresh cycle: Monthly

Operational Def:Percent of active population registered in SIMS receiving 2 doses MMR by age 2

Baseline: January 2012 - March 2012

Health System Performance Monitoring

0.0

0.5

1.0

1.5

2.0

2.5

20

02

-01

20

02

-08

20

03

-03

20

03

-10

20

04

-05

20

04

-12

20

05

-07

20

06

-02

20

06

-09

20

07

-04

20

07

-11

20

08

-06

20

09

-01

20

09

-08

20

10

-03

20

10

-10

20

11

-05

20

11

-12

20

12

-07

Deprivation Ratio DA1/DA5 (quarterly moving average in green)

Health System Performance Monitoring

0

5

10

15

20

25

30

35

40

45

2010 2011 2012

Percentage of Core Children Behind (by BHE definition)

behind % Target 52 per. Mov. Avg. (behind %)

Health System Performance Monitoring

0

10

20

30

40

50

60

70

80

90

100

Two-Year-Old 2 dose MMR coverage in DA5 with 12 month trailing average

Health System Performance Monitoring

Best Practise

Health Care System (Poore M., as cited in Neuwelt P. et al.., JNZMA 2009; 122(1290))

Organizational culture with equal emphasis on disease prevention and treatment

Investment in activities that influence determinants of health

Operational commitment to reducing health inequities

Intersectoral collaboration

Genuine community participation

Support for sustainable community development

Data collection that is comprehensive and includes ethnicity, deprivation and outcomes

Workforce development to support a wider population health approach

3. Health Equity Surveillance

• Key Objective:

To enhance the current population health status surveillance, analysis reporting, and knowledge translation within Saskatoon Health Region.

(Draft) Core Health Status Indicators

Population: Demographics Population projections Dependency ratio Newcomer/immigrant/refugee Ethnicity & language Environment & Health: Social Environment Education Employment Housing Affordability Crime Food security Community Health Physical Environment Air Quality Water Quality Built Environment

Mortality, Morbidity and HRQOL: Deaths by all cause, IDC code, PYLL, life/health expectancy Hospitalization all cause, Long term disability Self-rated health Chronic Disease & Injuries: Chronic Diseases Injury Health Behaviour: Smoking Alcohol Substance Abuse Gambling Physical Activity Nutrition & Healthy Weight Mental Health

Family Health: Sexual Health Reproductive Health Child & Adolescent Health Infectious Diseases Reportable Disease Immunization

Population Health Equity Surveillance

Differential exposure

Differential vulnerability

Differential health status

Differential health outcome

Differential health consequenceSo

cio

eco

no

mic

co

nte

xt a

nd

po

siti

on

Food security / built environment

Obesity

Smoking

Diabetes

Dietary practices

Physical activity

Heart disease rates (e.g. myocardial infarctions)

Mortality rates from heart disease

Life expectancy

SHR

Pop’n and public health / health promotion

Primary care programs - HCEA

Tertiary care cardiac - HCEA

Po

licy

mo

nit

ori

ng

–P

olic

y an

d p

olit

ical

en

viro

nm

ent

Figure 1. Framework for understanding the causal pathway of health inequity in heart disease, as well as the entry points for health system intervention

Health system

Health Disparity Report

The Community View Collaboration

Relationships and Partnerships

• Strengthen relationships to enhance reporting:

– Primary Health,

– First Nations and Métis Health,

– Saskatoon Tribal Council, and

– Metis Nation-Saskatchewan

Challenges associated with SDOH Monitoring and Reporting

• Choosing deficit- vs. asset-based measures

• Time lag between data collection and reporting

• Gaps in reporting on certain segments of population

• Challenges in obtaining data

• Challenges in reporting data

• Technical complexity in some activities

• Privacy issues

• Attribution

Challenges Associated with SDOH Action

• Communicating complex data constructively and effectively

• Involving those affected by inequities

• Focusing on needs vs. service provision

• Letting go

• Credibility gap

• Working with many partners

• Government engagement

Conclusion

Elements of Success

• Dynamic and credible leadership

• Credible research/evidence

• Multidisciplinary approach to monitoring and surveillance

• Knowledge translation

• Effective relationships

• Early engagement of stakeholders

• Community culture & public support

• Multi-sector approach

• Timing

• Patience

Conclusion

• Extensive research and reporting on the SDOH has been used by Saskatoon Health Region’s Population and Public Health (PPH) to understand health disparities

• Much health equity action has come from disparities analysis and has involved community partners

• Remember: Evidence, Action, Equity!

Conclusion

Questions? Cristina Ugolini

Manager, Public Health Observatory Cristina.ugolini@saskatoonhealthregion.ca

Dr. Julie Kryzanowski

Deputy Medical Health Officer Julie.Kryzanowski@saskatoonhealthregion.ca