What can the health system do to improvehealth equity?Cristina UgoliniJulie KryzanowskiThis Session is sponsored by:
Health Care Equity inSaskatoon Health RegionWhat can the health care system do toimprove health equity?2013 Health Care Qu...
Objectives• Define “health equity”• Connect “health care quality” to “healthequity”• Understand what the health care syste...
The Social Determinants of HealthPHAC. 2008. The Chief Public Health Officers Report on the State of PublicHealth in Canad...
The Social Determinants of HealthPHAC. 2008. The Chief Public Health Officers Report on the State of PublicHealth in Canad...
Life Expectancy in Saskatoon HealthRegion, 1997-20061997 1998 1999 2000 2001 2002 2003 2004 2005 2006SHR 78.8 79.0 79.3 79...
The Health Gradient01HealthAdvantage
The Health Gradient01HealthAdvantage
The Health Gradient01HealthAdvantage
Health Care Equity01HealthCareHealth Need
Equality vs. EquityInequity EquityInequalityEquality
Equality vs. EquityMostcommonInequity EquityInequalityEquality
Equality vs. EquityUndesirableMostcommonInequity EquityInequalityEquality
Equality vs. EquityUndesirable UnlikelyMostcommonInequity EquityInequalityEquality
Equality vs. EquityUndesirable UnlikelyMostcommonAchievableInequity EquityInequalityEquality
Health Care EquityAvailableAcceptableAccessibleAppropriate
The Plan for SaskatchewanHealth CareThe 4 “Betters” and How Equity RunsThrough Them
The 4 “Betters”
The 3 Levels of Action3. Advocate and partner with othersectors to improve social determinants ofhealth2. Integrate health...
Applications withinPopulation and Public HealthHealthEquityPublic HealthServiceDeliverySupportingHealth EquityAssessmentsH...
1. Public Health Service Delivery2002 2003 2004 2005 2006 2007Affluent 82.05 79.08 80.48 79.61 80.07 84.81Core 48.40 47.08...
Health Care Equity Audit CycleProblemEvidenceInterventionEvaluation
Health Care Equity Audit CycleLowimmunizationrates in coreneighbourhoodsBest-practiseliterature review& parent surveyPhone...
2007 2008 2009 2010 2011measles - Core 51.9 63.8 57.7 60.1 67.4measles - Non-Core 73.4 75.0 76.4 76.0 74.7measles - Rural ...
Other Areas for Health Care Equity Audit• Diabetes• Home Care• Mental Health• Surgical Procedures• Renal ServicesProblemEv...
Best PractiseHealthCareDelivery(SHR PublicHealthObservatory,2012)Culturally safe service provisionLanguage diversityInclus...
2. Health System PerformanceMonitoringIndexScoreDASHBOARD - FACT SHEETIMMUNIZATION DISPARITY RATIOMUMPS MEASLES RUBELLA (M...
0102030405060708090100MarAprMayJunJulAugSepOctNovDecJanFebMarPercentTwo-Year-Old MMR Immunization Coverage, SHRBaselineTar...
0.00.51.01.52.02.52002-012002-082003-032003-102004-052004-122005-072006-022006-092007-042007-112008-062009-012009-082010-0...
0510152025303540452010 2011 2012Percentage of Core Children Behind (by BHE definition)behind % Target 52 per. Mov. Avg. (b...
0102030405060708090100Two-Year-Old 2 dose MMR coverage in DA5with 12 month trailing averageHealth System PerformanceMonito...
Best PractiseHealthCareSystem(Poore M.,as cited inNeuwelt P. etal.., JNZMA2009;122(1290))Organizational culture with equal...
3. Health Equity Surveillance• Key Objective:To enhance the current population health statussurveillance, analysis reporti...
(Draft) Core Health Status IndicatorsPopulation:DemographicsPopulation projectionsDependency ratioNewcomer/immigrant/refug...
Population Health Equity SurveillanceDifferentialexposureDifferentialvulnerabilityDifferentialhealth statusDifferentialhea...
Health Disparity ReportThe Community View Collaboration
Relationships and Partnerships• Strengthen relationships to enhancereporting:– Primary Health,– First Nations and Métis He...
Challenges associated with SDOHMonitoring and Reporting• Choosing deficit- vs. asset-based measures• Time lag between data...
Challenges Associated with SDOH Action• Communicating complex data constructively andeffectively• Involving those affected...
Elements of Success• Dynamic and credible leadership• Credible research/evidence• Multidisciplinary approach to monitoring...
• Extensive research and reporting on the SDOH hasbeen used by Saskatoon Health Region’sPopulation and Public Health (PPH)...
Questions?Cristina UgoliniManager, Public Health ObservatoryCristina.ugolini@saskatoonhealthregion.caDr. Julie Kryzanowski...
What Can the Health System Do to Improve Health Equity?
What Can the Health System Do to Improve Health Equity?
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What Can the Health System Do to Improve Health Equity?

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Improvement Story session at the 2013 Saskatchewan Health Care Quality Summit. For more information about the summit, visit www.qualitysummit.ca. Follow @QualitySummit on Twitter.

It has been known for some time that there are wide variations in health status between different population groups and wide variations in appropriate use of high quality health services. Health care providers should aim to achieve equal service for equal need as a unique contribution to addressing this problem. For example, service utilization variations might be due to lack of service availability, accessibility, cultural appropriateness, or due to patient and family situations (i.e., affordability, emotional stress, language barriers). The challenge is to identify service utilization variations, understand reasons for them and take action to improve the situation. Solutions will depend on the active involvement of professionals, managers, patients and their families.
Better Health

Cristina Ugolini; Julie Kryzanowski

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What Can the Health System Do to Improve Health Equity?

  1. 1. What can the health system do to improvehealth equity?Cristina UgoliniJulie KryzanowskiThis Session is sponsored by:
  2. 2. Health Care Equity inSaskatoon Health RegionWhat can the health care system do toimprove health equity?2013 Health Care Quality Summit
  3. 3. Objectives• Define “health equity”• Connect “health care quality” to “healthequity”• Understand what the health care system cando to promote health equity
  4. 4. The Social Determinants of HealthPHAC. 2008. The Chief Public Health Officers Report on the State of PublicHealth in Canada, 2008. Ottawa, Canada.Impacts of Poverty on Marginalized Groups
  5. 5. The Social Determinants of HealthPHAC. 2008. The Chief Public Health Officers Report on the State of PublicHealth in Canada, 2008. Ottawa, Canada.Impacts of Poverty on Marginalized Groups
  6. 6. Life Expectancy in Saskatoon HealthRegion, 1997-20061997 1998 1999 2000 2001 2002 2003 2004 2005 2006SHR 78.8 79.0 79.3 79.3 79.4 79.8 79.7 79.8 79.9 79.9Core Nhd 74.7 75.4 76.4 75.0 75.0 75.0 74.1 74.4 74.3 73.47080Lifeexpectancyatbirthinyears
  7. 7. The Health Gradient01HealthAdvantage
  8. 8. The Health Gradient01HealthAdvantage
  9. 9. The Health Gradient01HealthAdvantage
  10. 10. Health Care Equity01HealthCareHealth Need
  11. 11. Equality vs. EquityInequity EquityInequalityEquality
  12. 12. Equality vs. EquityMostcommonInequity EquityInequalityEquality
  13. 13. Equality vs. EquityUndesirableMostcommonInequity EquityInequalityEquality
  14. 14. Equality vs. EquityUndesirable UnlikelyMostcommonInequity EquityInequalityEquality
  15. 15. Equality vs. EquityUndesirable UnlikelyMostcommonAchievableInequity EquityInequalityEquality
  16. 16. Health Care EquityAvailableAcceptableAccessibleAppropriate
  17. 17. The Plan for SaskatchewanHealth CareThe 4 “Betters” and How Equity RunsThrough Them
  18. 18. The 4 “Betters”
  19. 19. The 3 Levels of Action3. Advocate and partner with othersectors to improve social determinants ofhealth2. Integrate health equity into all parts ofthe health care system1. Deliver equitable health care services
  20. 20. Applications withinPopulation and Public HealthHealthEquityPublic HealthServiceDeliverySupportingHealth EquityAssessmentsHealthSystemPerformanceMonitoringDevelopingTools forHealth EquityResearch &EvaluationPopulationHealth EquitySurveillanceCommunityEngagement& PartnershipAdvocacy &PolicyDevelopment
  21. 21. 1. Public Health Service Delivery2002 2003 2004 2005 2006 2007Affluent 82.05 79.08 80.48 79.61 80.07 84.81Core 48.40 47.08 47.22 45.02 47.52 49.82Middle_Income 69.14 68.19 66.68 68.28 70.79 71.27Rural_or_PO_Box 71.75 74.79 75.32 75.90 74.23 77.480102030405060708090100%ofClientswithMMRx2Two-year-old immunization coverage for measles, mumps andrubella (MMR) by neighbourhood group, SHR, 2002-2007
  22. 22. Health Care Equity Audit CycleProblemEvidenceInterventionEvaluation
  23. 23. Health Care Equity Audit CycleLowimmunizationrates in coreneighbourhoodsBest-practiseliterature review& parent surveyPhone-basedreminder systemIncreasedimmunizationrates
  24. 24. 2007 2008 2009 2010 2011measles - Core 51.9 63.8 57.7 60.1 67.4measles - Non-Core 73.4 75.0 76.4 76.0 74.7measles - Rural 74.5 81.9 77.4 73.5 77.60102030405060708090%ofClientswithMMRx2Two-year-old immunization coverage for measles, mumps andrubella (MMR) by neighbourhood group, SHR, 2007-2011Impact of Health Equity Audit Cycle
  25. 25. Other Areas for Health Care Equity Audit• Diabetes• Home Care• Mental Health• Surgical Procedures• Renal ServicesProblemEvidenceInterventionEvaluationOther Areas forHealth Care Equity Audits
  26. 26. Best PractiseHealthCareDelivery(SHR PublicHealthObservatory,2012)Culturally safe service provisionLanguage diversityInclusion of skill building in behavioural interventionsSustainable, long-term programmingIntegration and inclusion of social supports in programsService provision in home, school, workplace and communityIntegration of services in housing initiativesMultidisciplinary case management for high-risk populationsIntegration of community health workers in health program deliveryStandardized provider care systems
  27. 27. 2. Health System PerformanceMonitoringIndexScoreDASHBOARD - FACT SHEETIMMUNIZATION DISPARITY RATIOMUMPS MEASLES RUBELLA (MMR)What is being measured?Equity is defined as providing care on basis of need notinfluenced by personal characteristics and circumstance.Immunization disparity can be expressed as a ratiocomparing the top socio-economic quintile to the bottomquintile. In other words, this compares the wealthiest fifth ofour population to the poorest fifth.The ratio is calculated by dividing the two year-old MMRcoverage rate in the top socio-economic quintile by thecoverage rate in the bottom quintile. A ratio equal to oneindicates equity while measures greater than oneindicate inequity.Socio-economic quintiles are based on the Total DeprivationIndex. This includes income, employment, education andsocial support indicators. It is calculated at theDissemination Area level geography for Saskatoon city only,and cannot be utilized at present for rural SHR.Immunization rates are calculated for populations in the topand bottom quintiles - 20% of the population.Why is it important?SHR has a mandate to reduce disparities based on theFederal Healthy Living Strategy. Health disparities make itdifficult for individuals and groups to participate fully insociety. Health disparities are also huge cost drivers whichare estimated to account for 20% of all healthcareexpenditures.How are we doing?The ideal disparity ratio is equal to 1.0, which indicatesequality between the upper and lower quintiles or socio-economic groups of population (i.e. no gap). In SHR thedisparity 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. InJanuary 2012, we initiated a targeted pilot campaign toaddress immunization rates in the lowest socioeconomicneighbourhoods and it has been successful in immunizingsome of the hardest to reach families in Saskatoon. In 2012-13, our Community Program Builders will continue to makepersonal connections and reminders via home visits andphone calls with the hardest to reach families andneighbourhoods.2.0Disparity ratio between top quintile and bottom quintile,MMR coverage rates by fiscal year and quarter 2002 - 2011with 12 Quarter Trailing Average1.81.61.41.22011-121.251.0Target = 1.16Turning 2 year and QuarterHealthiest people, healthiest communities, exceptional service.
  28. 28. 0102030405060708090100MarAprMayJunJulAugSepOctNovDecJanFebMarPercentTwo-Year-Old MMR Immunization Coverage, SHRBaselineTarget = 79%Current Month = 85.45%Date Prepared: March 4, 2013Report Contact: Dr. Cory Neudorf, Suzanne MahaffeySource:sims_extracts_frozen_stats.mdbRefresh cycle: MonthlyOperational Def:Percent of active population registered in SIMS receiving 2 doses MMR by age 2Baseline: January 2012 - March 2012Health System PerformanceMonitoring
  29. 29. 0.00.51.01.52.02.52002-012002-082003-032003-102004-052004-122005-072006-022006-092007-042007-112008-062009-012009-082010-032010-102011-052011-122012-07Deprivation Ratio DA1/DA5(quarterly moving average in green)Health System PerformanceMonitoring
  30. 30. 0510152025303540452010 2011 2012Percentage of Core Children Behind (by BHE definition)behind % Target 52 per. Mov. Avg. (behind %)Health System PerformanceMonitoring
  31. 31. 0102030405060708090100Two-Year-Old 2 dose MMR coverage in DA5with 12 month trailing averageHealth System PerformanceMonitoring
  32. 32. Best PractiseHealthCareSystem(Poore M.,as cited inNeuwelt P. etal.., JNZMA2009;122(1290))Organizational culture with equal emphasis on disease prevention and treatmentInvestment in activities that influence determinants of healthOperational commitment to reducing health inequitiesIntersectoral collaborationGenuine community participationSupport for sustainable community developmentData collection that is comprehensive and includes ethnicity, deprivation andoutcomesWorkforce development to support a wider population health approach
  33. 33. 3. Health Equity Surveillance• Key Objective:To enhance the current population health statussurveillance, analysis reporting, and knowledgetranslation within Saskatoon Health Region.
  34. 34. (Draft) Core Health Status IndicatorsPopulation:DemographicsPopulation projectionsDependency ratioNewcomer/immigrant/refugeeEthnicity & languageEnvironment & Health:Social EnvironmentEducationEmploymentHousingAffordabilityCrimeFood securityCommunity HealthPhysical EnvironmentAir QualityWater QualityBuilt EnvironmentMortality, Morbidity and HRQOL:Deaths by all cause, IDC code,PYLL, life/health expectancyHospitalization all cause,Long term disabilitySelf-rated healthChronic Disease & Injuries:Chronic DiseasesInjuryHealth Behaviour:SmokingAlcoholSubstance AbuseGamblingPhysical ActivityNutrition & Healthy WeightMental HealthFamily Health:Sexual HealthReproductive HealthChild & Adolescent HealthInfectious DiseasesReportable DiseaseImmunization
  35. 35. Population Health Equity SurveillanceDifferentialexposureDifferentialvulnerabilityDifferentialhealth statusDifferentialhealthoutcomeDifferentialhealthconsequenceSocioeconomiccontextandpositionFood security / builtenvironmentObesitySmokingDiabetesDietarypracticesPhysicalactivityHeart disease rates (e.g.myocardial infarctions)Mortality rates fromheart diseaseLife expectancySHRPop’n and publichealth / healthpromotionPrimary careprograms - HCEATertiary carecardiac - HCEAPolicymonitoring–PolicyandpoliticalenvironmentFigure 1. Framework for understanding the causal pathway of health inequity in heart disease, as well as the entrypoints for health system interventionHealth system
  36. 36. Health Disparity ReportThe Community View Collaboration
  37. 37. Relationships and Partnerships• Strengthen relationships to enhancereporting:– Primary Health,– First Nations and Métis Health,– Saskatoon Tribal Council, and– Metis Nation-Saskatchewan
  38. 38. Challenges associated with SDOHMonitoring 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
  39. 39. Challenges Associated with SDOH Action• Communicating complex data constructively andeffectively• Involving those affected by inequities• Focusing on needs vs. service provision• Letting go• Credibility gap• Working with many partners• Government engagementConclusion
  40. 40. 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• PatienceConclusion
  41. 41. • Extensive research and reporting on the SDOH hasbeen used by Saskatoon Health Region’sPopulation and Public Health (PPH) to understandhealth disparities• Much health equity action has come fromdisparities analysis and has involved communitypartners• Remember: Evidence, Action, Equity!Conclusion
  42. 42. Questions?Cristina UgoliniManager, Public Health ObservatoryCristina.ugolini@saskatoonhealthregion.caDr. Julie KryzanowskiDeputy Medical Health OfficerJulie.Kryzanowski@saskatoonhealthregion.ca

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