The Quality Improvement Conundrum: Do Efforts to Improve Care Decrease Disparities or Increase Inequity?

The Quality Improvement Conundrum: Do Efforts to Improve Care Decrease Disparities or Increase Inequity?

Article Highlights:

  • The existence of health care disparities has been increasingly documented over the past 2 decades, and future work must aim to understand and reduce inequities.
  • The inherent intent of quality improvement (QI) is to deliver better care to everyone, and QI should benefit the entire population by promoting high-quality and equitable care.
  • Patient navigation systems have proven successful in simultaneously decreasing disparities and improving overall quality of care, but they can also impose unrealistic expenses on already-struggling health care organizations.
  • In order to be successful, QI and disparity reduction goals should be linked.

Dr. Sandra L. Wong
Dr. Meredith J. Sorensen
By Meredith J. Sorensen, MD, and Sandra L. Wong, MD, MS

The existence of health care disparities has been increasingly documented over the past 2 decades. The 2001 Institute of Medicine (IOM) report Crossing the Quality Chasm included equity as one of the six pillars of high-quality health care,1 citing evidence from a growing body of literature demonstrating a lower quality of care based on race, ethnicity, gender, socioeconomic status, and geography. Although disparate outcomes can ultimately be attributed to multiple factors—including the preferences of individual patients, the decisions made by individual providers, and the influence of overarching health care systems—future work must aim to understand and, importantly, reduce inequities.2

Without a doubt, improving quality for all patients is a priority. The idea that quality improvement (QI) initiatives would result in diminished health care disparities has enormous face validity. After all, the goal of QI is to implement data-driven actions in order to close the gap between the care that is actually delivered and the ideal standard of care.3,4 Identifying these gaps is the first step, but addressing them in a scientifically rigorous fashion is a much more complex process. QI methods and tools vary, but the basic framework involves understanding the current state of the system, identifying an area of improvement and setting a goal, designing and implementing a strategy toward achieving that goal, and, finally, assessing progress and adjusting the strategy as needed.3,4 The urge to act should be balanced by evidence of effectiveness, as well as other important factors such as change readiness, resource allocation, and alignment of institutional priorities.3-5 Interestingly, many organizations have traditionally considered QI and disparity reduction to be related but exclusive efforts.6  

The inherent intent of QI is to deliver better care to everyone, and QI should benefit the entire population by promoting high-quality and equitable care. Fundamentally, QI is a multidisciplinary pursuit. In addition to the necessary collaboration across specialties and clinical disciplines, it requires the joint efforts of clinicians, members of the care team, researchers, hospital leaders, and patients. In order to coordinate such multifaceted efforts, some health care systems have established teams dedicated specifically to QI.5,7 An ongoing and continuous commitment from all key stakeholders is critical for trial and learning, which includes the process of audit-feedback, modification, and re-assessment to assure the sustained success of initiatives.

However, there is the potential for unintended consequences, and rather than reducing disparities, QI efforts may actually exacerbate inequities. Hospitals and health systems that already provide high-quality care have the resources to make it even better, and, conversely, hospitals that need to improve their quality may not be able to invest efforts in QI. A focus on QI could inadvertently marginalize disadvantaged populations, or a well-intentioned focus on inclusivity could result in compromised quality. The IOM’s 2010 Future Directions for the National Healthcare Quality and Disparities Reports consider equity to be a “cross-cutting dimension,” emphasizing the importance of integrating efforts: high quality does not exist without equity.8

QI and Disparity Reduction

Although some contributing factors to health care disparities, such as socioeconomic status, cultural norms, and provider bias, are not easily modifiable, QI initiatives offer a means to control certain elements of health care delivery in order to effect positive change. A six-step roadmap for reducing racial and ethnic disparities in care proposes making equity “an integral component of quality-improvement efforts.”6 However, a simple focus on equity may not, in fact, decrease health care disparities. A QI intervention that benefits all patient populations at the same rate will merely propagate a constant level of inequity. Only an intervention that disproportionately benefits a disadvantaged group will lead to a real reduction in disparity.4

One successful approach to achieving this involves targeted, or intensified, efforts toward vulnerable populations under the umbrella of larger-scale QI projects. Patient navigation systems, which specifically provide at-risk patients with individualized outreach during a system-wide intervention, have proven successful in simultaneously decreasing disparities and improving overall quality of care.9 Although effective, this requires significant resources, from identifying patients who might benefit to providing the services to facilitate their participation.

An even larger scale disparity-reduction strategy, involving seven primary care quality indicators ranging from glucose control to flu vaccination, demonstrated effectiveness and sustainability when 55 specific primary care clinics serving almost 400,000 patients from low socioeconomic and minority populations in Israel were targeted.10 When compared to 126 “nonintervention” clinics serving more than 2 million patients, the target clinics showed much more substantial improvements in all of the quality indicators. However, the applicability of these findings to the U.S. health care system is unclear, given that this work was carried out in a closed payer-provider system that administers care to half of Israel’s population. The United States’ fragmented system makes both designing and implementing interventions on a similar scale impractical.

Unintended Consequences: The Burden of QI

System-wide QI interventions, such as patient navigation systems, may be effective, but they can also impose unrealistic expenses on already-struggling health care organizations. The success of such programs is at least partially attributable to sophisticated health information technology infrastructure (including the ability to capture and analyze data); research backing from academic institution; and availability of manpower to provide translation services, counseling, and transportation. In some cases, the resource burden of QI could result in paradoxically increased disparities; moreover, the complicated relationship between effectiveness and cost-effectiveness of QI interventions is not well defined.11

Lessons Learned

Pay-for-performance programs are based on the principle of compensating physicians or hospitals based on how well their patient outcomes meet certain quality metrics. This is a seemingly simple formula of using financial incentives to motivate efforts in quality, and in some settings, pay for performance has resulted in measurable improvement in these providers.12 Many providers who care for vulnerable populations tend to perform at lower baseline levels.13 Studies have suggested that such programs actually had minimal effect on the reduction of inequity, and/or actually harmed disadvantaged patients by exaggerating disparities in care resulting from the fact that patients from minority or low–socioeconomic status groups tend to receive care at hospitals that are often already under resourced and at risk for further financial penalties. Some pay-for-performance programs have inadvertently encouraged providers to concentrate on their more privileged patients because of the inherent financial pressures.

Hospital Value-Based Purchasing, another attempt to financially to incentivize QI by rewarding hospitals based on their performance on certain outcome measures, has also proven to have unintended consequences. Analysis of the program’s first year (2012) demonstrated that hospitals caring for more socioeconomically disadvantaged patients fared significantly worse.14 Over time, the lack of additional resources may cause the quality of care at these centers to suffer further. Although pay-for-performance and Value-Based Purchasing are different than directed QI initiatives, there are lessons to be learned from these experiences. Notably, the ability to participate in QI programs, such as ASCO’s Quality Oncology Practice Initiative (QOPI®) can be costly, since the ability to collect data may be untenable for hospitals struggling to stay open.13

Future Directions

In order to be successful, QI and disparity reduction cannot be parallel yet separate goals. Rather, they should be inextricably linked. As we strive to narrow quality gaps, we must ensure that efforts to decrease inequities do not hinder overall improvements in care. Collaboration between academic institutions and the front lines of community providers will be essential to achieving these goals.

About the Authors: Dr. Sorensen is an assistant professor of Surgery at Dartmouth-Hitchcock Medical Center and The Geisel School of Medicine at Dartmouth. Dr. Wong is professor and chair of Surgery at Dartmouth-Hitchcock Medical Center and The Geisel School of Medicine at Dartmouth.