Increasing Equity While Improving the Quality of Care: JACC Focus Seminar 9/9.

This review summarizes racial and ethnic disparities in the quality of cardiovascular care-a challenge given the fragmented nature of the health care delivery system and measurement. Health equity for all racial and ethnic groups will not be achieved without a substantially different approach to quality measurement and improvement. The authors adapt a tool frequently used in quality improvement work-the driver diagram-to chart likely areas for diagnosing root causes of disparities and developing and testing interventions. This approach prioritizes equity in quality improvement. The authors demonstrate how this approach can be used to create interventions that reduce systemic racism within the institutions and professions that deliver health care; attends more aggressively to social factors related to race and ethnicity that affect health outcomes; and examines how hospitals, health systems, and insurers can generate effective partnerships with the communities they serve to achieve equitable cardiovascular outcomes.

Racial Disparities in Patient Characteristics and Survival After Acute Myocardial Infarction.

Importance: Black patients experience worse outcomes than white patients following acute myocardial infarction (AMI). Objective: To examine the degree to which nonrace characteristics explain observed survival differences between white patients and black patients following AMI. Design, Setting, and Participants: This cohort study used the extensive socioeconomic and clinical characteristics from patients recovering from an AMI that were prospectively collected at 31 hospitals across the contiguous United States between 2003 and 2008 for the Prospective Registry Evaluating Myocardial Infarction: Events and Recovery registry and the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status registry. Survival was assessed using data from the National Death Index. Data were analyzed from December 2016 to July 2018. Main Outcomes and Measures: Patient characteristics were categorized into 8 domains, and the degree to which each domain discriminated self-identified black patients from white patients was determined by calculating propensity scores associated with black race for each domain as well as cumulatively across all domains. The final propensity score was associated with 1- and 5-year mortality rates. Results: Among 6402 patients (mean [SD] age, 60 [13] years; 2127 [33.2%] female; 1648 [25.7%] black individuals), the 5-year mortality rate following AMI was 28.9% (476 of 1648) for black patients and 18.0% (856 of 4754) for white patients (hazard ratio, 1.72; 95% CI, 1.54-1.92; P < .001). Most categories of patient characteristics differed substantially between black patients and white patients. The cumulative propensity score discriminated race, with a C statistic of 0.89, and the propensity scores were associated with 1- and 5-year mortality rates (hazard ratio for the 75th percentile of the propensity score vs 25th percentile, 1.72; 95% CI, 1.43-2.08; P < .001). Patients in the lowest propensity score quintile associated with being a black individual (regardless of whether they were of white or black race) had a 5-year mortality rate of 15.5%, while those in the highest quintile had a 5-year mortality rate of 31.0% (P < .001). After adjusting for the propensity associated with being a black patient, there was no significant mortality rate difference by race (adjusted hazard ratio, 1.09; 95% CI, 0.93-1.26; P = .37) and no statistical interaction between race and propensity score (P = .42). Conclusions and Relevance: Characteristics of black patients and white patients differed significantly at the time of admission for AMI. Those characteristics were associated with an approximately 3-fold difference in 5-year mortality rate following AMI and mediated most of the observed mortality rate difference between the races.

Interventions to Improve Management of Chronic Conditions Among Racial and Ethnic Minorities.

Digital and mhealth interventions can be effective in improving health outcomes among minority patients with diabetes, congestive heart failure, and chronic respiratory diseases. A number of electronic and digital approaches to individual and population-level interventions involving telephones, internet and web-based resources, and mobile platforms have been deployed to improve chronic disease outcomes. This paper summarizes the evidence supporting the efficacy of various behavioral and digital interventions targeting intermediate outcomes and hospitalizations with particular emphasis on studies examining the effects of these interventions on racial and ethnic minority population.

Population health-based approaches to utilizing digital technology: a strategy for equity.

Health care disparities and high chronic disease rates burden many communities and disproportionally impact racial/ethnic populations in the United States. These disparities vary geographically, increase health care expenses, and result in shortened lifespans. Digital technologies may be one tool for addressing health disparities and improving population health by increasing individuals' access to health information-especially as most low-income U.S. residents gain access to smartphones. The Aetna Foundation partners with organizations to use digital technologies, including mobile applications, data collection, and related platforms, for learning and sharing. Projects range from the broad-childhood education, lifestyle modification, health IT training, and nutrition education, to the specific-local healthy foods, stroke rehabilitation, and collection of city-level data. We describe our approaches to grantmaking and discuss lessons learned and their implications. When combined with sound policy strategies, emerging, scalable, digital technologies will likely become powerful allies for improving health and reducing health disparities.

Why Your ZIP Code Matters More Than Your Genetic Code: Promoting Healthy Outcomes from Mother to Child.

Health equity has long been the dominant theme in the work of the Aetna Foundation. Recent data have focused on disparities through another lens, particularly the correlation between where people live (i.e., ZIP code) and their quality-and length-of life. In various cities across America, average life expectancies in certain communities are 20-30 years shorter than those mere miles away. In general, health disparities are founded on a complex interplay of racial, economic, educational, and other social factors. For example, breastfeeding rates in the United States differ significantly depending upon the race and income of the mother. Government policy makers are acutely aware of these disparities, but recent health system reforms have focused predominately on the processes used to administer, finance, and deliver care. What is needed is an approach that considers the health and wellness of all people in a geographic area, beyond established patients, and that measures more than clinical factors-such as genetics, environmental health, social circumstances, and individual behaviors. Solutions also must extend beyond the traditional healthcare arena. In particular, novel technological innovations show promise to bridge gaps between our healthcare capabilities and the needs of underserved populations. Digital tools are poised to revolutionize measurement, diagnostics, treatment, and global aspect of our healthcare system. The Aetna Foundation views technology as a core strategy in reducing health inequities through an approach that addresses both clinical and social factors in populations to dismantle the persistent paradigm of ZIP code as personal health destiny.

Quality of Care for Chronic Conditions Among Disabled Medicaid Enrollees: An Evaluation of a 1915 (b) and (c) Waiver Program.

IMPORTANCE: Examining the impact of Medicaid-managed care home-based and community-based service (HCBS) alternatives to institutional care is critical given the recent rapid expansion of these models nationally. OBJECTIVE: We analyzed the effects of STAR+PLUS, a Texas Medicaid-managed care HCBS waiver program for adults with disabilities on the quality of chronic disease care. DESIGN, SETTING, AND PARTICIPANTS: We compared quality before and after a mandatory transition of disabled Medicaid enrollees older than 21 years from fee-for-service (FFS) or primary care case management (PCCM) to STAR+PLUS in 28 counties, relative to enrollees in counties remaining in the FFS or PCCM models. MEASURES AND ANALYSIS: Person-level claims and encounter data for 2006-2010 were used to compute adherence to 6 quality measures. With county as the independent sampling unit, we employed a longitudinal linear mixed-model analysis accounting for administrative clustering and geographic and individual factors. RESULTS: Although quality was similar among programs at baseline, STAR+PLUS enrollees experienced large and sustained improvements in use of ß-blockers after discharge for heart attack (49% vs. 81% adherence posttransition; P<0.01) and appropriate use of systemic corticosteroids and bronchodilators after a chronic obstructive pulmonary disease event (39% vs. 68% adherence posttransition; P<0.0001) compared with FFS/PCCM enrollees. No statistically significant effects were identified for quality measures for asthma, diabetes, or cardiovascular disease. CONCLUSION: In 1 large Medicaid-managed care HCBS program, the quality of chronic disease care linked to acute events improved while that provided during routine encounters appeared unaffected.