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Importance: At least 10 million people in the United States have an intellectual and/or developmental disability (IDD). People with IDD experience considerably higher rates of poor overall health, chronic conditions including diabetes, mental health challenges, maternal mortality, and preventable deaths. This Special Communication proposes national goals based on a community-led consensus model that advances priority health outcomes for people with IDD and their caregivers/partners and identifies critical policy opportunities and challenges in achieving these goals. A community-led consensus agenda offers a foundation for focusing research, improving data collection and quality measurement, enhancing coverage and payment for services, and investing in a prepared clinical workforce and infrastructure in ways that align with lived experiences and perspectives of community members. Observations: People with IDD prioritize holistic health outcomes and tailored supports and services, driven by personalized health goals, which shift over their life course. Caregivers/partners need support for their own well-being, and easy access to resources to optimize how they support loved ones with IDD. Development of an adequately prepared clinical workforce to serve people with IDD requires national and regional policy changes that incentivize and structure training and continuing education. Ensuring effective and high-value coverage, payment, and clinical decisions requires investments in new data repositories and data-sharing infrastructure, shared learning across public and private payers, and development of new technologies and tools to empower people with IDD to actively participate in their own health care. Conclusions and Relevance: Consensus health priorities identified in this project and centered on IDD community members' perspectives are generalizable to many other patient populations. Public and private payers and regulators setting standards for health information technology have an opportunity to promote clinical data collection that focuses on individuals' needs, quality measurement that emphasizes person-centered goals rather than primarily clinical guidelines, and direct involvement of community members in the design of payment policies. Clinical education leaders, accrediting bodies, and investors/entrepreneurs have an opportunity to innovate a better prepared health care workforce and shared data infrastructure to support value-based care programs.
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Discapacidades del Desarrollo , Política de Salud , Discapacidad Intelectual , Humanos , Discapacidad Intelectual/terapia , Discapacidades del Desarrollo/terapia , Estados UnidosRESUMEN
BACKGROUND: The lack of consensus on equity measurement and its incorporation into quality-assessment programs at the hospital and system levels may be a barrier to addressing disparities in surgical care. This study aimed to identify population-level and within-hospital differences in the quality of surgical care provision. STUDY DESIGN: The analysis included 657 NSQIP participating hospitals with more than 4 million patients (2014 to 2018). Multilevel random slope, random intercept modeling was used to examine for population-level and in-hospital disparities. Disparities in surgical care by Area Deprivation Index (ADI), race, and ethnicity were analyzed for 5 measures: all-case inpatient mortality, all-case urgent readmission, all-case postoperative surgical site infection, colectomy mortality, and spine surgery complications. RESULTS: Population-level disparities were identified across all measures by ADI, 2 measures for Black race (all-case readmissions and spine surgery complications), and none for Hispanic ethnicity. Disparities remained significant in the adjusted models. Before risk adjustment, in all measures examined, within-hospital disparities were detected in: 25.8% to 99.8% of hospitals for ADI, 0% to 6.1% of hospitals for Black race, and 0% to 0.8% of hospitals for Hispanic ethnicity. After risk adjustment, in all measures examined, less than 1.1% of hospitals demonstrated disparities by ADI, race, or ethnicity. CONCLUSIONS: After risk adjustment, very few hospitals demonstrated significant disparities in care. Disparities were more frequently detected by ADI than by race and ethnicity. The lack of substantial in-hospital disparities may be due to the use of postoperative metrics, small sample sizes, the risk adjustment methodology, and healthcare segregation. Further work should examine surgical access and healthcare segregation.
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Disparidades en Atención de Salud , Humanos , Disparidades en Atención de Salud/estadística & datos numéricos , Disparidades en Atención de Salud/etnología , Masculino , Femenino , Estados Unidos , Persona de Mediana Edad , Readmisión del Paciente/estadística & datos numéricos , Anciano , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Hospitales/estadística & datos numéricos , Mortalidad Hospitalaria , Adulto , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etnologíaRESUMEN
During the COVID-19 vaccination rollout from March 2021- December 2022, the Centers for Disease Control and Prevention funded 110 primary and 1051 subrecipient partners at the national, state, local, and community-based level to improve COVID-19 vaccination access, confidence, demand, delivery, and equity in the United States. The partners implemented evidence-based strategies among racial and ethnic minority populations, rural populations, older adults, people with disabilities, people with chronic illness, people experiencing homelessness, and other groups disproportionately impacted by COVID-19. CDC also expanded existing partnerships with healthcare professional societies and other core public health partners, as well as developed innovative partnerships with organizations new to vaccination, including museums and libraries. Partners brought COVID-19 vaccine education into farm fields, local fairs, churches, community centers, barber and beauty shops, and, when possible, partnered with local healthcare providers to administer COVID-19 vaccines. Inclusive, hyper-localized outreach through partnerships with community-based organizations, faith-based organizations, vaccination providers, and local health departments was critical to increasing COVID-19 vaccine access and building a broad network of trusted messengers that promoted vaccine confidence. Data from monthly and quarterly REDCap reports and monthly partner calls showed that through these partnerships, more than 295,000 community-level spokespersons were trained as trusted messengers and more than 2.1 million COVID-19 vaccinations were administered at new or existing vaccination sites. More than 535,035 healthcare personnel were reached through outreach strategies. Quality improvement interventions were implemented in healthcare systems, long-term care settings, and community health centers resulting in changes to the clinical workflow to incorporate COVID-19 vaccine assessments, recommendations, and administration or referrals into routine office visits. Funded partners' activities improved COVID-19 vaccine access and addressed community concerns among racial and ethnic minority groups, as well as among people with barriers to vaccination due to chronic illness or disability, older age, lower income, or other factors.
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As the use of artificial intelligence has spread rapidly throughout the US health care system, concerns have been raised about racial and ethnic biases built into the algorithms that often guide clinical decision making. Race-based medicine, which relies on algorithms that use race as a proxy for biological differences, has led to treatment patterns that are inappropriate, unjust, and harmful to minoritized racial and ethnic groups. These patterns have contributed to persistent disparities in health and health care. To reduce these disparities, we recommend a race-aware approach to clinical decision support that considers social and environmental factors such as structural racism and social determinants of health. Recent policy changes in medical specialty societies and innovations in algorithm development represent progress on the path to dismantling race-based medicine. Success will require continued commitment and sustained efforts among stakeholders in the health care, research, and technology sectors. Increasing the diversity of clinical trial populations, broadening the focus of precision medicine, improving education about the complex factors shaping health outcomes, and developing new guidelines and policies to enable culturally responsive care are important next steps.
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Equidad en Salud , Racismo , Humanos , Inteligencia Artificial , Atención a la Salud , Etnicidad , Toma de Decisiones ClínicasRESUMEN
BACKGROUND: Disparity in surgical care impedes the delivery of uniformly high-quality care. Metrics that quantify disparity in care can help identify areas for needed intervention. A literature-based Disparity-Sensitive Score (DSS) system for surgical care was adapted by the Metrics for Equitable Access and Care in Surgery (MEASUR) group. The alignment between the MEASUR DSS and Delphi ratings of an expert advisory panel (EAP) regarding the disparity sensitivity of surgical quality metrics was assessed. STUDY DESIGN: Using DSS criteria MEASUR co-investigators scored 534 surgical metrics which were subsequently rated by the EAP. All scores were converted to a 9-point scale. Agreement between the new measurement technique (ie DSS) and an established subjective technique (ie importance and validity ratings) were assessed using the Bland-Altman method, adjusting for the linear relationship between the paired difference and the paired average. The limit of agreement (LOA) was set at 1.96 SD (95%). RESULTS: The percentage of DSS scores inside the LOA was 96.8% (LOA, 0.02 points) for the importance rating and 94.6% (LOA, 1.5 points) for the validity rating. In comparison, 94.4% of the 2 subjective EAP ratings were inside the LOA (0.7 points). CONCLUSIONS: Applying the MEASUR DSS criteria using available literature allowed for identification of disparity-sensitive surgical metrics. The results suggest that this literature-based method of selecting quality metrics may be comparable to more complex consensus-based Delphi methods. In fields with robust literature, literature-based composite scores may be used to select quality metrics rather than assembling consensus panels.
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Benchmarking , Calidad de la Atención de Salud , Humanos , Técnica Delphi , ConsensoRESUMEN
BACKGROUND: In the US, disparities in surgical care impede the delivery of uniformly high-quality care to all patients. There is a lack of disparity-sensitive measures related to surgical care. The American College of Surgeons Metrics for Equitable Access and Care in Surgery group, through research and expert consensus, aimed to identify disparity-sensitive measures in surgical care. STUDY DESIGN: An environmental scan, systematic literature review, and subspecialty society surveys were conducted to identify potential disparity-sensitive surgical measures. A modified Delphi process was conducted where panelists rated measures on both importance and validity. In addition, a novel literature-based disparity-sensitive scoring process was used. RESULTS: We identified 841 potential disparity-sensitive surgical measures. From these, our Delphi and literature-based approaches yielded a consensus list of 125 candidate disparity-sensitive measures. These measures were rated as both valid and important and were supported by the existing literature. CONCLUSION: There are profound disparities in surgical care within the US healthcare system. A multidisciplinary Delphi panel identified 125 potential disparity-sensitive surgical measures that could be used to track health disparities, evaluate the impact of focused interventions, and reduce healthcare inequity.
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Calidad de la Atención de Salud , Humanos , Consenso , Técnica DelphiRESUMEN
Women continue to be underrepresented in medicine, especially in senior leadership positions, and they experience challenges related to gender bias and sexual harassment. Women who are members of multiple groups that experience marginalization, including, for example, women who are American Indian, Alaskan native, indigenous, Black, or Hispanic, face a compounded challenge. In this article, we explore how institutions and professional organizations in medicine can use metrics to better understand the structural disparities that create and promote gender inequity in the work environment and how to employ these metrics to track progress in narrowing these gaps. Examples in health care (clinical medicine, scientific organizations, scientific publishing), business, and law are used to illustrate how impactful metrics can promote accountability when coupled with transparent reporting.
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Benchmarking/tendencias , Equidad de Género , Médicos Mujeres/tendencias , Sexismo/tendencias , Lugar de Trabajo , Benchmarking/estadística & datos numéricos , Femenino , Humanos , Médicos Mujeres/estadística & datos numéricos , Sexismo/estadística & datos numéricos , Lugar de Trabajo/estadística & datos numéricosAsunto(s)
Atención a la Salud/tendencias , Reforma de la Atención de Salud/tendencias , Equidad en Salud , Política de Salud/tendencias , Indicadores de Calidad de la Atención de Salud , Accesibilidad a los Servicios de Salud , Necesidades y Demandas de Servicios de Salud , Humanos , Sociedades Médicas , Estados UnidosRESUMEN
Efforts to implement the use of patient decision aids to stimulate shared decision making are gaining prominence. Patient decision aids have been designed to help patients participate in making specific choices among health care options. Because these tools clearly influence decisions, poor quality, inaccurate or unbalanced presentations or misleading tools are a risk to patients. As payer interest in these tools increases, so does the risk that patients are harmed by the use of tools that are described as patient decision aids yet fail to meet established standards. To address this problem, the National Quality Forum (NQF) in the USA convened a multi-stakeholder expert panel in 2016 to propose national standards for a patient decision aid certification process. In 2017, NQF established an Action Team to foster shared decision making, and to call for a national certification process as one recommendation among others to stimulate improvement. A persistent barrier to the setup of a national patient decision aids certification process is the lack of a sustainable financial model to support the work.
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Certificación/normas , Técnicas de Apoyo para la Decisión , Participación del Paciente , Toma de Decisiones , Humanos , Estados UnidosRESUMEN
Current approaches to health care quality have failed to reduce health care disparities. Despite dramatic increases in the use of quality measurement and associated payment policies, there has been no notable implementation of measurement strategies to reduce health disparities. The National Quality Forum developed a road map to demonstrate how measurement and associated policies can contribute to eliminating disparities and promote health equity. Specifically, the road map presents a four-part strategy whose components are identifying and prioritizing areas to reduce health disparities, implementing evidence-based interventions to reduce disparities, investing in the development and use of health equity performance measures, and incentivizing the reduction of health disparities and achievement of health equity. To demonstrate how the road map can be applied, we present an example of how measurement and value-based payment can be used to reduce racial disparities in hypertension among African Americans.