Measuring Equity in Readmission as a Distinct Assessment of Hospital Performance.

Importance: Equity is an essential domain of health care quality. The Centers for Medicare & Medicaid Services (CMS) developed 2 Disparity Methods that together assess equity in clinical outcomes. Objectives: To define a measure of equitable readmissions; identify hospitals with equitable readmissions by insurance (dual eligible vs non-dual eligible) or patient race (Black vs White); and compare hospitals with and without equitable readmissions by hospital characteristics and performance on accountability measures (quality, cost, and value). Design, Setting, and Participants: Cross-sectional study of US hospitals eligible for the CMS Hospital-Wide Readmission measure using Medicare data from July 2018 through June 2019. Main Outcomes and Measures: We created a definition of equitable readmissions using CMS Disparity Methods, which evaluate hospitals on 2 methods: outcomes for populations at risk for disparities (across-hospital method); and disparities in care within hospitals' patient populations (within-a-single-hospital method). Exposures: Hospital patient demographics; hospital characteristics; and 3 measures of hospital performance-quality, cost, and value (quality relative to cost). Results: Of 4638 hospitals, 74% served a sufficient number of dual-eligible patients, and 42% served a sufficient number of Black patients to apply CMS Disparity Methods by insurance and race. Of eligible hospitals, 17% had equitable readmission rates by insurance and 30% by race. Hospitals with equitable readmissions by insurance or race cared for a lower percentage of Black patients (insurance, 1.9% [IQR, 0.2%-8.8%] vs 3.3% [IQR, 0.7%-10.8%], P < .01; race, 7.6% [IQR, 3.2%-16.6%] vs 9.3% [IQR, 4.0%-19.0%], P = .01), and differed from nonequitable hospitals in multiple domains (teaching status, geography, size; P < .01). In examining equity by insurance, hospitals with low costs were more likely to have equitable readmissions (odds ratio, 1.57 [95% CI, 1.38-1.77), and there was no relationship between quality and value, and equity. In examining equity by race, hospitals with high overall quality were more likely to have equitable readmissions (odds ratio, 1.14 [95% CI, 1.03-1.26]), and there was no relationship between cost and value, and equity. Conclusion and Relevance: A minority of hospitals achieved equitable readmissions. Notably, hospitals with equitable readmissions were characteristically different from those without. For example, hospitals with equitable readmissions served fewer Black patients, reinforcing the role of structural racism in hospital-level inequities. Implementation of an equitable readmission measure must consider unequal distribution of at-risk patients among hospitals.

Addressing Racial Capitalism's Impact on Black Essential Workers During the COVID-19 Pandemic: Policy Recommendations.

Black Americans are more likely to be essential workers due to racial capitalism. Because of the COVID-19 pandemic, essential workers are less able to adhere to social distancing and stay-at-home guidelines due to the nature of their work, because they are more likely to occupy crowded households, and are more likely to possess pre-existing health conditions. To assist Black essential workers in preventing infection or reducing the intensity of symptoms if contracted, vaccination against the virus is essential. Unfortunately, Black essential workers face considerable barriers to accessing vaccinations and are hesitant to receive the vaccine due to widespread misinformation and justified historical mistrust of the American medical system. The purpose of this work is to (1) describe the disproportionate impact of COVID-19 on Black essential workers due to racial capitalism, (2) outline the socioeconomic and racial barriers related to vaccination within this population, and (3) to suggest policy-related approaches to facilitate vaccination such as access to on-site vaccination opportunities, the funding of community outreach efforts, and the mandating of increased employee benefits.

SAFER model: Strategic allocation of fundamental epidemic resources.

BACKGROUND: To describe the Strategic Allocation of Fundamental Epidemic Resources (SAFER) model as a method to inform equitable community distribution of critical resources and testing infrastructure. METHODS: The SAFER model incorporates a four-quadrant design to categorize a given community based on two scales: testing rate and positivity rate. Three models for stratifying testing rates and positivity rates were applied to census tracts in Milwaukee County, Wisconsin: using median values (MVs), cluster-based classification and goal-oriented values (GVs). RESULTS: Each of the three approaches had its strengths. MV stratification divided the categories most evenly across geography, aiding in assessing resource distribution in a fixed resource and testing capacity environment. The cluster-based stratification resulted in a less broad distribution but likely provides a truer distribution of communities. The GVs grouping displayed the least variation across communities, yet best highlighted our areas of need. CONCLUSIONS: The SAFER model allowed the distribution of census tracts into categories to aid in informing resource and testing allocation. The MV stratification was found to be of most utility in our community for near real time resource allocation based on even distribution of census tracts. The GVs approach was found to better demonstrate areas of need.

Incorporating health inequality impact into economic evaluation in low- and middle-income countries: a systematic review.

INTRODUCTION: As well as improving population health, promoting equity in health is one of the key goals of health policy in low- and middle-income countries (LMICs). However, it is less clear how equity is defined, or how it may impact on resource allocation decisions. We investigated the degree to which health inequalities have been considered in economic evaluation of health interventions in LMICs, and what demographic or socioeconomic characteristics were used to define equity relevant subgroups. AREAS COVERED: We reviewed publications since 2010 from three main databases following the search strategy developed by including the key terms 'health inequalities/health disparities/health equity,' 'economics' and 'low- and middle-income countries' in the title or abstract. Twelve studies were identified, mainly focusing on interventions for the more vulnerable groups such as children and women. EXPERT OPINION: Some attempts have been made to assess interventions' impact on health inequality and there is increasing interest in evaluating it, although research in this area is lacking. Population subgroups highlighted in the included studies were those differing in socioeconomic status. Most studies reported the results across subgroups to illustrate inequality impact, and the newly developed methods, extended cost-effectiveness analysis and distributional cost-effectiveness analysis, have also been applied.

Risky business: COVAX and the financialization of global vaccine equity.

BACKGROUND: During the first year and a half of the COVID-19 pandemic, COVAX has been the world's most prominent effort to ensure equitable access to SARS-CoV-2 vaccines. Launched as part of the Access to COVID-19 Tools Accelerator (Act-A) in June 2020, COVAX suggested to serve as a vaccine buyers' and distribution club for countries around the world. It also aimed to support the pharmaceutical industry in speeding up and broadening vaccine development. While COVAX has recently come under critique for failing to bring about global vaccine equity, influential politicians and public health advocates insist that future iterations of it will improve pandemic preparedness. So far COVAX's role in the ongoing financialization of global health, i.e. in the rise of financial concepts, motives, practices and institutions has not been analyzed. METHODS: This article describes and critically assesses COVAX's financial logics, i.e. the concepts, arguments and financing flows on which COVAX relies. It is based on a review of over 109 COVAX related reports, ten in-depth interviews with global health experts working either in or with COVAX, as well as participant observation in 18 webinars and online meetings concerned with global pandemic financing, between September 2020 and August 2021. RESULTS: The article finds that COVAX expands the scale and scope of financial instruments in global health governance, and that this is done by conflating different understandings of risk. Specifically, COVAX conflates public health risk and corporate financial risk, leading it to privilege concerns of pharmaceutical companies over those of most participating countries - especially low and lower-middle income countries (LICs and LMICs). COVAX thus drives the financialization of global health and ends up constituting a risk itself - that of perpetuating the downsides of financialization (e.g. heightened inequality, secrecy, complexity in governance, an ineffective and slow use of aid), whilst insufficiently realising its potential benefits (pandemic risk reduction, increased public access to emergency funding, indirect price control over essential goods and services). CONCLUSION: Future iterations of vaccine buyers' and distribution clubs as well as public vaccine development efforts should work towards reducing all aspects of public health risk rather than privileging its corporate financial aspects. This will include reassessing the interplay of aid and corporate subsidies in global health.

Improving health equity and ending the HIV epidemic in the USA: a distributional cost-effectiveness analysis in six cities.

BACKGROUND: In the USA, Black and Hispanic or Latinx individuals continue to be disproportionately affected by HIV. Applying a distributional cost-effectiveness framework, we estimated the cost-effectiveness and epidemiological impact of two combination implementation approaches to identify the approach that best meets the dual objectives of improving population health and reducing racial or ethnic health disparities. METHODS: We adapted a dynamic, compartmental HIV transmission model to characterise HIV micro-epidemics in six US cities: Atlanta, Baltimore, Los Angeles, Miami, New York, and Seattle. We considered combinations of 16 evidence-based interventions to diagnose, treat, and prevent HIV transmission according to previously documented levels of scale-up. We then identified optimal combination strategies for each city, with the distribution of each intervention implemented according to existing service levels (proportional services approach) and the racial or ethnic distribution of new diagnoses (between Black, Hispanic or Latinx, and White or other ethnicity individuals; equity approach). We estimated total costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios of strategies implemented from 2020 to 2030 (health-care perspective; 20-year time horizon; 3% annual discount rate). We estimated three measures of health inequality (between-group variance, index of disparity, Theil index), incidence rate ratios, and rate differences for the selected strategies under each approach. FINDINGS: In all cities, optimal combination strategies under the equity approach generated more QALYs than those with proportional services, ranging from a 3·1% increase (95% credible interval [CrI] 1·4-5·3) in New York to more than double (101·9% [75·4-134·6]) in Atlanta. Compared with proportional services, the equity approach delivered lower costs over 20 years in all cities except Los Angeles; cost reductions ranged from $22·9 million (95% CrI 5·3-55·7 million) in Seattle to $579·8 million (255·4-940·5 million) in Atlanta. The equity approach also reduced incidence disparities and health inequality measures in all cities except Los Angeles. INTERPRETATION: Equity-focused HIV combination implementation strategies that reduce disparities for Black and Hispanic or Latinx individuals can significantly improve population health, reduce costs, and drive progress towards Ending the HIV Epidemic goals in the USA. FUNDING: National Institute on Drug Abuse.