Presenters: Kristina Nazareth-Pidgeon, MD, Michelle White, MD, MPH, Victoria Parente, MD, Mikelle Key-Solle, MD, and Abby Nerlinger, MD, MPH
Equity is a pillar of quality health care yet despite overall improvement in clinical measures of quality care, there has been little improvement in health care disparities over the past two decades.1,2 Dr. Parente described that research in the health-equity domain has focused on documenting existing disparities with minimal activity in implementing targeted efforts to reduce inequity. She further explained that quality improvement (QI) efforts tend to incorporate interventions that benefit the entire population, which explains the global improvement in health care quality but has done little to reduce disparities. She clarified that QI interventions must be carefully designed to avoid worsening health care disparities and that efforts that disproportionately benefit disadvantaged groups are the only way to decrease inequity.
Next, Dr. Nerlinger spoke about designing scholarly work with a focus on equity. It is essential to develop QI interventions thoughtfully so as not to exacerbate inequity. Further, clinicians must collect relevant demographic information and actively assess for intervention-generated inequity. She discussed the importance of data-collection techniques that may exacerbate inequity (i.e., binary gender variables, etc.) and warned against inappropriate interpretation which can perpetuate bias. She also cautioned that when statistical significance is eliminated at the health-system level by adjusting for covariates, race, and ethnicity are social constructs, and disparity likely remains at the structural level and should be recognized. Speakers provided examples for equity databases to be used as resources and spoke to the benefits and potential pitfalls of using secondary databases.3-7
Finally, Dr. Nazareth-Pidgeon rounded out the session by discussing how to incorporate these concepts into writing abstracts and manuscripts. She highlighted the importance of word choice that supports diversity and conveys respect. She spoke to several practices that perpetuate bias in scholarly work such as the use of collective or umbrella terms and inconsistent use of capitalization. Best practices include the use of self-reported race and ethnicity, the use of person-first language, and reporting demographic categories in alphabetical order to decentralize white participants in research. She offered a few key points for each section of medical writing. Introductions should consider the historical context of the research and how race or ethnicity is intertwined with that medical condition. Methods should be detailed and include the source of data, how participants were classified, and the rationale for chosen descriptors. Data should be collected to mitigate disparities. Careful consideration should be placed on how to display results.8 Titles of figures and tables are common opportunities to reframe the message to convey the main finding. Discussions should evaluate how race and ethnicity play into the results and how these social constructs inform conclusions and next steps.
- QI interventions must be carefully designed to avoid worsening health care disparities. Reducing inequity requires targeted intervention to benefit disadvantaged groups disproportionately.
- Actively assessing for intervention-generated inequity requires the collection of relevant demographic information.
- Care must be taken when interpreting demographic data. Many health indicators of equity, such as race and ethnicity, are social constructs and important structural differences exist, even when not recognized at the health-system level.
- Language matters and should support diversity and convey respect and should not imply bias. The use of capitalization, ordering, and abbreviations are important considerations in medical writing.
- “For content published in medical journals, language and terminology must be accurate, clear, and precise, and must reflect fairness, equity, and consistency in use and reporting of race and ethnicity.”9
Dr. Potts is a pediatric hospitalist, associate chair of the department of pediatrics, medical director of hospital-based services, and the medical director of hospital medicine advanced practice providers at Akron Children’s Hospital in Akron, Ohio.
- Institute of Medicine Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington DC: National Academies Press; 2001. DOI: 10.17226/10027
- Agency for Healthcare Research and Quality. 2017 National Healthcare Quality and Disparities Report [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2018. https://www.ncbi.nlm.nih.gov/books/NBK579743/. Accessed October 12, 2023.
- Child Opportunity Index 2.0 (COI 2.0). diversitydatakids.org website. https://www.diversitydatakids.org/child-opportunity-index. Published 2020. Accessed October 12, 2023.
- Centers for Disease Control and Prevention. Social Vulnerability Index: Vaccinations. CDC website. https://data.cdc.gov/Vaccinations/Social-Vulnerability-Index/ypqf-r5qs. Updated June 17, 2021. Accessed October 12, 2023.
- Kind AJH, Buckingham WR. Making neighborhood-disadvantage metrics accessible — the Neighborhood Atlas. N Engl J Med. 2018;378(26):2456-8.
- United States Environmental Protection Agency. EJScreen: environmental justice screening and mapping tool. EPA website. https://www.epa.gov/ejscreen. Published September 3, 2014. Updated September 6, 2023. Accessed October 12, 2023.
- United States Census Bureau. American Community Survey (ACS). Census.gov website. https://www.census.gov/programs-surveys/acs. Accessed October 12, 2023.
- Schwabish J, Feng A. Do no harm guide: Applying equity awareness in data visualization. Urban Institute website. https://www.urban.org/research/publication/do-no-harm-guide-applying-equity-awareness-data-visualization. Published June 9, 2021. Accessed October 12, 2023.
- Flanagin A, Frey T, et al. Updated guidance on the reporting of race and ethnicity in medical and science journals. JAMA. 2021;326(7):621-7.