Equity: The Missing Piece of the Healthcare Evaluation Puzzle

Welcome to the second entry in Verto’s three-part blog series on the importance of equity in improving health system performance. The series began last week with an exploration of the history of health system evaluation and the progression of the Triple Aim to the Quadruple Aim, and ultimately, the Quintuple Aim.   

This installment dives deeper into the impetus to add equity considerations into the Quintuple Aim and how doing so can help health systems realize improved clinical outcomes.

The COVID-19 pandemic forced healthcare systems across the world under the microscope. Experts reported increased spending, growing concerns regarding provider burnout, and tragic outcomes for seniors living in congregate living facilities. COVID-19 undoubtedly impeded the ability of healthcare systems to pursue the goals of the Quadruple Aim. 

The pandemic highlighted pre-existing issues and shortcomings in health systems across the world. Of the problems brought to light, perhaps the longest-standing issue was the inherent inequity in modern healthcare delivery.  

In response, a group of experts set out to tackle the challenge of health equity in a January 2022 publication in JAMA. The article suggests another expansion to the ‘aims’ of healthcare improvement: this time, from the Quadruple Aim to the Quintuple Aim. The authors argued that the COVID-19 pandemic highlighted a global lack of health equity, to which higher rates of infection, morbidity, and mortality can be attributed. Health equity needed to be added to the discussion of healthcare improvement frameworks if real progress was to be made.

Lost in the margins

Why did health equity take so long to become part of the healthcare improvement framework? Well, the pandemic exacerbated health inequities and put such a critical lens on governments, policy, and healthcare systems that the problem became inescapable. 

Adequate policies were not in place, and equity was not a priority throughout the pandemic. In Canada, substantial disparities in COVID-related deaths were found among those in lower-income neighbourhoods, racialized groups, and newer immigrants. In the United States, a study from Kansas found African Americans accounted for nearly one-third of COVID-19 deaths, despite only making up just over 4.5% of the sample population. The data is irrefutable: marginalized groups simply suffered more during the pandemic. 

The Triple Aim framework, as mentioned in our previous blog post, was widely adopted, but equity was not explicitly included in any of the aims. The authors suggest that while equity was an important factor, “[these] decisions lie in the realms of policy, [and equity] is not technically inherent in the Triple Aim.” As the pandemic has shown us, the ramifications of excluding equity from both the Triple and Quadruple Aim have become increasingly apparent.

You can’t manage what you can’t measure

There are many challenges in pursuing health equity, but the most significant problems lie upstream. Governments and policy makers struggled to identify equity-seeking populations during the pandemic. For example, researchers found there was little data available on patients’ ethnicities, socioeconomic status, and other critical demographic information. These omissions were undoubtedly a factor in the poorer outcomes experienced by these groups. We need to address the social determinants of health at the population level if we want to make any real progress addressing health equity.   

Can technology move the needle?

Verto’s solutions offer one opportunity to advance equity outcomes in healthcare. Verto is proudly partnering with Youth Wellness Hubs Ontario to help their population discover relevant services by leveraging digital solutions. The program will help improve mental health access for youths in over 20 hubs across Ontario, many of which are in traditionally underserved communities.However, technology must be used thoughtfully so as to not widen the digital divide. We should aim to deliver flexible and adaptable technologies for individuals with varying levels of access, technological literacy, and accessibility needs wherever possible.  

There’s no “silver bullet” solution to tackle all circumstances, but we need to start somewhere. Verto has created an open-source accessibility widget available for use by the broader development community on github. The Astral Accessibility widget is designed to enable web developers help users of varied needs by adding a screen reader, contrast control, and various text options to any web page.

There’s still lots of work to do, but acknowledging that equity has been missing from healthcare evaluation frameworks and data collection is a good starting point. Adding equity, previously the missing piece, as the fifth dimension of the Quintuple Aim gives health systems the best framework yet to deliver 5-star care.

Stay tuned for the final entry in our three-part series where we will hear from Dr. Michael Anderson, Chief Medical Officer at Verto, on his thoughts on equity’s role in front-line care delivery.

September 20, 2023
Eric Phillipson
Share this Post