The Path to Health Equity Through Multidisciplinary Collaboration

Why did this call for articles focused on health disparities result in a record number of theme submissions to the Journal of Patient-Centered Research and Reviews (JPCRR)?

Why are health systems, academic health centers, community organizations and health professional organizations launching multipronged efforts to promote health equity?

Why do health disparities matter, and what can be done to address them?

Over the last decade, health professionals and their organizations have paid greater attention to health disparities in response to a tsunami of evidence revealing that the U.S. health care system is spending more money on health care costs per capita than any other nation but achieving worse health outcomes.¹ It is difficult to ignore that U.S. population health outcomes compare poorly with those measured in other high-income countries around the world.¹

At the most fundamental level, the life expectancy for people living in the most affluent neighborhoods may be decades longer than for people living in low-income communities.² People who are disadvantaged and/or living in poverty unduly suffer from increased burdens of illness in relation to those who are economically, educationally or socially well off. From pregnancy to end-of-life, researchers have amassed myriad evidence related to differences in the quality of health care received and health outcomes experienced between the rich and poor, and among people who are white and of color.^3,4

Why the discrepancies? First, let’s review a pair of definitions:

Health disparities, or absolute differences in health-related quality of life, morbidity and mortality rates between groups of people, reflect stark contrasts both within and between countries.⁵

Health inequities, or differences in health that are avoidable, unfair and unjust, result in millions of people who suffer unnecessarily and die prematurely.⁵

Most health disparities are, in fact, the result of a complex web of social and economic inequities. Access to affordable, high-quality health care services for all is one way to reduce health inequities and disparities. Yet health outcomes are more profoundly influenced by social, economic and environmental conditions, which in turn influence health behaviors, than by actual health care services provided.^3,4

Looking Beyond the Health System

Health professionals do not have the skills, time or resources to address the “social determinants” of health and illness on their own. Promoting health equity requires collaboration among key stakeholders in health and social systems; developing strategic partnerships; and engaging across institutional boundaries to identify local needs, promote best practices, and establish monitoring and evaluation to ensure these efforts are mutually beneficial and sustainable over time.⁶

Promoting health equity requires development of new competencies such as: understanding social determinants; identifying upstream approaches to prevention; providing outreach to underserved, disadvantaged people and communities;⁷ cultivating health and social policy advocacy;⁸ promoting multidisciplinary teamwork; integrating clinical medicine and public health; recognizing racism and its effects;⁹ and promoting diversity in medical education, clinical and public health services. This work also will require resources, incentives and reimbursement mechanisms to promote prevention of, in addition to treatment for, adverse health outcomes.

Pathways for health professionals to promote such changes exist,¹⁰ yet few have been well-prepared to cultivate community collaborations or advocate for change.¹¹ Fortunately, many outstanding efforts are in progress to address these challenges.

Recognizing the complexity of this task, many groups like the American Association of Medical Colleges,^12,13 Beyond Flexner,¹⁴ the Social Medicine Consortium¹⁵ and the World Health Organization¹⁶ have launched efforts that promote changes in medical education and practice to encompass these goals. The Institute of Medicine has provided a comprehensive framework to educate health professionals in how to address the social determinants of health.⁸ These groups have acknowledged that health equity cannot be adequately addressed through a few isolated efforts, but is best addressed in an integrated fashion throughout the curriculum and health system using a health equity framework or lens. The University of Wisconsin School of Medicine and Public Health has joined with others to develop a health equity lens and infuse content throughout its curriculum to introduce medical students to these topics.¹⁷ Targeted programs have been created to recruit and train students to address rural and urban health inequities.^18,19 Early outcomes demonstrate these efforts can be successful.²⁰

Addressing Inequities in Many Forms

The importance and timeliness of health disparities research galvanized our interest in serving as guest editors for this special issue of JPCRR, which includes a variety of contemporary efforts to promote health equity. In their study of measuring patient-centered outcomes, Solberg and colleagues discovered that many outcomes deemed important by patients who had experienced abdominal and/or back pain serious enough to require computed tomography or magnetic resonance imaging could not be identified through the patient’s medical records.²¹ They also concluded that documenting patients’ opinions could influence broader care practices. Despite mountains of electronic health records, researchers still need to ask patients directly about the most important outcomes that matter to them.

Hammarlund and colleagues explored knowledge, attitudes and behaviors regarding health care disparities among resident physicians in Louisiana.²² They found that residents’ patient interactions changed after relatively brief educational interventions. As a result, residents wanted more information about how to access community resources to help their patients combat health disparities.

In a collaboration of several health systems, Dillon and colleagues explored the influence of patient engagement in research that has been encouraged by the federally funded Patient-Centered Outcomes Research Institute by conducting a workshop to define and measure critical outcomes of research engagement.²³ This productive pilot points to the need for additional studies to engage patients in the design and conduct of research, and to carefully assess patient satisfaction with and influence on ultimate research outcomes.

A sobering study by LeCounte and Swain revealed that life expectancy at birth varies by as much as 12 years among zip codes in Milwaukee County, Wisconsin.²⁴ Similar to the findings of Ansell and colleagues in Chicago,² differences in life expectancy were strongly correlated with social and economic conditions. These findings point to the importance of advocacy for social and policy changes to promote health equity.

Finally, given the serious epidemic of opioid overuse and overdose deaths, Cardarelli and colleagues tested a model to improve care for patients suffering from chronic pain in rural Appalachia.²⁵ They found promising improvements in the quality of care after a practice facilitator trained clinical teams in community and academic practices to implement chronic pain tools and workflows. This multisite study confirmed that clinical educational interventions can be effective in improving processes of care and interdisciplinary management of patients with chronic pain.

Recently, a bright young medical student asked during her first clinical rotation, “Why are patients treated differently depending on their insurance status or the color of their skin? Shouldn’t all patients have the same chances to live healthy lives and receive the same quality of health care?”

Since health inequities are avoidable, they can be addressed! We invite you to join us and the authors of these articles to become part of the solution.