The IHI Innovation team is working to identify and test high-leverage approaches for hospitals and health systems to work with their communities to improve outcomes for the entire population and distribute those outcomes for all. Mara Laderman, MSPH, is a Senior Research Associate on IHI’s Innovation Team, and John Whittington, MD, is an IHI Senior Fellow and Lead Faculty for the Triple Aim at IHI.
Improving population health does not always mean better outcomes for all. In their seminal paper on population health, David Kindig and Greg Stoddart define population health as, “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” It’s the part after the comma we often forget; while we may improve outcomes for the entire population, the distribution of outcomes by demographic characteristics such as race/ethnicity, socioeconomic status, or gender, could remain unchanged or perhaps even worsen.
For example, infant mortality, a key health indicator, has generally declined in the US during the 20th century, but racial and ethnic disparities have endured and even widened in some places. In 2011, the infant mortality rate per 1,000 live births was 6.1 for the US population as a whole, 5.1 for non-Hispanic white infants, and 11.5 for non-Hispanic black infants. Looking at the population rate obscures the fact that black infants die at over twice the rate of their non-Hispanic white counterparts. Infant mortality is just one example. We could have talked about similarly appalling statistics showing inequities in cardiovascular disease, deaths from certain cancers, and countless others. Some argue that we have reached a plateau that can only be overcome by addressing these persistent inequities. We agree, and it is time to act. So, how will we address this?
The predominant narrative of health production (and thus the way in which we often allocate resources) in the US is that providing health care will lead to better health. If we applied this model to health equity, access would be the answer. However, evidence suggests that this is simply not the case. When we talk about addressing the multiple determinants of health – health behaviors, social and economic factors, the physical environment, and health care – it seems as if we want to tackle all known problems in a society. This can be overwhelming and outside the realm of what hospitals and health systems can undertake – it is unclear where to start.
Fortunately, health care organizations can – and should – directly influence these determinants of health, such as by working with their own employees, increasing their involvement in adjacent neighborhoods, and investing capital in their local community. These are some ideas; there are many more out there, and we’d love to hear from you about how you are addressing health equity in your community. In our next 90-day innovation cycle, IHI will be working to identify and test high-leverage approaches for hospitals and health systems to work with their communities to improve outcomes for the entire population and the distribution of those outcomes for all. Will you join us?