Improvement Story session at the 2013 Saskatchewan Health Care Quality Summit. For more information about the summit, visit www.qualitysummit.ca. Follow @QualitySummit on Twitter. It has been known for some time that there are wide variations in health status between different population groups and wide variations in appropriate use of high quality health services. Health care providers should aim to achieve equal service for equal need as a unique contribution to addressing this problem. For example, service utilization variations might be due to lack of service availability, accessibility, cultural appropriateness, or due to patient and family situations (i.e., affordability, emotional stress, language barriers). The challenge is to identify service utilization variations, understand reasons for them and take action to improve the situation. Solutions will depend on the active involvement of professionals, managers, patients and their families. Better Health Cristina Ugolini; Julie Kryzanowski

1. What can the health system do to improve
health equity?
Cristina Ugolini
Julie Kryzanowski
This Session is sponsored by:

2. Health Care Equity in
Saskatoon Health Region
What can the health care system do to
improve health equity?
2013 Health Care Quality Summit

3. Objectives
• Define “health equity”
• Connect “health care quality” to “health
equity”
• Understand what the health care system can
do to promote health equity

4. The Social Determinants of Health
PHAC. 2008. The Chief Public Health Officer's Report on the State of Public
Health in Canada, 2008. Ottawa, Canada.
Impacts of Poverty on Marginalized Groups

5. The Social Determinants of Health
PHAC. 2008. The Chief Public Health Officer's Report on the State of Public
Health in Canada, 2008. Ottawa, Canada.
Impacts of Poverty on Marginalized Groups

6. Life Expectancy in Saskatoon Health
Region, 1997-2006
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
SHR 78.8 79.0 79.3 79.3 79.4 79.8 79.7 79.8 79.9 79.9
Core Nhd 74.7 75.4 76.4 75.0 75.0 75.0 74.1 74.4 74.3 73.4
70
80
Lifeexpectancyatbirthinyears

7. The Health Gradient
0
1
Health
Advantage

8. The Health Gradient
0
1
Health
Advantage

9. The Health Gradient
0
1
Health
Advantage

10. Health Care Equity
0
1
Health
Care
Health Need

11. Equality vs. Equity
Inequity Equity
Inequality
Equality

12. Equality vs. Equity
Most
common
Inequity Equity
Inequality
Equality

13. Equality vs. Equity
Undesirable
Most
common
Inequity Equity
Inequality
Equality

14. Equality vs. Equity
Undesirable Unlikely
Most
common
Inequity Equity
Inequality
Equality

15. Equality vs. Equity
Undesirable Unlikely
Most
common
Achievable
Inequity Equity
Inequality
Equality

17. Health Care Equity
Available
AcceptableAccessible
Appropriate

18. The Plan for Saskatchewan
Health Care
The 4 “Betters” and How Equity Runs
Through Them

19. The 4 “Betters”

21. The 3 Levels of Action
3. Advocate and partner with other
sectors to improve social determinants of
health
2. Integrate health equity into all parts of
the health care system
1. Deliver equitable health care services

22. Applications within
Population and Public Health
Health
Equity
Public Health
Service
Delivery
Supporting
Health Equity
Assessments
Health
System
Performance
Monitoring
Developing
Tools for
Health Equity
Research &
Evaluation
Population
Health Equity
Surveillance
Community
Engagement
& Partnership
Advocacy &
Policy
Development

23. 1. Public Health Service Delivery
2002 2003 2004 2005 2006 2007
Affluent 82.05 79.08 80.48 79.61 80.07 84.81
Core 48.40 47.08 47.22 45.02 47.52 49.82
Middle_Income 69.14 68.19 66.68 68.28 70.79 71.27
Rural_or_PO_Box 71.75 74.79 75.32 75.90 74.23 77.48
0
10
20
30
40
50
60
70
80
90
100
%ofClientswithMMRx2
Two-year-old immunization coverage for measles, mumps and
rubella (MMR) by neighbourhood group, SHR, 2002-2007

24. Health Care Equity Audit Cycle
Problem
Evidence
Intervention
Evaluation

25. Health Care Equity Audit Cycle
Low
immunization
rates in core
neighbourhoods
Best-practise
literature review
& parent survey
Phone-based
reminder system
Increased
immunization
rates

26. 2007 2008 2009 2010 2011
measles - Core 51.9 63.8 57.7 60.1 67.4
measles - Non-Core 73.4 75.0 76.4 76.0 74.7
measles - Rural 74.5 81.9 77.4 73.5 77.6
0
10
20
30
40
50
60
70
80
90
%ofClientswithMMRx2
Two-year-old immunization coverage for measles, mumps and
rubella (MMR) by neighbourhood group, SHR, 2007-2011
Impact of Health Equity Audit Cycle

27. Other Areas for Health Care Equity Audit
• Diabetes
• Home Care
• Mental Health
• Surgical Procedures
• Renal Services
Problem
Evidence
Intervention
Evaluation
Other Areas for
Health Care Equity Audits

28. Best Practise
Health
Care
Delivery
(SHR Public
Health
Observatory,
2012)
Culturally safe service provision
Language diversity
Inclusion of skill building in behavioural interventions
Sustainable, long-term programming
Integration and inclusion of social supports in programs
Service provision in home, school, workplace and community
Integration of services in housing initiatives
Multidisciplinary case management for high-risk populations
Integration of community health workers in health program delivery
Standardized provider care systems

29. 2. Health System Performance
Monitoring
IndexScore
DASHBOARD - FACT SHEET
IMMUNIZATION DISPARITY RATIO
MUMPS MEASLES RUBELLA (MMR)
What is being measured?
Equity is defined as providing care on basis of need not
influenced by personal characteristics and circumstance.
Immunization disparity can be expressed as a ratio
comparing the top socio-economic quintile to the bottom
quintile. In other words, this compares the wealthiest fifth of
our population to the poorest fifth.
The ratio is calculated by dividing the two year-old MMR
coverage rate in the top socio-economic quintile by the
coverage rate in the bottom quintile. A ratio equal to one
indicates equity while measures greater than one
indicate inequity.
Socio-economic quintiles are based on the Total Deprivation
Index. This includes income, employment, education and
social support indicators. It is calculated at the
Dissemination Area level geography for Saskatoon city only,
and cannot be utilized at present for rural SHR.
Immunization rates are calculated for populations in the top
and bottom quintiles - 20% of the population.
Why is it important?
SHR has a mandate to reduce disparities based on the
Federal Healthy Living Strategy. Health disparities make it
difficult for individuals and groups to participate fully in
society. Health disparities are also huge cost drivers which
are estimated to account for 20% of all healthcare
expenditures.
How are we doing?
The ideal disparity ratio is equal to 1.0, which indicates
equality between the upper and lower quintiles or socio-
economic groups of population (i.e. no gap). In SHR the
disparity ratio has been decreasing most rapidly since 2007.
This signals greater equity in immunization rates.
Our 2011-12 target was 1.16, and our Q4 ratio was 1.25. In
January 2012, we initiated a targeted pilot campaign to
address immunization rates in the lowest socioeconomic
neighbourhoods and it has been successful in immunizing
some of the hardest to reach families in Saskatoon. In 2012
-13, our Community Program Builders will continue to make
personal connections and reminders via home visits and
phone calls with the hardest to reach families and
neighbourhoods.
2.0
Disparity ratio between top quintile and bottom quintile,
MMR coverage rates by fiscal year and quarter 2002 - 2011
with 12 Quarter Trailing Average
1.8
1.6
1.4
1.2
2011-12
1.25
1.0
Target = 1.16
Turning 2 year and Quarter
Healthiest people, healthiest communities, exceptional service.

30. 0
10
20
30
40
50
60
70
80
90
100
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Percent
Two-Year-Old MMR Immunization Coverage, SHR
Baseline
Target = 79%
Current Month = 85.45%
Date Prepared: March 4, 2013
Report Contact: Dr. Cory Neudorf, Suzanne Mahaffey
Source:sims_extracts_frozen_stats.mdb
Refresh cycle: Monthly
Operational Def:Percent of active population registered in SIMS receiving 2 doses MMR by age 2
Baseline: January 2012 - March 2012
Health System Performance
Monitoring

31. 0.0
0.5
1.0
1.5
2.0
2.5
2002-01
2002-08
2003-03
2003-10
2004-05
2004-12
2005-07
2006-02
2006-09
2007-04
2007-11
2008-06
2009-01
2009-08
2010-03
2010-10
2011-05
2011-12
2012-07
Deprivation Ratio DA1/DA5
(quarterly moving average in green)
Health System Performance
Monitoring

32. 0
5
10
15
20
25
30
35
40
45
2010 2011 2012
Percentage of Core Children Behind (by BHE definition)
behind % Target 52 per. Mov. Avg. (behind %)
Health System Performance
Monitoring

33. 0
10
20
30
40
50
60
70
80
90
100
Two-Year-Old 2 dose MMR coverage in DA5
with 12 month trailing average
Health System Performance
Monitoring

34. Best Practise
Health
Care
System
(Poore M.,
as cited in
Neuwelt P. et
al.., JNZMA
2009;
122(1290))
Organizational culture with equal emphasis on disease prevention and treatment
Investment in activities that influence determinants of health
Operational commitment to reducing health inequities
Intersectoral collaboration
Genuine community participation
Support for sustainable community development
Data collection that is comprehensive and includes ethnicity, deprivation and
outcomes
Workforce development to support a wider population health approach

35. 3. Health Equity Surveillance
• Key Objective:
To enhance the current population health status
surveillance, analysis reporting, and knowledge
translation within Saskatoon Health Region.

36. (Draft) Core Health Status Indicators
Population:
Demographics
Population projections
Dependency ratio
Newcomer/immigrant/refugee
Ethnicity & language
Environment & Health:
Social Environment
Education
Employment
Housing
Affordability
Crime
Food security
Community Health
Physical Environment
Air Quality
Water Quality
Built Environment
Mortality, Morbidity and HRQOL:
Deaths by all cause, IDC code,
PYLL, life/health expectancy
Hospitalization all cause,
Long term disability
Self-rated health
Chronic Disease & Injuries:
Chronic Diseases
Injury
Health Behaviour:
Smoking
Alcohol
Substance Abuse
Gambling
Physical Activity
Nutrition & Healthy Weight
Mental Health
Family Health:
Sexual Health
Reproductive Health
Child & Adolescent Health
Infectious Diseases
Reportable Disease
Immunization

37. Population Health Equity Surveillance
Differential
exposure
Differential
vulnerability
Differential
health status
Differential
health
outcome
Differential
health
consequence
Socioeconomiccontextandposition
Food security / built
environment
Obesity
Smoking
Diabetes
Dietary
practices
Physical
activity
Heart disease rates (e.g.
myocardial infarctions)
Mortality rates from
heart disease
Life expectancy
SHR
Pop’n and public
health / health
promotion
Primary care
programs - HCEA
Tertiary care
cardiac - HCEA
Policymonitoring–Policyandpoliticalenvironment
Figure 1. Framework for understanding the causal pathway of health inequity in heart disease, as well as the entry
points for health system intervention
Health system

38. Health Disparity Report
The Community View Collaboration

39. Relationships and Partnerships
• Strengthen relationships to enhance
reporting:
– Primary Health,
– First Nations and Métis Health,
– Saskatoon Tribal Council, and
– Metis Nation-Saskatchewan

40. Challenges associated with SDOH
Monitoring and Reporting
• Choosing deficit- vs. asset-based measures
• Time lag between data collection and reporting
• Gaps in reporting on certain segments of population
• Challenges in obtaining data
• Challenges in reporting data
• Technical complexity in some activities
• Privacy issues
• Attribution

41. Challenges Associated with SDOH Action
• Communicating complex data constructively and
effectively
• Involving those affected by inequities
• Focusing on needs vs. service provision
• Letting go
• Credibility gap
• Working with many partners
• Government engagement
Conclusion

42. Elements of Success
• Dynamic and credible leadership
• Credible research/evidence
• Multidisciplinary approach to monitoring and surveillance
• Knowledge translation
• Effective relationships
• Early engagement of stakeholders
• Community culture & public support
• Multi-sector approach
• Timing
• Patience
Conclusion

43. • Extensive research and reporting on the SDOH has
been used by Saskatoon Health Region’s
Population and Public Health (PPH) to understand
health disparities
• Much health equity action has come from
disparities analysis and has involved community
partners
• Remember: Evidence, Action, Equity!
Conclusion

44. Questions?
Cristina Ugolini
Manager, Public Health Observatory
Cristina.ugolini@saskatoonhealthregion.ca
Dr. Julie Kryzanowski
Deputy Medical Health Officer
Julie.Kryzanowski@saskatoonhealthregion.ca