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Equity Is Essential for Quality

December 12, 2021
Elizabeth Brem, MD

Dr. Elizabeth Brem (@DrLizBrem) is an assistant professor in the Division of Hematology/Oncology, Department of Medicine, at University of California, Irvine School of Medicine. She specializes in lymphomas (B- and T-cell, Hodgkin lymphoma), chronic lymphocytic leukemia, and multiple myeloma. She attended medical school at SUNY Buffalo in her hometown of Buffalo, New York, and did her residency and fellowship at Beth Israel Deaconess Medical Center/Harvard Medical School in Boston. She currently lives in Huntington Beach, California. Dr. Brem is a prolific ASH volunteer. Prior to joining ASH News Daily, she served as an associate editor for ASH Clinical News and has also been a member of the ASH Trainee Council and Committee on Communications. She looks forward to her next adventure in 2022 as a member of the ASH Publications Committee. In addition to a wealth of knowledge about ASH, Dr. Brem contributes some deep-rooted journalistic chops. “In high school, I wrote for the kid’s section of the local paper, The Buffalo News,” she shared. “I still have a ‘Reporters Notebook’ that they gave me! 

Diversity, equity, and inclusion (DEI) are front and center at this year’s ASH annual meeting, which will have the first-ever Anti-Racism Studio (check the program for a list of sessions and relevant details) and will kick off ASH’s new Health Equity Rounds, which will continue the conversation on DEI through 2022. This year’s Special Symposium on Quality, “Identifying and Eliminating Inequity in the Provision of Healthcare” (available on-demand via the virtual platform) also built on this theme. Co-chaired by Drs. Amy Billett and Jacquelyn Powers (seated right in photo), the session focused on how each of us can play a role in improving equity. Dr Billett is a pediatric hematologist/oncologist and the inaugural Chief Quality and Safety Officer at the Nemours/Alfred I. duPont Hospital for Children and Dr. Powers is the director of the Iron Disorders and Nutritional Anemias Program at Texas Children’s Hospital. In an interview prior to the symposium, Dr. Powers noted that a 2001 Institute of Medicine report called Crossing the Quality Chasm has identified six dimensions of health care quality: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. She stated that the goals of this year’s Symposium on Quality were to center it “around equity and to clearly demonstrate how it [equity] is a pillar of quality within our field of hematology.” 

Dr. Maureen Okam Achebe (seated left in photo), who is the Clinical Director of the Nonmalignant Hematology Clinic and Director of the Sickle Cell Program at Brigham and Women’s Hospital, presented “Equity in Patient Care and Outcomes.” Dr. Achebe co-authored a Blood Perspective article published  earlier this year titled, “When non-Whiteness becomes a condition.” In the article, she and co-author Dr. Lauren Merz discuss the condition known as “benign ethnic neutropenia,” a name implying that people who are non-white are abnormal. Additionally, having this label of neutropenia causes undue anxiety and costs to the health care system. Dr. Achebe offered a new name for this condition: “Duffy–associated neutrophil count (DANC),” which accounts for the mechanism of the laboratory finding and does not label it as a neutropenia, as it is clear that the blood counts are “clinically irrelevant.” In the paper and in the presentation, Dr Achebe called attention to the need to examine this and other practices in hematology that contribute to systemic racism. There are “far-reaching consequences to something so seemingly ‘benign,’” says Dr. Achebe. This work “highlighted the impact of racism within hematology in a very powerful way that we believe resonated with a lot of hematologists,” said Dr. Powers. 

In her talk, Dr. Achebe explained the difference between health inequity and health inequality. Equity refers to fairness and focuses on the needs of the individual, while equality focuses on equal sharing, regardless of the needs of an individual. Barriers to equity include impaired access to care and systems that affect quality of care. She reminded us that race is a socially structured construct, but despite race not being rooted in science, it still matters and leads to psychosocial stressors and poor health outcomes. Dr. Achebe shared strategies we can all use to “successfully and sustainably address health inequity.” 

President and Chief Health Officer at the Foundation for Sickle Cell Disease Research, Dr. Lanetta Bronte-Hall (shown speaking) has devoted most of her career to improving access to care for patients with sickle cell disease. Dr. Bronte-Hall spoke on “Excellent and Equitable Sickle Cell Care and Research in Florida” and the experience that her foundation has had in Florida to make sickle cell disease a “livable, non-threatening condition.” Dr. Powers hoped that this talk would be “action-focused, demonstrating mechanisms for change related to health equity,” and indeed it was! Dr. Bronte-Hall reminded us of the real-world burden of sickle cell disease and the lack of equitable access to care: 75 percent of adults fail to receive U.S. Food and Drug Administration–approved therapies and drugs. The majority of patients are in the community; only about 15 percent are treated at academic centers. Her center is comprehensive, providing many services on site, including imaging and treatment for pain crises. With these efforts, hospitalizations and re-admissions have been reduced by 60 percent and 40 percent, respectively, between 2015 and 2021. 

The keynote speaker for the session, Dr. Kara Odom Walker, is a family physician who previously served as the Secretary of Delaware Health and Social Services department and currently serves as Executive Vice President and Chief Population Health Officer for Nemours Children’s Health System. Her keynote presentation gave “a broader perspective on the impact of policy on equity and how equitable care can improve value-based care and patient outcomes.” Dr. Walker explained that as a health care community, “we need more ways to reduce inequities in care based on clinical pathways, understanding implicit bias, and how quality improvement techniques can be leveraged to address health equity.” Her presentation focused on “how racism has impacted health and health outcomes.” Dr. Walker reminded us that racism persists in medicine, that we must be aware of this and interpret tests and patients appropriately and as individuals, not just chalk differences or outcomes up to race. Dr. Walker believes we can all “learn and unlearn” racism to move in the right direction. Quality improvement will also be needed to reduce health inequities. “Disease is a product of social forces,” said Dr. Walker. “Quality improvement and data methodology can address health equity, establish strategies to frame equity as a quality initiative, and finally, provide recommendations to reduce inequities in care.” She acknowledged that things like zip code can be “new vital signs,” and also underscored that, leadership and representation matter. Dr. Walker provided numerous strategies to empower us all to contribute to improving health equity, like the idea of “equity report cards” for our individual practices and organizations. “This is only the start of the conversation,” she said.   

The goal of the speakers and co-chairs was for attendees to walk away understanding that by addressing equity in care, we can all improve the quality of care we deliver as well as patient outcomes. Dr. Walker said, “Achieving improved health is not possible without reducing health inequities.” Dr. Achebe agrees: “Achieving high quality health for all people is dependent on eliminating health inequality,” she said, adding that “80% of one’s health is determined by social determinants, rather than medical.” 

This Special Symposium on Quality and the multitude of other programs at the annual meeting focused on DEI strive to inspire ASH members to “develop projects and proposals that work to address and improve equity at their own centers, and we hope to be able to highlight such work at future ASH meetings,” stressed Dr. Powers. She noted that a “Call to Action” will be issued soon to ASH members to address health inequities.  

Dr. Brem indicated no relevant conflicts of interest. 

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