Quintuple Aim: Health Equity Added to Healthcare Improvement Directive

Health equity should be added as the fifth element of a Quintuple Aim to guide healthcare improvement efforts, a recent Viewpoint article published by JAMA says.

In 2008, the Triple Aim for healthcare improvement was introduced, featuring improvement of population health, enhancement of the care experience, and reduction of costs. In 2014, the Quadruple Aim for healthcare improvement was created with the addition of workforce well-being as a fourth element to address healthcare worker burnout.

Healthcare improvement efforts also require a focus on health equity, a co-author of the recent Viewpoint article told HealthLeaders.

“If we look at our work on the Triple and Quadruple Aims, many people have noted that there have been challenges to achieving those. When we considered the failure points in achieving the Triple and Quadruple Aims, our view was in large part that many of the ways we have not achieved them was because of the lack of attention to the equity dimensions of healthcare. When you look at where the challenges are in health outcomes, cost of care, care experience, and where the workforce suffers the most, it is often in under-resourced communities and more marginalized and historically oppressed populations. That is why the co-authors of the JAMA Viewpoint article thought that the inclusion of a fifth aim around equity was so important,” said Kedar Mate, MD, president and CEO of the Institute for Healthcare Improvement (IHI).

There are four essential steps to address health equity, the Viewpoint article’s co-authors wrote. “To address the fifth aim, healthcare leaders and practitioners must identify disparities, design and implement evidence-based interventions to reduce them, invest in equity measurement, and incentivize the achievement of equity.”

1. Identifying disparities

The first step in addressing health equity is identifying disparities, Mate said. “Without knowing where the challenges are, without knowing where the system is falling down, you do not know where to concentrate your energy. You cannot build a strategy without clear aims. Knowing where the disparities are and knowing where populations are not getting the kinds of care that they need most is vital to design a different system that can address those disparities.”

Many health disparities have already been identified, he said. “When you look at the troubling issues in healthcare—everything from access to care to achieving high quality care—disparities are present. For example, colorectal cancer screening rates are higher in White populations than they are in Black and Hispanic populations. We know our Black maternal survival is much lower than White maternal survival—the excess morbidity and mortality is four times greater in Black women than it is in White women. We know infant mortality is higher in Black and Hispanic babies than in White babies.”

Disparities extend beyond the racial factor, Mate said. “We know poorer folks face healthcare disparities. There are disparities based on gender and disparities based on sexual identification. There are many forms of disparity that are present in any given context—there are differences between rural and urban populations that are very substantial. The hypothesis that the Viewpoint article co-authors has for adding a fifth aim is that if we start paying attention to disparities and build our systems to address them, then we will be able to achieve the original goals of the Triple and Quadruple Aims.”

2. Designing and implementing evidence-based interventions

Evidence-based interventions are pivotal in addressing health equity, he said. “This comes down to how committed we are to improving healthcare for our country. The thesis that we are putting out is that much of the excess morbidity and mortality in our nation is driven by disparities and inequity. That is what we have seen at IHI, not only in the United States, but also around the world. If we are serious about improving life expectancy, if we are serious about making our communities safe and the best places for our kids to grow up, then it requires us to take a proactive position about reducing the disparities that are present with evidence-based interventions.”

Interventions designed to tackle health inequities do not only benefit populations who are suffering from disparities, Mate said. “What we have learned over time is that a system that helps the most marginalized, and is built to include everyone, has the effect of improving care for all parties. For example, IHI was working with a health system on perioperative pain. There was a big difference between pain scores for Black patients compared to White patients. The health system built a better system that addressed the difference in pain scores. What was interesting was not only did the disparity go away, but the pain scores for all populations got better, including for White folks.”

3. Investing in equity measurement

Equity measurement is crucial to determine whether care that is being delivered is equitable or not, Mate said. “When we looked at our own data at IHI several years ago, we did not have data on self-identified demographics or economic indicators, so we could not know whether the program or project that we were conducting was benefitting everyone equivalently. We should invest in equity measurement because it allows us to understand whether everyone is having the opportunity to benefit from improvement initiatives. With that information, we can design initiatives and interventions that make sure everyone has a chance to thrive and succeed.”

Mate gave two examples of equity metrics. “One way of thinking about equity metrics is taking your existing clinical metrics and stratifying them by important demographic identifiers such as race and gender. You can take data for controlled blood pressure or cancer screening rates, and you can stratify them by race, ethnicity, language, or gender identifiers. You can stratify the data based on this kind of self-identified information, and that is one category of equity measurement. A different category of equity measurement is measures of social need and whether those social needs are being met. Examples include housing stability and food security because those factors are important contributors to health outcomes.”

4. Incentivizing achievement of equity

Financial incentives will be required to promote health equity work, he says. “In the long run, the ability of our systems to maintain their focus on equity and to continue to prioritize equity will require financial alignment; so that when we do things that improve equity, we are getting supported to continue that work. Organizations that are working with populations that experience more inequity should be supported to do equity work.”

There will likely be a progression of incentives for health equity work, Mate says. “In the early days of equity work, the incentives are going to flow to better data collection and better measurement. That is a worthy goal because without an unambiguous understanding of where the inequities are and what is creating the most pernicious effects on a population, we are going to struggle to design good interventions. Eventually, the incentives will start to flow to organizations that are working with populations that are under-resourced and experiencing inequity. Then the next step will be having incentives flow to organizations that are taking important steps toward remediating or closing inequity gaps.”