GRADE equity guidelines 3: considering health equity in GRADE guideline development: rating the certainty of synthesized evidence

Objectives: The aim of this paper is to describe a conceptual framework for how to consider health equity in the Grading Recommendations Assessment and Development Evidence (GRADE) guideline development process. Study Design and Setting: Consensus-based guidance developed by the GRADE working group members and other methodologists. Results: We developed consensus-based guidance to help address health equity when rating the certainty of synthesized evidence (i.e., quality of evidence). When health inequity is determined to be a concern by stakeholders, we propose five methods for explicitly assessing health equity: (1) include health equity as an outcome; (2) consider patient-important outcomes relevant to health equity; (3) assess differences in the relative effect size of the treatment; (4) assess differences in baseline risk and the differing impacts on absolute effects; and (5) assess indirectness of evidence to disadvantaged populations and/or settings. Conclusion: The most important priority for research on health inequity and guidelines is to identify and document examples where health equity has been considered explicitly in guidelines. Although there is a weak scientific evidence base for assessing health equity, this should not discourage the explicit consideration of how guidelines and recommendations affect the most vulnerable members of society

New England Regional Health Equity Profile & Call to Action

Good health is a foundation that allows people to participate in the most important aspects of life. The purpose of the New England Regional Health Equity Profile and Call to Action is to identify where differences in good health exist among racial, ethnic, and disability populations in New England as well as foster policy, programmatic, and individual action to combat health disparities and achieve health equity for racial, ethnic, disability and underserved populations in New England. The report was written by the members of the New England Regional Health Equity Council (RHEC), one of ten regional health equity councils formed by the Office of Minority Health at the federal Department of Health and Human Services. The mission of the New England RHEC is to achieve health equity for all through collective action in the New England region. The New England RHEC’s vision is to achieve health equity through cross-sector interaction and collaboration of activities and resources to optimize health for all where they live, learn, work, and play. The New England Regional Health Equity Profile and Call to Action uses a “social determinants of health” approach. A social determinants of health approach focuses on understanding how the intersection of the social and physical environments; individual behaviors; and access to education, income, healthy foods and health care, impacts a wide range of health and quality-of-life outcomes. The report examines the following topics: Socio-Economic Status, Healthy Eating and Physical Activity, Risky Behaviors, Cultural Competency in Health Care, Health Care Access, Health Outcomes, and the Intersection of Race/Ethnicity & Disability. It also includes a description of State Health Equity Activities and a Regional Call to Action

GRADE equity guidelines 4: guidance on how to assess and address health equity within the evidence to decision process

Objective: The aim of this paper is to provide detailed guidance on how to incorporate health equity within the GRADE (Grading Recommendations Assessment and Development Evidence) evidence to decision process. Study design and setting: We developed this guidance based on the GRADE evidence to decision (EtD) framework, iteratively reviewing and modifying draft documents, in person discussion of project group members and input from other GRADE members. Results: Considering the impact on health equity may be required, both in general guidelines, and guidelines that focus on disadvantaged populations. We suggest two approaches to incorporate equity considerations: 1) assessing the potential impact of interventions on equity and; 2) incorporating equity considerations when judging or weighing each of the evidence to decision criteria. We provide guidance and include illustrative examples. Conclusion: Guideline panels should consider the impact of recommendations on health equity with attention to remote and underserviced settings and disadvantaged populations. Guideline panels may wish to incorporate equity judgments across the evidence to decision framework

Equity and Health

This article raises the problem of equity in the health system in Switzerland. Three dimensions of the concept of equity are taken into consideration: the inequality in the financing of the health system, the inequality in the distri-bution of the state of good health, and, finally, the iniquity in the access to health care. Some methodological devel-opments are presented as well as the results. In conclusion we observe that the state of good health does not depend strongly on income but that it exists some iniquity in the access to health services from specialists and that the in-come inequality is increasing due to the financing of the health system.health system; equity

No equity, no triple aim: strategic proposals to advance health equity in a volatile policy environment

Health professionals, including social workers, community health workers, public health workers, and licensed health care providers, share common interests and responsibilities in promoting health equity and improving social determinants of health—the conditions in which we live, work, play, and learn. This article summarizes underlying causes of health inequity and comparatively poor health outcomes in the U.S. It describes barriers to realizing the hope embedded in the 2010 Patient Protection and Affordable Care Act that moving away from fee-for-service payments will naturally drive care upstream as providers respond to greater financial risk for the health of their patients by undertaking greater prevention efforts. The article asserts that health equity should serve as the guiding framework for achieving the Triple Aim of health care reform. It outlines practical opportunities for improving care and for promoting stronger efforts to address social determinants of health. These proposals include developing a dashboard of measures to assist providers committed to health equity and community-based prevention and to promote institutional accountability for addressing socio-economic factors that influence health

Risk Equity: A New Proposal

What does distributive justice require of risk regulators? Various executive orders enjoin health and safety regulators to take account of “distributive impacts,” “equity,” or “environmental justice,” and many scholars endorse these requirements. But concrete methodologies for evaluating the equity effects of risk regulation policies remain undeveloped. The contrast with cost-benefit analysis--now a very well developed set of techniques --is stark. Equity analysis by governmental agencies that regulate health and safety risks, at least in the United States, lacks rigor and structure. This Article proposes a rigorous framework for risk-equity analysis, which I term “probabilistic population profile analysis” (PPPA). PPPA is both novel, yet firmly grounded in the social-welfare-function tradition in welfare economics. The PPPA framework conceptualizes both the status quo, and possible policies, as probability distributions across population profiles -- where each population profile is, in turn, a concatenation of lifetime health-longevity-income histories, one for each member of the population. A utility function transforms each such profile into a utility vector. An equity-regarding social welfare function (SWF) is then specified. Policy analysts can employ the equity-regarding SWF both (1) to determine how policies compare purely as a matter of equality; and (2) to determine how they compare all-things-considered, considering both equality and overall welfare. The proposal may seem utopian, but is not. Scholars in the field of optimal tax policy already use SWFs to evaluate policies. Characterizing policies as distributions across population health-longevity-income profiles builds on existing risk assessment and general-equilibrium-modeling techniques. Utility functions can be specified through survey research and, in the interim, by building on standard functional forms. Plausible normative axioms considerably narrow the possible forms of the SWF, and survey research or thought experiments narrow the field further. Part I of the Article describes and criticizes existing approaches to risk equity that have been proposed in the scholarly literature: the environmental justice conception of risk equity; “individual risk” approaches; QALY-based equity analysis; incidence analysis; inclusive equality measurement; and cost-benefit analysis with distributive weights. Part II describes and defends PPPA. PPPA has many virtues. It recognizes that well-being is multidimensional, a function of both income and health/longevity; furnishes a metric for inequality; provides a framework for making tradeoffs between equality and overall well-being; and understands that distributive justice includes (but is not limited to) inequalities between high and low-status social groups

Can equity be included in a performance evaluation system? Some evidences from the tuscan health care system

Objectives. Can Equity be included in a performance evaluation system? In Italy, the Tuscan Region has tested and now is adopting an integrated model for performance measurement to which the regional administration, the local health authorities, and other stakeholders may refer either in terms of indicators and shared responsibilities. Thoughout this performance evaluation system it is now possible to measure also the capacity to persue equity at a regional and local level. Methods. In 2005 aspects as equity and access to services, that, in a public system, are very relevant and characterize the political strategy, were included in the performance evaluation system to evaluate the action carried out by the local health authorities, i.e. the operative actors of the system. This was achieved identifing equity measures and including them in an essential number of indicators, classified in six dimensions and represented in diagram targets. Results. This comprehensive performance evaluation system helped managers and the regional healthcare system as a whole to learn and to consider equity not only as a political issue but as a management goal. Conclusions. This system, used continuously and systematically at a regional level, is now a public policy tool and supports the Local Health Authorities in keeping equity in their management goals.Performance, Evaluation, Balanced Scorecard, Equity, Health Service Access, Health Targets.

Concerns for Equity and the Optimal Co-Payments for Publicly Provided Health Care

In countries where health care is publicly provided and where equity considerations play an important role in policy decisions, it is often argued that an increase in co-payments is unacceptable as it will be particularly harmful to the less well-off in society. The present paper derives socially optimal co-payments in a simple model of health care where people differ in income and in severity of illness. The social optimum depends on the welfare weights given to persons with different levels of expected utility. Increased concern for equity may increase optimal co-payments for illnesses with homogeneous severity across the population. For illnesses where the severity varies strongly across the population, optimal co-payments go down as a response to increased concern for equity, provided income differences in the society are sufficiently small.public health, co-payments, equity concerns