In the heat of World War II, the U.S. military asked a group of Columbia University mathematicians for help. Bomber planes were taking heavy fire over enemy lines leading to substantial casualties, and military leadership needed to know where to strategically shore up their planes’ armor. If they reinforced the whole plane, it would be too heavy. If they reinforced the wrong parts — well, you get the idea.
Naturally, the first thought was to examine the planes returning from raids that had taken heavy fire, plot the areas with the most consistent damage and reinforce accordingly. But Abraham Wald, one of the Columbia mathematicians, proposed a different approach.
The damage to the returning aircraft represented areas where a bomber could take fire and still return to base. As a result, Wald proposed reinforcing areas where the returning aircraft were unharmed.
It was the planes that didn’t return that held the deeper insight.
Wald’s approach is a helpful reminder of our bias for the visible, and healthcare is no exception. A hallmark of the scientific method, healthcare brings reason to some of life’s greatest mysteries, thanks in large part to the foundation of sound measurement. But COVID-19 and broader conversations around the systemic biases and racism that permeate our culture have helped expose the deep cracks in this foundation. While a person’s environment is the most important contributor to their overall health, the indicators for health inequity, social determinants of health and systemic bias often go beyond the visible. Measuring these indicators in a standardized, inclusive manner presents a unique challenge for hospitals and health systems, as the needs of their community go beyond the four walls of a facility and its patients.
The path forward is complex, but the time has come to shift our dialogue around health equity from ambition to action. And the first step toward meaningful action is sound measurement.
Measuring the unseen
Collecting data to treat sick patients and collecting data to improve population health outcomes are two different pursuits. While hospitals are uniquely equipped to address the former, they are increasingly expected to handle the latter as well. Hospitals cannot, and should not, shoulder the population health burden alone, but there is no denying their essential role in the process. And it starts with measurement.
However, as I mentioned earlier, hospitals often share the same dilemma as the military did in WWII. Their data reflects the patients who come through their doors, accurately complete intake forms and follow the appropriate steps for care. But what about those who never make it through the front doors? What about the intake forms that include inherent biases or unintentionally ostracize those they seek to help? What about the environmental obstacles to care that prevent a person from pursuing a healthy lifestyle? Vizient data from 2020 shows half of patients with COVID-19 had not been seen in that health system in at least three years.
One place to start is incorporating reliable public health data to better understand the needs of a local community. A variety of public indexes exist to provide insights about individual social determinants of health, such as poverty and food deserts. But none of them offer a holistic view at the local level. Vizient’s patent-pending Vulnerability Index™ closes this gap by leveraging insights from a range of public data around eight specific social determinants at the neighborhood level.
Combined with patient data like Vizient’s Clinical Data Base (CDB), a repository of 1,000 Vizient member hospitals with 88 million distinct patients, hospitals gain a deeper understanding of the obstacles their patients face in accessing healthcare and how those obstacles impact health outcomes. For example, one analysis showed a strong correlation between housing vulnerability and severe maternal complications such as sepsis, transfusion rates and mortality. Patients from neighborhoods with lower rates of homeownership, homes with incomplete plumbing, crowded housing, and housing expenses greater than 50% of income were three times more likely to suffer severe maternal complications.
Watch: Leveraging Data to Map Health Equity
Equipped with this level of insight, hospitals can see beyond their walls and gain a deeper understanding of their community.
Measurement falls flat without effective communication
While an effective health equity strategy starts with better measurement, it can fall flat if not communicated effectively. Sg2 recently led an exercise with over 100 healthcare organizations across 35 states to evaluate the organizations’ readiness for implementing a successful health equity strategy. While most participants scored favorably in their ability to collect data, nearly 60% received their lowest scores in the assessment when it came to communicating their findings effectively. Without a clear understanding of how to translate data into valuable insights and recommendations, organizations lose the opportunity to gain buy-in from internal and external stakeholders.
Organizations must keep their end-user at the forefront when communicating. Creating content in a context familiar to their audience can help ensure the signal is not lost in the noise. Sg2 outlines a few examples:
One-page handouts for community members and leaders with graphics rather than paragraphs of text
Collaborative hubs for partner organizations to sync clinical data sets that can identify opportunities for codeveloping health equity interventions
Easily accessible dashboards for C-suite and hospital leaders that clearly display relevant data with indicators for progress and a summary of historical performance
Measurement and action go hand-in-hand
Wald’s counterintuitive discovery saved lives and contributed seminal work to his field — but imagine if the U.S. military had not taken his recommendation seriously. At the same time, had the military not prioritized measurement, Wald may have never had the opportunity to make his discovery in the first place.
Measurement and action need each other.
If leaders refuse to acknowledge the power of effective measurement as they devise their health equity strategy, or those tasked with doing the measuring are unable to properly communicate their findings, both efforts are wasted.
But as I mentioned, hospitals cannot shoulder this alone. One Vizient member modeled the way for collaboration after identifying the need for more education and support for uninsured patients with Type-2 diabetes and those with a pre-diabetic diagnosis. They partnered with a local YMCA to offer a yearlong program for diabetes prevention and a 12-week program for diabetes control that included programs focused on nutrition, physical activity and weight reduction. They also offered motivators such as free personal training and grocery store gift cards to keep participants engaged. One-third of participants in the prevention program achieved 5% weight loss, and control program participants improved their glycemic levels by 18%, along with a 30% decrease in depressive symptoms.
While more work is needed to develop standardized measurement practices for health equity and social determinants of health at the national level, Vizient’s Vulnerability Index and CDB are pioneering insights to equip organizations with the information they need to make the best decisions for their communities. When hospitals and health systems are focused on sound measurement, effective communication and local partnership, they set the table for transformative action. But just as the disparities we seek to eliminate are often hidden beneath the surface, so too are the underlying biases of our own measurement practices. We cannot focus on a returning plane’s war-torn wings. Rather, we must look deeper to find and protect what is truly vulnerable.
About the author: Byron Jobe is president and chief executive officer of Vizient. Jobe has been with the company for over 10 years and he has a long history of leadership roles in the health care industry, including in the areas of strategy, operations and finance. Jobe began his career at PricewaterhouseCoopers, and he has a broad and diverse experience, including later positions with Baylor Scott & White Health, Healthvision and Vizient.