NU712 Unit 7 QI Equity Analysis Example

Six Percent for the Insured, Seventeen for the Uninsured: A Unit 7 Equity Analysis of a Year of Insulin Discharge Bundle Data

[Student Name]

Purdue University Global

NU712: Quality Improvement and Interprofessional Collaboration for the Doctoral Nurse

Unit 7 Equity Analysis

[Instructor Name]

[Date]

The hospital, units, patients and figures are composite and illustrative; the studies and guide cited are real.

Why Split the Data

An improvement that lowers the overall rate can still leave some patients behind, or even widen the distance between groups. Lion and Raphael (2015) point out that improvement work aimed at quality overall may not narrow disparities and can worsen them when the change is taken up more readily, or works better, among patients who were already doing well. Reichman et al. (2021) make the same argument for neonatal care and describe equity-focused improvement as work that builds equity into every stage, from the choice of aim to the way results are reported, rather than checking for gaps at the end. This analysis is a late check, which is a weakness, but it is better done before the bundle spreads to six more units than after.

The Data

The bundle's first full year on the two pilot units covered 212 patients discharged on new insulin. The project's data set records each patient's payer, age, home ZIP code, preferred language and self-reported race and ethnicity, together with whether each bundle component was delivered and whether a glucose problem brought the patient back to a ward or the emergency room inside 30 days. Language was examined in an earlier course, and the interpreter gap it found has its own plan, so it is not repeated here. Distance from home was measured as road miles from the patient's ZIP code to the hospital, with more than 30 miles counted as rural.

Results by Payer

Payer showed the widest spread. Patients with commercial insurance, 64 of them, had four returns, about 6 percent. Medicare patients, 96, had eight returns, about 8 percent. Medicaid patients, 40, had six, or 15 percent, and the 12 uninsured patients had two, about 17 percent. The process data explain much of that pattern. The pen was in the patient's hands by the first insulin day for 92 percent of commercially insured patients but for only 70 percent of Medicaid patients and 58 percent of uninsured patients. For Medicaid patients the delay usually came from prior authorization for the pen brand used in teaching; for uninsured patients, from the time it took to enroll them in a manufacturer assistance program.

The bundle's most important part reached the insured on day one and the uninsured, too often, on the way out the door.

Results by Age

Patients aged 80 and older, 31 of them, had five returns, about 16 percent, against roughly 8 percent for younger patients. Teaching and pens reached older patients at about the same rate as everyone else. The gap was in the three-day check-in: the educator completed it for 84 percent of patients under 80 but for only 55 percent of those 80 and older. Call notes show why. Older patients more often missed calls, could not hear well on the phone or had a family member who handled their medications but had not been at the teaching session.

Results by Distance From Home

Fifty-eight patients lived more than 30 miles away. Seven of them returned, about 12 percent, against 13 of 154 who lived closer, a little over 8 percent. The clearest process difference was the outpatient diabetes class. A reserved seat was offered to everyone, but only 9 percent of rural patients attended, against 31 percent of patients living closer. Rural patients told the educator that a two-hour class an hour's drive away, three weeks after discharge, was not realistic.

Race and Ethnicity

Of the 212 patients, 178 identified as White, 15 as Hispanic or Latino, 14 as Black and five as another group. Returns in the three smaller groups were one or two each. Numbers this small cannot show a difference or rule one out, and reporting a rate for a group of five would risk identifying patients. The analysis therefore reports counts only and commits to combining two years of data before drawing any conclusion. Bundle delivery rates did not differ visibly among these groups, but that statement is weak for the same reason.

What the Numbers Can and Cannot Say

These are a year of data from two units. A difference between 6 and 17 percent rests on two returns among 12 uninsured patients, and the confidence intervals around each group's rate overlap widely. The analysis does not claim that the bundle causes disparities or that payer itself explains the gap; uninsured and Medicaid patients in this hospital are also younger on average and more likely to have had diabetic ketoacidosis at admission. What the data do show, more firmly, is that delivery of specific bundle components differed by group. Those process differences are measured on every patient, not only on the minority who return, and they point to fixes.

Applying an Equity Framework

Wyatt et al. (2016), in the Institute for Healthcare Improvement's guide to health equity, ask organizations to make equity a strategic priority, build structures and processes to support it, act on the determinants that drive it, address institutional racism and partner with community organizations. Two of those apply directly here. A process built for insured, younger, nearby patients has quietly become the standard, and the project's dashboard reports only the average. Changing that is a matter of structure. The second is community partnership, since the gaps for rural and older patients lie largely outside the hospital's walls.

Proposed Changes

1. Start the pen process at admission for Medicaid and uninsured patients. When insulin is first ordered, the pharmacist begins prior authorization or assistance enrollment the same day and, if approval is not likely before discharge, teaching switches to a pen or vial the patient can obtain immediately.

2. Include the medication helper in teaching. For patients aged 80 and older, the nurse asks at admission who manages medications at home and books the teaching session for a time that person can join, in the room or by video.

3. Change the check-in route for older patients. Patients 80 and older are offered the check-in as a video or in-person visit through the hospital's home health partner, in addition to the call or text.

4. Bring the class closer. The diabetes educator and two rural clinics will pilot a one-hour virtual class, offered within a week of discharge, with the clinic's nurse present for patients who lack a reliable connection.

5. Stratify the dashboard. Every bundle measure will be reported by payer, age group and distance each month, with counts shown for small groups and rates only once a group reaches 20 patients.

Measures of Success

Success will be judged first on process gaps closing: pens dispensed on the first insulin day for at least 85 percent of Medicaid and uninsured patients, check-ins completed for at least 75 percent of patients aged 80 and older and class or virtual class attendance for at least 25 percent of rural patients within a year. Returns by group will be watched over two years, because a single year gives each group too few patients for a fair verdict. As a balancing measure, the minutes from a signed discharge order to the moment the patient is wheeled out will show whether earlier pen work holds anyone up.

Conclusion

The bundle's overall result hid a pattern: the parts that matter most reached insured, younger and nearby patients more reliably than others. The numbers are small, and the analysis claims no more than they support, but the process gaps are clear and fixable. Starting pen access early, teaching the person who manages medications, changing the check-in route for the oldest patients, bringing the class closer and reporting every measure by group would make the spread to six more units an equity improvement as well as a quality one.

References

Lion, K. C., & Raphael, J. L. (2015). Partnering health disparities research with quality improvement science in pediatrics. Pediatrics, 135(2), 354-361. https://doi.org/10.1542/peds.2014-2982

Reichman, V., Brachio, S. S., Madu, C. R., Montoya-Williams, D., & Peña, M. M. (2021). Using rising tides to lift all boats: Equity-focused quality improvement as a tool to reduce neonatal health disparities. Seminars in Fetal and Neonatal Medicine, 26(1), 101198. https://doi.org/10.1016/j.siny.2021.101198

Wyatt, R., Laderman, M., Botwinick, L., Mate, K., & Whittington, J. (2016). Achieving health equity: A guide for health care organizations [IHI White Paper]. Institute for Healthcare Improvement. https://www.ihi.org/resources/white-papers/achieving-health-equity-guide-health-care-organizations