The Problem (and a Solution) to the One-Size-Fits-All Health Inequity

Health care aims to improve patient health and quality of care. Scientific studies are a major foundation for meeting these aims. Health inequities, however, prevent some populations from experiencing the same benefit from disease-specific guidelines.

Women, older adults, Black, Hispanic, and other racially minoritized individuals, and persons with multiple disabilities are some of the people largely underrepresented in clinical trials relative to their proportion of the affected population. Furthermore, the outcomes studied in these trials may not be what matters most to some members of the underrepresented populations. These limitations create a “one size fits all” health inequity — while the population and outcomes are not proportionately studied, everyone receives the same recommendations.

To break down this inequity, Mary Tinetti, MD, Gladys Phillips Crofoot Professor of Medicine (Geriatrics), Melissa deCardi Hladek, PhD, CRNP, and Deborah Ejem, PhD, propose focusing on health priorities-tailored care in a recent JAMA Internal Medicine Viewpoint. These health priorities represent patients’ own health outcome goals and care preferences.

“Clinical trial evidence that informs care focuses primarily on preventing future events, optimizing disease-specific outcomes, or extending survival. These outcomes are defined by investigators, not by patients who vary in the outcomes that matter most to them,” write the authors.

Addressing health inequities begins by recognizing the uncertain benefit of many guidelines-driven interventions, the variable health priorities of individuals, and the importance of currently considered non-medical interventions.

Despite a growing interest in social determinants of health, socioeconomic interventions are rarely included in clinical trials and are “haphazardly addressed in clinical care,” according to the authors. Tinetti et al. recommend breaking down the separation between what is considered medical care and what is considered social services.

“Assistance with housing, transportation, hunger, or social isolation is often more important than the latest antidiabetic or immunologic agent, medical device, or procedure in addressing the health priorities — and disease-specific outcomes — of many disabled individuals or individuals with multimorbidity,” they write. To aid this shift, the authors believe in fully supporting the interdisciplinary team, equitable payment for all members of health care team, coverage of community-based services, and institution of quality and payment metrics that support health priorities-tailored care.

Lastly, for health priorities-tailored care to be realized, health care professionals will need to acquire new communication and decision-making skills to help patients identify their health priorities in a way that’s reliable and actionable enough to inform decision-making.

This approach can empower currently disadvantaged patients to communicate with their health care team and feel more in control of their health.

“This empowerment fosters trust between patients and health care professionals, which is critical to dismantling all health inequities,” write the authors.

Read “One Size Fits All—An Underappreciated Health Inequity” in JAMA Internal Medicine.