The fields of Quality Improvement (QI) and Social Determinants of Health (SDH) sometimes seem to reside in their own realms, as if being bestowed with a memorable acronym relegates each entity to its own pathway and followers. Attending physicians, trainees, and students interested in improving patient outcomes are seemingly compelled to self-identify with one or the other—they must become “one of the QI people” or “one of the SDH people.” Moreover, the QI realm tends to gravitate to the inpatient setting, where a canon of memorable topics has emerged. Medication errors, falls, CAUTIs, CLABSIs, and VAPs dominate the landscape, in large part because of the colorful posters in comic sans font that line the hallways and break rooms in any given med-surg unit. In reality the thoughtful practitioner must be cross-trained across these fundamental ways of understanding health and society, and be competent in the principles of implementing meaningful change. Application of QI science is necessary to meet the challenges of investigating, understanding, and eventually mitigating the inequities associated with SDH.
SGIM has issued a call to action by way of this year’s annual meeting theme: we must better understand the impact of SDH on clinical outcomes. Efforts such as the SDH Fast Facts1 are crucial to help clinicians build a toolkit rooted in evidence and focused on identifying and intervening upon health inequities. Developing ways to support this effort at the graduate medical education level can seem challenging at first glance. But when I reflect on the lessons learned through a SDH related QI project at my resident continuity clinic, I see a clear path forward.
During my residency at Emory in Atlanta, Georgia, my primary clinical training site was Grady Memorial Hospital. Grady is the public safety-net hospital and Level 1 trauma center for Metro Atlanta primarily serving an under- and uninsured, marginalized, and poor patient population. As such, Grady holds nothing back in orienting residents to the harsh realities of gun violence, homelessness, and inequities in access to care. The ups and downs of training at Grady leave such a permanent, memorable impression that a resident is said to be “Grady-made” at the end of training. To me, that meant coming away with not just a strong foundation of clinical training, but an equally strong foundation in understanding the SDH which are integral to every patient’s experience.
Nearly 34% of patients seen at the Grady primary care center have a diagnosis of Type 2 diabetes. It is indisputable that patients with diabetes and low socioeconomic status have worse outcomes compared to those with higher status.2 Not only is the risk of developing diabetes higher but also there are higher rates of associated retinopathy and nephropathy.3 And as trainees, a harsh reality we had to reconcile with our ideals and aspirations as physicians was that low socioeconomic status portended patients receiving worse care for their diabetes.4 As well-meaning internists-in-training being taught by other well-meaning internists, we wanted to understand more about why our diabetic patients weren’t receiving optimal care and how we might improve their quality of care.
To address this issue, our Primary Care program cohort created a QI project aimed to improve diabetes outcomes among patients at Grady’s primary care center. To foster durable change, we established a legacy project involving all three resident classes in the Primary Care program. Iterative Plan-Do-Study-Act (PDSA) cycles were aimed at identifying opportunities for process improvement in clinic, with the overarching goal to lower the A1c of our most poorly controlled patients with diabetes (defined as A1c greater than 10%).
We surveyed our patients to assess their knowledge about diabetes and management of diabetes, and very quickly recognized that the prevailing factors affecting their diabetes control extended far beyond our clinic walls. We assumed that cost and low health literacy were likely to be important issues, but the survey responses starkly demonstrated the true impact of these issues on the health of our patients. There was a palpable weight to our findings, which showed that—even with access to a sliding-scale pharmacy—difficulties affording medications prevailed, and this was associated with poor control. On the other hand, self-report of eating vegetables in the last 24 hours correlated with an A1c less than 10%. We extended our work determining the most common zip codes among our patients, and this highlighted the extent to which access to a major grocery store was limited. As my time in residency neared its end, our focus shifted towards developing an affordable grocery shopping list, based on informal price analyses and discussion with clinical nutritionists to develop easy, practical, diabetes-friendly recipes.
I learned many lessons through this three-year journey. But as I reflect on this experience as now an attending myself, the following three key points are most important to share with my colleagues and trainees:
- When given the time, support, and opportunity, residents will always dig deeper to serve their patients, far beyond the problem lists generated by the electronic medical record. Our supporting faculty ensured protected time for all three residency classes of the Primary Care program to meet in-person, brainstorm, and pursue actionable steps to move this project forward.
- Quality improvement is as much at home in the wards as it is in clinic. A strong foundation in QI principles provided us with continued momentum to generate new ideas of improving our delivery of care in the outpatient setting, and unexpectedly served as a vehicle to more intentionally explore our patients’ SDH.
- Understanding and integrating SDH is a critical component of any QI project. Without a deliberate effort to understand what was truly impacting the health of our patients, we never would have created interventions that were most likely to have an impact.
Now more than ever, we realize the magnitude of effect that SDH have on clinical outcomes. Cost, access to food and medications, and cultural biases are among the plethora of factors that demand our attention. Breaking down any perceived academic silos between “QI” and “SDH” is critical for success. Applying QI science in the primary care setting—especially as an educational tool among residents—is a simple way to understand the SDH unique to our patient populations.
I would like to express my thanks to Drs. Stacy Higgins and Shelly-Ann Fluker for creating the space to make this work possible, my colleagues Alejandra Bustillo, John Ricketts, and Gretchen Snoeyenbos for their work on the project, and the patients of Grady Memorial Hospital for participating in our survey.