Developing a Sociotechnical Systems Analysis Approach for Investigating Systems Inequities

虽然结构性不平等存在于广泛的系统中，但新出现的证据表明，卫生系统受到系统性偏见的困扰。先前的研究已经确定了175多项研究，记录了医疗保健中的种族/民族差异。通过有偏见的算法、糟糕的流程设计、持续使用种族主义医疗做法、对有色人种不可靠的医疗设备、隐性偏见和对文化不敏感的护理，不公平地进入了系统。由于缺乏定义良好的概念模型，数据可用性和质量方面的挑战（包括不敏感的测量）以及定义不明确的数据分析方法，表征系统偏差非常困难。工业和系统工程（ISE）方法已被用于改进许多领域的系统设计，并且特别适合于识别导致不同结果的潜在系统问题。ISE为检查系统公平性提供了强有力的理论基础，长期记录的系统性缺陷可能导致设计过程未能考虑到关键用户群体，包括在卫生系统设计中被忽视或拒绝代表的边缘化社区。这项研究的创新之处在于将ise与传统的对安全的强调结合起来，并利用交叉性来理解边缘化社区的不成比例的风险。公平挑战特别突出的一个具体保健背景是孕产妇保健。在过去20年中，加拿大的产妇死亡率和严重产妇发病率有所上升。种族和民族差异普遍存在于孕产妇死亡和SSM的所有原因中。在美国，孕产妇死亡率和SMM也与数十亿美元的医疗支出有关。通过及时和适当的风险护理，可以预防一半的孕产妇死亡和孕产妇死亡。在控制患者和医院因素后，存在大量和持续的差异，表明产妇保健系统设计中的系统性不公平。利用孕产妇保健作为范例，这项工作将调查使用ISE的卫生系统中的不公平现象。该工作旨在开发一种定义良好的ISE方法，该方法可用于识别系统不公平，识别导致这些不公平的原因因素，并作为正在进行的系统安全工作的一部分监控变化。随着加拿大人口继续多样化，了解卫生系统如何为其服务的人群工作或不工作对于重新设计临床途径以提供安全，公平和具有成本效益的护理至关重要。关注导致差异的临床系统贡献者是本研究的一个新的潜在线索，在概念上与人口健康和医疗保健工程框架保持一致，并为任何卫生系统提供远远超出孕产妇健康差异的深刻含义。

While structural inequities exist in a broad range of systems, there is emerging evidence that health systems are plagued by systemic biases. Prior research has identified over 175 studies documenting racial/ethnic disparities in healthcare. Inequities designed into the system through biased algorithms, poor process design, continued use of racist medical practices, medical devices unreliable for people of colour, and implicit bias and culturally insensitive care. Characterizing systems biases are extremely difficult due to a lack of a well-defined conceptual model, challenges in the availability and quality of data (including insensitive measures), and ill-defined data analysis approaches. Industrial and systems engineering (ISE) approaches have been utilized to improve system design in many domains and would be exceptionally well-suited for identifying underlying systemic issues contributing to disparate outcomes. ISE provides a strong theoretical basis for examining systems equity, having long documented systemic deficiencies that can result when the design processes fail to account for key groups of users, including marginalized communities ignored or denied representation in the design of the health systems. This research is innovative in combining ISE-with its traditional emphasis on safety-and leveraging intersectionality for understanding disproportionate risks on marginalized communities. One specific healthcare context where equity challenges are particularly salient is maternal health. Maternal mortality and severe maternal morbidity (SSM) have increased in Canada in the past 20 years. Racial and ethnic disparities are prevalent across all causes of maternal mortality and SSM. In the US, Maternal mortality and SMM are also associated with billions of dollars in healthcare expenditures. Half of all maternal deaths and SMM are preventable through timely and risk-appropriate care. The presence of substantial and persistent disparities after controlling for patient and hospital factors suggest systemic inequities in the design of the maternal care systems. Utilizing maternal care as a paradigm, this work will investigates inequity in health systems using ISE. The work seeks to develop a well-defined ISE methodology that can applied to identify system inequities, identify causal factors contributing to these inequities, and monitor variations as part of ongoing system safety efforts. As the Canadian population continues to diversify, understanding how health systems do or do not work for the populations they serve is essential for redesigning clinical pathways to provide safe, equitable care, and cost-effective care. Focusing on clinical system contributors to disparities is a novel underlying thread of this research aligning conceptually with population health and healthcare engineering frameworks and offering profound implication that extend far-beyond maternal health disparities for any health system.