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，但有新的证据表明，卫生系统受到系统性偏见的困扰。先前的研究已经确定了超过175项研究，记录了医疗保健中的种族/民族差异。由于有偏见的算法、糟糕的流程设计、继续使用种族主义医疗做法、对有色人种不可靠的医疗器械以及隐含的偏见和对文化不敏感的护理，这些不平等被设计到系统中。由于缺乏定义明确的概念模型、数据的可用性和质量方面的挑战(包括不敏感的衡量标准)以及定义不明确的数据分析方法，表征系统偏差是极其困难的。工业和系统工程(ISE)方法已被用来改进许多领域的系统设计，特别适合于确定导致不同结果的潜在系统性问题。ISE为检查系统公平性提供了坚实的理论基础，具有长期记录的系统性缺陷，当设计过程未能考虑到关键的用户群体时，可能会导致这些缺陷，包括在卫生系统设计中被忽视或被拒绝代表的边缘化社区。这项研究在将ISE与其传统的安全重点相结合方面具有创新性，并利用交叉性来了解边缘化社区面临的不成比例的风险。公平挑战特别突出的一个具体医疗保健背景是产妇健康。在过去的20年里，加拿大的孕产妇死亡率和严重孕产妇发病率(SSM)有所增加。种族和族裔差异在产妇死亡和SSM的所有原因中普遍存在。在美国，产妇死亡率和SMM也与数十亿美元的医疗支出有关。一半的产妇死亡和SMM可通过及时和适当的风险护理加以预防。在控制了病人和医院因素之后，存在显著和持续的差异，这表明在产妇保健系统的设计中存在系统性的不平等。利用产妇保健作为范例，这项工作将使用ISE调查卫生系统中的不公平。这项工作旨在开发一种定义明确的ISE方法，该方法可以应用于识别系统不公平，识别导致这些不公平的原因，并作为持续的系统安全努力的一部分来监控变化。随着加拿大人口的继续多样化，了解卫生系统如何为其服务的人群发挥作用，对于重新设计临床路径以提供安全、公平和具有成本效益的护理至关重要。关注造成差异的临床系统因素是这项研究的一条新的基本线索，在概念上与人口健康和医疗保健工程框架保持一致，并提供了远远超出任何卫生系统的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.