Boston Medical Center (BMC) is deeply committed to its mission of providing “exceptional care without exception” for its diverse patient population, in which 65% identify as “nonwhite” (primarily Black, Hispanic, or Latino/a). However, the social and medical context of 2020 forced the health center to recognize that it was not fully delivering on this mission: deep racial health inequities exist across the United States and among the center’s patients. BMC acknowledged that to drive change, we must recognize the role that all health care institutions have in amplifying disparities that are rooted in complex barriers to economic mobility as well as systemic discrimination within health care. In 2021, BMC launched its Health Equity Accelerator with the vision of transforming health care to deliver health justice and well-being. BMC is reimagining a new approach to accelerate its journey toward health equity and address core issues associated with traditional methodologies. Those involved in the accelerator have found that, to understand and address drivers of racial inequities, we need to challenge conventional wisdom in multiple ways: (1) revisit conclusions derived from standard statistical analyses; (2) adopt a mindset that if you do not find an inequity, you need to look harder; (3) seek novel insights through primary research with the appropriate mix of patients; and (4) engage with community members to achieve both insights and impact. The BMC accelerator addresses these fundamental issues through focused and multidisciplinary teams that are resourced to be dynamic, to break through convention, and to do things differently. The purposes of the present article are to describe the novel approach BMC is taking to address health inequities, illustrate the approach in action through BMC’s work on equity in pregnancy, share lessons learned from the journey so far, and emphasize the need for a shared goal of achieving health equity through intentionality, innovation, and sustained commitment.
Boston Medical Center (BMC) is an academic safety-net health system. Our origin as the first municipal hospital in the United States dates back to 1864. Today, our system includes an approximately 500-bed safety-net hospital and BMC HealthNet Plan (BMCHP), a predominately Medicaid health plan with approximately 400,000 members. We are deeply committed to our mission of providing “exceptional care without exception”. However, 2020 forced us to recognize that we are not delivering on this mission when there are significant gaps in health care outcomes among people of different races and ethnicities in Boston as well as in the rest of the United States. For example, Black neighbors have a 2.6-times higher rate of prostate cancer-related deaths than white neighbors, the infant mortality rate is 3.4 times higher for Hispanic infants than for white infants, and Covid-19 cases and deaths have been rampant among communities of color (Figure 1).1,2 We believe that our mission-driven approach may have even created blinders that have prevented us from examining the ways in which discrimination on the basis of race and ethnicity occurs within our four walls.
While these data are not new or surprising, the pandemic has forced us to acknowledge that we are not doing enough to equally promote health for people of all races and ethnicities. Like many others, we had adopted a largely “color-blind” approach to improving care. We subsequently realized that we need to be much more intentional and explicitly address health injustices in traditionally underserved and underinvested populations such as Black and Hispanic or Latino/a communities.
We also need to shift away from an approach that avoids accountability by focusing on patient factors to explain health outcome gaps. The advances of the last few decades have not translated into materially closing gaps and, in some instances, gaps have widened. Instead, we have come to believe that intentionality to address inequities will in fact improve outcomes for all.
We serve a highly diverse population in which over two-thirds of our patients identify as “nonwhite,” primarily Black, Hispanic, or Latino/a. If we want to fulfill our mission of providing “exceptional care without exception,” we need to truly understand the specific health needs of our population. We have many of the pieces in place to advance health equity: deep relationships with our community, passionate and talented colleagues, and a willingness to revisit all our practices. However, in 2020, we realized that these pieces were still working in siloes, and we started to align them to more purposefully address racial health inequities.
The Role of Health Systems in Creating and Perpetuating Health Inequities
Deep racial health inequities across the country are rooted in complex barriers to economic mobility as well as systemic discrimination within health care. As health systems, we must understand and address how we contribute to health inequities. The existing literature has identified at least four different mechanisms that stand in the way of health justice, both inside and outside the walls of health systems3:
1. Barriers to economic mobility.4,5 When people lack sufficient economic means to address their basic needs, they are not able to prioritize their health; instead, they are prioritizing survival.6 Decades of discriminatory policies (redlining, anti-Chinese laws, etc.) have caused Black, Indigenous, and People of Color (BIPOC) communities, for example, to face significant barriers to a life trajectory of thriving, which requires access to jobs, housing, education, and pathways to building wealth. Such barriers to economic mobility have a significant impact on health.
We realized that we need to be much more intentional and explicitly address health injustices in traditionally underserved and underinvested populations such as Black and Hispanic or Latino/a communities.
2. Institutions that are not approachable or relatable.3 Health care institutions often lack a diversity of care providers and languages offered and utilize clinical approaches that are not always inclusive of different cultures. Such factors create a health environment that is not always relatable to all members of a community.
3. A health system that is not always trustworthy.7 The national health system has a long history of medical practices that have directly or indirectly had negative impacts on marginalized groups, and therefore it must build trust with communities of color. Some of these practices (e.g., use of race in clinical protocols) still need to be reviewed and corrected. Such practices, particularly in context of an unapproachable system, erode trust among community members, who often feel that they do not have agency in their own health care and that decisions are being handed to them rather than being made with them.
4. Bias in individual interactions.8,9 Pervasive racial, gender, and other biases in our society permeate our health care institutions as well. In the near term, we must minimize all opportunities for bias to impact clinical outcomes. In the long term, we will need to retrain ourselves and unlearn harmful stereotypes and practices that negatively impact our community.
Understanding the Role That We Play in Perpetuating Inequities
We started this journey by looking internally: we needed to determine which of these health inequities are present within our patient population, understand their drivers and our contributions, and take accountability for them. In the fall of 2020, we conducted a robust diagnostic review of all areas within our system to identify those with the largest inequities in health outcomes by race and ethnicity. We chose to examine data from the greater Boston area (where most of our patients live) and pieced together public health data from publicly available reports such as the 2019 Community Needs Health Needs Assessment from the Boston CHNA-CHIP Collaborative,1 BMC patient-level data from our Electronic Health Record (EHR) system, and claims data from members of BMC’s accountable care organization (ACO).1 We found that health disparities are most prevalent in the following areas.
Maternal and Child Health
In the U.S., Black women are much more likely to die from pregnancy-related causes than white women. From 2007 to 2016, pregnancy-related deaths per 100,000 live births was 40.8 for Black women vs. 12.7 for white women (i.e., 3.2 times greater for Black women). The inequity becomes greater as education level, for example, increases: Black women with a college degree or more in the U.S. are 5.2-times more likely to die from pregnancy-related causes than their white counterparts.10
Given that maternal mortality is a rare event, there are not enough data in Boston or at BMC to look exclusively at trends by race. However, there are other negative outcomes related to pregnancy that we can investigate for inequities. For example, at BMC, the risk of severe maternal morbidity for Black mothers is 1.7 times the risk for white mothers, after adjusting for substance use disorder (SUD). This trend is also evident in infant health outcomes: infant mortality is 4.1 times higher for Black infants than white infants in Boston. Black infants are also more likely to be born prematurely or to have a low birth weight: in Boston, 12.5% of Black infants are low birth weight, compared with 6.1% of white infants.1 At BMC, Black infants are 1.5 times more likely to be born small for gestational age (SGA) compared with white infants.
Data show that there are stark inequities in the prevalence of chronic conditions between Black and white communities. For adults, our Black ACO members are 2.0 times as likely to be diagnosed with type 2 diabetes and 1.5 times as likely to be diagnosed with hypertension. In Boston overall, these gaps widen to 3.1 times and 1.9 times, respectively.1 For children, our Black ACO members are 1.3 times as likely to be diagnosed with asthma. In Boston overall, the emergency-department visit rate age among individuals 3 to 5 years of age is 5.7 times higher for Black children than their white counterparts.1
Infectious Diseases (e.g., Covid-19, sexually transmitted infections, influenza)
As of late March 2022, we estimate that Black Boston residents were 1.3 times more likely to have been diagnosed with Covid-19 and 1.6 times more likely to have died from Covid-19 compared with white residents.2 At BMC, we have observed lower Covid-19 vaccination rates for Black and Hispanic/Latino/a patients compared to white patients. We also have seen that Black ACO members are more likely than their white counterparts to be diagnosed with sexually transmitted diseases and infections (e.g., HIV/AIDS, gonorrhea, and chlamydia).
The existing gaps in health outcomes make it clear that what we have been doing to date is insufficient and too slow. Over the last year, we have worked to identify how we needed to shift our approach to accelerate progress.
Black ACO adults are less likely than white adults to be diagnosed with a behavioral health (BH) need (although the absolute prevalence is high for both groups): 54% for Black adults, compared with 71% for white adults. This pattern holds true for adults with SUD diagnoses, with rates of 22% for Black adults and 40% for white adults. Similarly, Black ACO children are less likely than white children to be diagnosed with major depression (5% vs. 7%).
However, some risk factors and negative outcomes related to BH are more common among Black ACO members, signaling potential underdiagnosis. For example, known suicidal/homicidal ideations and attempts are 1.2 times higher for Black children than for white children, and abuse and neglect are identified 1.8 times more frequently among Black children than among white children. Additionally, data suggest that the opioid epidemic is accelerating more quickly in the Black community: in Massachusetts, from 2019 to 2020, the opioid-related death rate for Black males increased by 63% (from 22.1 to 36.0 per 100,000 [age-adjusted]).11
In Boston, premature mortality due to cancer is 1.5 times higher for Black residents than for white residents.1 We saw particularly acute disparities between Black and white communities for breast cancer and prostate cancer. In Boston, Black women are 1.2 times more likely than white women to die from breast cancer.1 Black ACO members are 1.4 times more likely than their white counterparts to be diagnosed with breast cancer. We did not see disparities in mammography screening rates for Black BMC patients. Black men are 2.6 times more likely to die from prostate cancer than white men.1 We saw a similar degree of inequity in the prevalence of prostate cancer between our Black and white ACO members. Additionally, Black BMC patients who were diagnosed with prostate cancer were more likely than their white counterparts to be diagnosed at a later stage.
In the fall of 2020, we prioritized an effort to mobilize our entire health system for the purpose of developing an approach to advance health equity. We structured and resourced this process as we would any large-scale, long-term, transformational effort in order to create real, sustained progress. We formed six work groups to focus on (1) routine clinical operations, (2) areas of identified high inequity, (3) social determinants of health (SDOH) and community engagement, (4) research and education, (5) advocacy, and (6) workforce diversity, equity, inclusion, and belonging. A diverse group of 80 leaders reviewed our data, the academic literature, and patient and colleague interviews to develop an approach to address health equity from all angles within our system.
We Must Develop New Methodologies to Understand Inequities
The existing gaps in health outcomes make it clear that what we have been doing to date is insufficient and too slow. Over the last year, we have worked to identify how we needed to shift our approach to accelerate progress. We have learned that we must revisit traditional methodologies in at least four ways.
1. Revisit Conclusions Derived from Standard Statistical Analyses
Drivers of racial health inequities are often second-order effects. In addition, we often disregard some of the very issues we are trying to study because of incomplete race and ethnicity data or difficulty achieving sufficient power to detect statistically significant differences. For example, we relied on hospital analytics to merge clinical and SDOH data from across the hospital and its many community service sites to identify disparities experienced by our patients. The sophistication of the work lay in the integration of data, and by intent we decided not to embark on usual multivariable analyses as the common covariates associated with poor health outcomes are impossible to disentangle from structural racism (education, income, obesity, chronic disease, etc.).
To that end, as the categorization of race is inextricable from the lived experience of racism, we did not arbitrarily place the cutoff for further assessment at a p value of 0.05 but rather sought trends to ensure that we did not dismiss important leads and potential foundational contributors to racial inequity. This design was intended to ensure that we did not miss racism in unanticipated settings, many of which are cumulative from a life-course perspective. Our analytic goal was honesty with the data in the interest of genuinely improving the care that we deliver. This approach is intended not to reduce the importance of rigorous scientific approaches as we strive for change, but rather to ensure that standard statistical approaches do not reduce the likelihood of exposing critical contributors to health care inequities.
Accelerator teams are able to deconstruct a problem into its core elements and extract insights and solutions at a much faster pace than traditional models have done.
2. Adopt a Mindset That If You Don’t Find an Inequity, You Need to Dig Deeper
Not infrequently, the initial review of data suggested that no inequity was present. With persistence and continued exploration, inequities were revealed. For example, when we looked at the prevalence of mental health disorders, we found few disparities between white and Black patients. However, further investigation revealed signals pointing to underlying inequities. In particular, we found that white patients had higher rates of depression than Black patients, whereas Black patients were 1.6 times more likely to have attempted suicide and reported a 38% higher prevalence of persistent sadness. We suspect that these findings may be driven by underdiagnosis and decreased access to mental health treatment for Black patients, resulting in those inequities not being captured in medical records or health care claims.
3. Generate New Insights with Deep Primary Research (with the Appropriate Patients)
Traditional quality-improvement approaches are often heavily focused internally and do not leverage primary voices enough, especially from patients in historically marginalized groups. We need to (1) partner more deeply with the patients who are impacted by inequities to develop the areas of research that are most relevant to our community, (2) design studies that truly address the challenges of our patients of different races and ethnicities, (3) work with our colleagues in the biopharmaceutical industry to ensure that they understand the complexity and unique challenges of research studies in multicultural communities, and (4) develop solutions that truly meet the needs and aspirations of our patients.
For example, the Covid-19 pandemic disproportionately affected Black and Hispanic/Latino/a patients, prompting BMC to prioritize increasing vaccination rates for these communities. We conducted multiple focus-group sessions during which community members expressed their concerns about vaccination and suggested actions that BMC could take to improve uptake. We anticipated and confirmed a sometimes-profound lack of trust that would need to be overcome. Importantly, we also learned of practical barriers (e.g., vaccination sites being too far away, the inability to take time off work) that (1) led us to establish multiple smaller-scale community vaccination sites (as opposed to a central mass-vaccination approach), and (2) shaped our advocacy efforts to secure an adequate vaccine supply from the Commonwealth of Massachusetts during the early stages of the vaccination effort.
4. Partner with Community Leaders to Achieve Both Insights and Impact
We also need to partner with community leaders to design better interventions and further amplify their reach. For example, in the case of the Covid-19 vaccine, we knew that community leaders would play a critical role in overcoming trust issues and misinformation. We built on existing relationships and developed partnerships that provided invaluable insight and changed how we communicated with the community. We partnered with community leaders to open six vaccination sites at locally trusted institutions such as places of worship, the YMCA, and local Community Health Centers (CHCs).
We Launched the Health Equity Accelerator to Develop a More Effective Approach
As we reflected on the need to develop a new path, we launched the Health Equity Accelerator to elevate equity to a top priority, further interrogate our data, and develop new, innovative approaches to break through old dynamics and help us achieve health justice (Figure 2).
The name “Accelerator” reflects that we build from a base of existing efforts, but that we also recognize a desire to move much faster toward health equity. We have found that it takes a focused, multidisciplinary, interprofessional team to break through convention and start doing things differently. This approach provides an elevated path by which to establish an agile and highly effective partnership between analytics, operations, research methodologies, and patient input that is focused on the areas with the highest inequities.
Analysis of the causal mechanism of inequity in SMM rates between Black and white patients revealed that 59% of this inequity is driven by complications of preeclampsia.
Accelerator teams are able to deconstruct a problem into its core elements and extract insights and solutions at a much faster pace than traditional models have done. These teams are resourced to conduct deep primary research and to use those insights to analyze the data differently. To that end, they look intentionally for ways to isolate and uncover the second-order effects that may drive racial inequities and partner with community leaders to amplify the impact of any intervention.
The accelerator focuses on addressing the areas with the highest racial inequities, specifically, maternal and child health, infectious diseases, behavioral health, chronic conditions, and oncology and end-stage renal disease (ESRD), with an emphasis on maintaining a rigorous scientific mindset to ensure accuracy and to allow others to validate our findings and approaches.
We also have found that making progress requires focusing our attention and resources on one area at a time. Our first area of focus is pregnancy, as described in the section below.
The Accelerator Team
Elevating this work to have transformative impact required dedicated resources and expertise. Over a period of 12 months, we built out a core team of centralized resources and expanded capacity in certain functions for dedicated equity work streams. Functions in which we expanded resources include:
Executive leadership: clinical, strategy, community engagement, and research
Core enablers: project managers, analysts, patient engagement specialists, human resources and training resources, advocacy, communications, employee engagement, and administrative support
Resources to address inequities in social determinants of health: navigators, a social needs screener and referral system, economic mobility initiatives, and neighborhood revitalization investments
Research infrastructure: equity research grants; funded positions including research assistants, postdocs, methodological experts, or analysts; and connections to the broader research infrastructure of the institution
Special initiatives: equity in Covid-19 vaccine distribution, equity in pregnancy
Our Approach in Action: Equity in Pregnancy
The accelerator is developing a road map to address each area of inequity in a focused, resource-intensive way. The first area in which we are testing this new agile, multidisciplinary, interprofessional approach is pregnancy, which is consistently one of the areas with the largest gaps in health outcomes by race across the country.
Our appraisal of the situation started in the spring of 2020, when we started to test new approaches that would uncover novel insights on drivers of inequity. We convened a multidisciplinary team of more than 20 BMC experts in maternal-infant health, including researchers, physicians, nurses, community liaisons, and operations leaders from Obstetrics & Gynecology, Pediatrics, and Family Medicine. This group employed a number of key resources to enable a rapid assessment of inequities in pregnancy, including data and analytics support, multiple rounds of patient surveys and interviews, an intensive literature review, and input from frontline staff and pregnancy experts (Figure 3).
The first action of this team was to select two specific measures of important health outcomes within pregnancy in which inequities are among the largest among BMC patients: severe maternal morbidity (SMM) and the rate of babies born small for their gestational age (SGA). We found that our Black patients were 45% more likely to develop SMM (with rates 5.5% for Black patients compared with 3.8% for white patients) and 28% more likely to have babies born SGA (with rates of 8.6% for Black patients compared with 6.7% for white patients).
If You Don’t See an Inequity, Dig Deeper
When we first looked at pregnancy outcomes, the racial inequities based on race were smaller than what we had seen in the data from other states, so we conducted further analyses. We realized that, in the case of our patients, SUD co-occurrence was masking racial inequities. Specifically, among our pregnant population, SUD, which increases the likelihood of SMM, was far more prevalent among white patients than Black patients. Once we adjusted for SUD, the SMM inequity grew from 45% to 67%, the SGA inequity grew from 28% to 53%, and we discovered greater racial disparities than those initially observed (Figure 4).
They also reported that they fear that providers sometimes make ‘assumptions that they won’t follow through with a recommended course of treatment and take options off the table for us for that reason.’
Inequities in Severe Maternal Morbidity are Driven by Preeclampsia
Analysis of the causal mechanism of inequity in SMM rates between Black and white patients revealed that 59% of this inequity is driven by complications of preeclampsia. In particular, we found that (1) Black patients were 67% more likely to have preeclampsia (with a rate of 10% for Black patients vs. 6% for white patients), and (2) when Black patients have preeclampsia, they have about 2.2 times the risk of SMM as compared with their white counterparts (Figure 5).
We continue to seek to uncover what may be driving this difference in outcomes through data mining, focus groups, and quality-improvement methodologies. After eliminating common patient characteristics as drivers of differences in outcomes, we hypothesized that bias in certain processes (such as expediency in the management of preeclampsia) or interpersonal dynamics that influence decision-making may play a role in these disparities.
For example, in 2019, in the context of our quality-improvement work, we found that our “decision to incision” time for urgent C-sections was significantly longer for Black patients than for white patients. We then introduced a metric to focus on the “decision to incision” time and significantly reduced the time disparity. By focusing on this metric and standardizing this process, we decreased the apparent process bias and, as a result, made progress toward closing this gap.
Information obtained from our patients during our primary research is also pushing us to further investigate all critical points of clinical decision-making during preeclampsia management. For example, we interviewed 24 patients who identified as Black women and had preeclampsia during their pregnancy. During those interviews, patients told us that even though they believe that our providers “demonstrate they care through active listening, being responsive, following up and being kind,” they also said they “did not feel heard during labor and delivery, including in the decision-making process.” They also reported that they fear that providers sometimes make “assumptions that they won’t follow through with a recommended course of treatment and take options off the table for us for that reason.” These insights are shaping our approach to training our staff in delivering equitable care.
Socioeconomic Disparities May Drive Inequities in Birth Weight
In contrast to our findings regarding preeclampsia and SSM, preeclampsia did not seem to be associated with inequity in SGA rates between Black and white patients. While preeclampsia was found to contribute to the rate of SGA among our patients overall, this contribution was similar for Black and white patients and therefore was not contributing to the racial disparity in outcomes.
SGA was more highly linked with Medicaid coverage, suggesting that low-income status or poverty was a significant driver of SGA.
Instead, SGA was more highly linked with Medicaid coverage, suggesting that low-income status or poverty was a significant driver of SGA. Black patients were more likely than white patients to be covered by Medicaid due to structural inequities impacting income and wealth. Additional analysis revealed several risk factors that were linked with both Medicaid coverage and higher SGA rates for Black patients, such as mental health disorders (especially depression), alcohol use during gestation, homelessness, and low BMI. Furthermore, there is already a body of evidence linking stress due to racism or discrimination to low birth weight.12-14
We have much more to understand going forward, but we believe that we have a foundation of insight from which to begin to dismantle obstetric racism during the prepartum, labor, birth, and postpartum stages. As a result of this work, we are preparing to launch a set of foundational interventions while continuing to research the findings and questions that have been uncovered by our work to date. These foundational interventions include, but are not limited to, the following (Figure 6):
Improve patient education and support patient agency
Expand Birth Sisters, BMC’s doula service, to provide enhanced support for Black patients with high-risk pregnancies.
Develop an AI-driven, text-based chatbot to share information about pregnancy (including preeclampsia and diabetes) and to connect patients with social services.
Enhance access, quality, and experience
Expand access to remote monitoring for gestational hypertension and diabetes, which we hope will help overcome barriers and build trust through consistent and timely interactions as well as opportunities for education.
Codesign interventions with patients and community members. For example, we completed a series of in-depth patient interviews focused on Black patients who had delivered at BMC and had preeclampsia and held two focus group sessions to help us design the chatbot intervention.
Approach clinical care with an anti-racist lens
Review our care practices for patients with hypertensive disorders of pregnancy (e.g., how we prescribe and follow-up on adherence to low-dose aspirin).
Continue to study our own clinical data to understand differences in preeclampsia care for Black and white patients and how those differences may contribute to inequities in SMM.
Understand the experience of racism in pregnancy care
Participate in a 15-month capacity-development program designed and facilitated by Birthing Cultural Rigor, LLC.
Implement the novel and valid Patient-Reported Experience Measure of Obstetric Racism (the PREM-OB Scale™ Suite).15
Complete a rhetorical analysis of language used in de-identified electronic medical records, a structural analysis of power and access to a SACRED (Safety, Autonomy, Communication, Racism, Empathy, and Dignity) birth, and an ethnographic analysis of patient, community, and hospital perspectives of obstetric racism.16
Expand overall capacity of our ob-gyn service to address issues of inequity
Expand operational and project management resources.
Expand patient-facing roles to support specific initiatives (e.g., by utilizing nurses to support remote monitoring, community wellness advocates to support the chatbot, etc.).
Expand salary support for physician leads.
Expand data, analytics, and evaluation support (e.g., by utilizing postdoctoral students and research assistants to advance the evaluation of interventions).
Shifting Our Core Approach to Care Delivery Is Essential to Achieve Health Justice
Through this work, we have learned that, while there is no “magic bullet” to eliminate inequities, health systems can accelerate their journey toward closing these gaps by incorporating the following principles into their approach:
Shift focus from describing inequities to interrogating and eliminating them. Develop a more sophisticated understanding of the barriers to health equity to inform effective, actionable solutions.
Deploy a multidisciplinary approach that includes patient and community voices and has a bias to action. Enable researchers, operations experts, and clinical staff to work together to rapidly understand barriers to equity and develop solutions in partnership with patients and community members.
Prioritize and resource efforts focused on racial equity in a sustainable way.
Approach the work with a long-term commitment, not just a short-term initiative.
Ensure that there is an academic approach to studying the current situation, being willing to challenge the status quo and ensuring that there is a commitment to educate and inform at every level of the health system.
Focus on one clinical area at a time and address it from many angles to transform the holistic care delivery experience.
Leverage insights from others. Racial inequities are pervasive across our country, and we have found that many trends seen at the national level hold true at BMC. For systems that may not have the capacity to do the same in-depth research, leveraging insights from others and starting to implement solutions will drive progress.
Consider community context. We are continually reminded that “all change is local,” and we must understand the distinct needs and desires of the communities that we serve to address health equity in a truly transformative way.
Health systems owe it to their patients to take a more intentional approach to racial health equity and develop bold, innovative solutions to finally address this long-standing problem of racial health inequity. We anticipate that this journey will be long and will require organizations to examine every aspect of the care they deliver and the way in which medicine is practiced to eliminate inequities. At BMC, our Health Equity Accelerator incorporates the dynamic approach that we believe is required and represents our long-term commitment. Our belief is that health justice can be accomplished with intentionality, innovation, and sustained commitment. Our hope is that our journey will inspire other health systems to address inequities as a moral imperative in their communities.
*Elena Mendez-Escobar and Tejumola M. Adegoke are co-first authors. Alastair Bell and Thea James are co-last authors.
We thank Ravin Davidoff, MB, BCh, Rob Koenig, MBA, Nina Kalluri, and Perri Smith for their countless contributions to the Health Equity Accelerator; Petrina Martin Cherry, MBA, and Sophie Wilson for their leadership of BMCHS’s community engagement efforts; John Goldie, MBA, Jason Flood, MBA, Jerry Sobieraj, MD, and Sidney Jean, MPH for their contributions to our internal data analysis of racial inequities; Ron Iverson for his leadership of the “Decision to Incision” Quality Improvement initiative; Rob Graham, MPA, Josh Read, Ryan Wilson, and Zanefa Walsh for their contributions to the branding of the Health Equity Accelerator and the visualizations in this piece; Linda Sprague Martinez, PhD, for her leadership of patient interviews focused on how Black patients with preeclampsia experience care at BMC; and Karen Scott, MD, MPH, FACOG, and her team at Birthing Cultural Rigor, LLC, for their ongoing partnership.
Elena Mendez-Escobar, Tejumola M. Adegoke, Aviva Lee-Parritz, Julie Spangler, Stephen A. Wilson, Christina Yarrington, Ziming Xuan, and Alastair Bell have nothing to disclose.
City of Boston. Racial Data on Boston Resident COVID-19 Cases. Boston.gov. Updated March 21, 2022. Accessed March 23, 2022. https://www.boston.gov/departments/mayors-office/racial-data-boston-resident-covid-19-cases.
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Petersen EE, Davis NL, Goodman D, et al. Racial/ethnic disparities in pregnancy-related deaths — United States, 2007–2016. MMWR Morb Mortal Wkly Rep 2019;68:762-765 https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6835a3-H.pdf.
Massachusetts Department of Public Health. Opioid-Related Overdose Deaths, All Intents, MA Residents - Demographic Data Highlights. November 2021. Accessed March 23, 2022. https://www.mass.gov/doc/opioid-related-overdose-deaths-demographics-november-2021/download.
Larrabee Sonderlund A, Schoenthaler A, and Thilsing T. The association between maternal experiences of interpersonal discrimination and adverse birth outcomes: a systematic review of the evidence. Int J Environ Res Public Health 2021;18:1465 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7913961/.
Alhusen JL, Bower KM, Epstein E, and Sharps P. Racial discrimination and adverse birth outcomes: an integrative review. J Midwifery Womens Health 2016;61:707-720 .
Giscombé CL and Lobel M. Explaining disproportionately high rates of adverse birth outcomes among African Americans: the impact of stress, racism, and related factors in pregnancy. Psychol Bull 2005;131:662-683 .
White VanGompel E, Lai J-S, Davis D-A, et al. Psychometric validation of a patient-reported experience measure of obstetric racism© (The PREM-OB Scale™ suite). Birth 2022;00:1-12 https://onlinelibrary.wiley.com/doi/10.1111/birt.12622.
Scott KA. Prioritizing Patient Narratives & Community Wisdom in Quality Improvement and Implementation Science. In: Advancing Maternal Health Equity and Reducing Maternal Morbidity and Mortality: Proceedings of a Workshop. Washington, DC: The National Academies Press, 2021:31-34. https://www.ncbi.nlm.nih.gov/books/NBK575266/#_NBK575266_pubdet_.
Scott KA. The rise of Black feminist intellectual thought and political activism in perinatal quality improvement: a righteous rage about racism, resistance, resilience, and rigor. Feminist Anthropol 2021;2:155-160. https://anthrosource.onlinelibrary.wiley.com/doi/10.1002/fea2.12045.
Davis D. Reproductive Injustice: Racism, Pregnancy, And Premature Birth. New York: NYU Press, 2019.
Scott KA, Chambers BD, McKenzie-Sampson S, et al. The Virtual Perinatal Quality Improvement Prioritization By Affected Communities (V-QPAC) Protocol. Health Serv Res 2021;56:56-57 https://onlinelibrary.wiley.com/doi/10.1111/1475-6773.13776.
NEJM Catalyst Innovations in Care Delivery
June 7, 2022
Copyright ©2022 Massachusetts Medical Society.
Published in issue: May 1, 2022
Published online: June 7, 2022
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