Research and reducing inequity in healthcare

The World Health Organization defines equity as the absence of avoidable, unfair or remediable differences among groups of people [1]. Health equity is about fairness and justice and implies that everyone should have an equal opportunity to attain their full potential for health or for the use of health care. It is different to equality which is the equal distribution of resources so that all receive the same amount. If such a distribution is unfair or unjust as it leads to adverse outcomes it is considered inequitable. The idea of equity goes above equality and health inequities are more than just inequalities [2].

Equity in healthcare is an important issue affecting politicians, clinicians and health economists. One of the core values of the NHS is to provide fair and equitable services for all to reduce inequities in experience, access or outcomes between differing groups or sections of society requiring health care [3]. Driven by the Darzi report, commissioning of such services is often dependent on evidence base. While it is reasonable not to develop services unless there is evidence of benefit, one must question why there is a lack of evidence; is it because research has not adequately covered an area of interest or patient group, or is it because an intervention truly is not beneficial? Absence of evidence is not evidence of absence [4]. It is vital that research and researchers do not unwittingly contribute to inequity by excluding vulnerable groups without good reason. Equally policy makers should not over interpret its absence, as a means of disinvesting or rationing-an example of MacNamara’s fallacy assuming that the reason something has not be measured or investigated is because it does not exist. This may result in denying groups of patients the interventions that may benefit them. It is well recognised older people are often underrepresented in clinical trials and this is unfair as often older people carry a disproportionate burden of disease [5]. In addition older people also present new challenges of frailty, chronic disease and coexisting multiple co-morbidity and polypharmacy that have an impact on the delivery of new treatments. It is often difficult to practice evidence based medicine in older people because there are not the research data to support it.

In a study published in this issue Sheehan et al. [6] set out to determine the extent to which equity factors contributed to eligibility criteria of trials of rehabilitation interventions after hip fracture. They identified randomised controlled trials using a systematic search of various databases from 1 January 2008 and 30 May 2018. They defined equity factors according to the PROGRESS-PLUS framework, extracting data for equity factors in eligibility criteria, baseline characteristics, and subgroup analyses. They identified 69 equity factors included as eligibility criteria in 35 trials. In more than 50% of trials, potential participants were excluded because of residency in a nursing home, cognitive impairment, mobility or functional impairment, minimum age, and/or nonsurgical candidacy. This amounted to the exclusion of 2,383 out of 8,736 (27.3%) potential participants based on equity factors in the studies that reported these data. Residency in a nursing home and cognitive impairment were the major contributors with a 17% exclusion rate. 82.9% of trials excluded potential participants based on cognitive impairment.

This raises legitimate questions about the generalisability of trial results on rehabilitation post hip fracture to the general population that includes frail older people with cognitive impairment since one third of patients admitted with hip fracture are cognitively impaired [7]. One cannot and indeed should not generalise results that may be invalid or not be applicable to particular groups. This is often what happens in real life when evidence is extrapolated to these equity groups. Clinicians need more guidance as to what treatments work best. In addition when resources are limited, this lack of evidence also perpetuates the belief and assumption that such patients don’t benefit from rehabilitation interventions and there is nothing one can do without providing the evidence for this [8]. It also becomes more difficult to challenge these perceptions [9]. Seeing that they have higher complication rates and death it is possible that there are ways how they could benefit but the lack of trial evidence makes it unclear what interventions work if any. After all as Sheehan et al. [6] point there are a number of studies that have shown benefits of rehabilitation in cognitively impaired patients by way of increased mobility and better functional and cognitive outcomes.

One of the limitations of the paper is that it is restricted to rehabilitation after hip fractures however the issues it raises have broader implications. The question whether inequity in research in general leads to inequity in health delivery needs to be considered. Research undertaken in various areas of medicine, not just post hip fracture, shows disparities in health and health outcomes within and between populations [10, 11]. There is a lack of evidence how to reduce health inequities and this challenges commissioners when tackling inequity [12]. It is important to avoid aggravating this inequity among research participants and produce information that is useful to decision-makers. This is not an easy task and there are issues of practicality and feasibility to be overcome. Recruitment, retention, data collection and adherence to the intervention may be difficult when researching some equity groups. In addition there are ethical and legal aspects to consider. One such example, English mental capacity law states that one cannot research people who lack capacity if the same research can be done on those with capacity. There are various recommendations to improve research in equity groups [6] but it is up to researchers and funding bodies to facilitate this process by developing research that specifically targets areas of inequity, not just cognitive impairment and nursing homes, but also other broader important areas such as frailty. There is a need to design studies that have sound methodology including having homogenous populations as much as possible and have explicit criteria for the inclusion of vulnerable and disadvantaged populations when planning interventions. They need to be properly accommodated in the design, conduct and analysis of the trial, allowing for the possibility of subgroup analysis and regression [13, 14]. A concerted effort to reduce inequity in research is needed to avoid unwittingly promoting inequity in service provision and development because of ongoing lack of evidence.

Apart from highlighting where important gaps in knowledge in rehabilitation post hip fracture, this paper highlights the need for more equity-relevant trials to avoid aggravating inequity and to produce information that is useful to decision-makers.

Conflict of interest

None.

Funding

None.

REFERENCES