Advancing health equity: The quintuple aim

Since 2008, the triple aim framework[1] has supported health care improvement through the simultaneous pursuit of three goals—improving population health, enhancing the care experience, and reducing costs—to optimize health system performance. The triple aim was expanded to the quadruple aim in recognition of the growing challenge of burnout (i.e., exhaustion, cynicism, and professional dissatisfaction) among physicians and the health care workforce.[2] Now there is an imperative to advance health system improvement beyond the quadruple aim to the quintuple aim, with simultaneous advancement of health equity, purposefully focusing on individuals and communities who need improvement and innovation the most.[3]

Health equity is defined by the World Health Organization as “the absence of avoidable or remediable differences among groups of people.”[4] It is achieved when everyone can attain their full health potential and no one is disadvantaged because of social position or other socially determined circumstances. While Vancouver is one of the healthiest cities in the world, life expectancy between neighborhoods just 5 km apart can vary by as much as 9.5 years; some neighborhoods have mortality rates 17 times higher than others.[5] Some of the areas with better outcomes have more services, more green space, and more transit; there may be attribution to specific policies and social factors that are remediable.[5] Living conditions are often made worse by discrimination, stereotyping, and prejudice. Discriminatory practices are often embedded into institutional and systems processes, resulting in underrepresentation in decision-making at all levels and underservice.

A person’s physical and mental health and well-being are influenced by social, economic, and environmental factors, which can cluster in populations. Protective factors include access to a healthy diet, physical activity, education, stable employment, a stable support network, and quality housing. Risk factors include smoking, adverse childhood experiences, exposure to violence, and alcohol and drug misuse. Without an explicit focus on reduction of disparity and correction of systemic inequities, the opportunities to promote or restore health and well-being can be lost. Addressing inequity benefits current and future generations.

Primary health care has strong potential for reducing health disparities. Fostering innovation and development of integrated community-based care can be critical to reducing disparities. Low-income people have greater prevalence of chronic illness and fewer resources to manage them. They have poorer housing, less access to transportation, and less income for prescriptions and healthy food. Finally, they are less likely to have strong social supports. Not only do these factors affect mortality rates of chronic diseases over time, but they are also drivers for acute health crises, such as the opioid overdose crisis and the COVID-19 pandemic. Services that are centrally located, are designed to fill support gaps, and provide outreach for early detection, follow-up, and ongoing care will reduce disparities. The best model includes health care teams of multiple providers, with coordinated, continuous, relationship-based care provided by community longitudinal family physicians and practice teams throughout a patient’s lifetime.

There is an urgent need to address the inequities caused by unjust and unfair factors within health systems. Adopting the quintuple aim will lead to reduction of disparity and correction of systemic inequities to improve conditions of daily life. With patients as our partners, we must all be learners and active participants in decolonizing BC’s health care system, returning the right to access quality health care that is safe and free of racism and discrimination. Health systems should alleviate challenges that people face, not add to them, and facilitate access to the care that people need.
—Katharine McKeen, MD, MBA, FCFP
Member, COHP

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This article is the opinion of the authors and not necessarily the Council on Health Promotion or Doctors of BC. This article has not been peer reviewed by the BCMJ Editorial Board.

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

References

1.    Berwick DM, Nolan TW, Whittington J. The triple aim: Care, health, and cost. Health Aff 2008;27:759-769.

2.    Bodenheimer T, Sinsky C. From triple to quadruple aim: Care of the patient requires care of the provider. Ann Fam Med 2014;12:573-576.

3.    Nundy S, Cooper LA, Mate KS. The quintuple aim for health care improvement: A new imperative to advance health equity. JAMA 2022;327:521-522.

4.    World Health Organization. Health equity. Accessed 16 December 2022. www.who.int/health-topics/health-equity.

5.    Yu J, Dwyer-Lindgren L, Bennett J, et al. A spatiotemporal analysis of inequalities in life expectancy and 20 causes of mortality in sub-neighborhoods of Metro Vancouver, British Columbia, Canada, 1990–2016. Health Place 2021;72:102692.