Equity in evidence shouldn’t be an afterthought

Author: Suzanne McGurn 

We can’t achieve health equity in Canada, or globally, without considering equity in the evidence we use to make healthcare decisions. That’s why I was so pleased to see that this year’s World Evidence-Based Healthcare Day campaign was ‘evidence and global health equity’.

I began my career as a registered nurse. I lived and worked in northern Ontario for one of my practicum placements, which included flying into an Indigenous community to provide care. I quickly learned how equity (or more precisely, inequity) directly influenced the care provided.

In the communities where I was working, pregnant people were expected to leave their homes and support networks during the last weeks of their pregnancy and travel alone, often for hundreds of kilometres, to give birth in the hospital. I saw first-hand how inequitable access to health services created unnecessarily difficult and, in some cases, unsafe conditions for those individuals and their families.

My early nursing experiences and exposure to health equity issues influenced me profoundly. They’ve shaped my career as a clinician, as a public servant, and now as the CEO of a national health technology assessment (HTA) agency, where considering equity in the evidence we assess is a top priority.

On World Evidence-Based Healthcare Day, I’m looking forward to learning how organisations around the world are incorporating equity into evidence, as well as sharing the experiences of the Canadian Agency for Drugs and Technologies in Health (CADTH) in Canada.

What is equity in evidence and why does it matter?
Equity exists when people are treated according to their diverse needs in a way that enables them to participate, perform and engage. This differs from equality, which means people are treated equally, regardless of their needs.

Equity considerations in the evidence used to assess health technologies can enhance decision-making, optimise resource allocation, improve patient trust, prevent unintended consequences, address disparities, and promote social justice.

Equity at CADTH
Since 1989, CADTH has been a trusted source of independent information and advice for Canada’s publicly funded health care systems. Health administrators and policy experts rely on us to help inform their decisions about the life cycle management and appropriate use of the drugs, devices and services used to prevent, diagnose and treat medical conditions.

CADTH has evolved significantly over the past 35 years to include more equity considerations in our evidence, library sciences, and reports and recommendations.

Last year, we launched a new strategic plan that includes equity as one of the guiding principles. With the strategic plan as our guide, CADTH is taking an integrated approach to equity and applying an equity lens to everything we do.

To help expand our expertise in this area, we recently created and staffed two new positions focused on equity: a strategic partner for inclusion, diversity, equity, and accessibility; and a strategic partner for Indigenous engagement and partnerships.

These new employees are helping us evaluate who is represented on CADTH’s expert and advisory committees and ensuring that we consult with clinicians and patients with diverse lived and living experience. They also help ensure that the language we use in our reports and recommendations – and with one another – is inclusive, nonbiased and respectful.

Equity in the evidence CADTH assesses

Incorporating Indigenous knowledge
We recently developed a CADTH Statement of Reconciliation as a first step to better understand how we can work with Indigenous peoples and communities to support their health priorities. We’re also investigating respectful approaches to locate and present Indigenous knowledges for consideration in our HTAs. A HTA is the systematic evaluation of the direct and intended effects, and the indirect and unintended consequences, of a drug, diagnostic test, and medical device or procedure (collectively referred to as health technologies).

In many cases, the transmission of Indigenous knowledges relies on oral traditions, and we miss this information when we only search for evidence in mainstream information resources published in research journals or online databases.

There are many questions about who has the right to access sacred knowledge, and when and how it is shared. We are continuing to explore these questions as we develop an Indigenous relations and engagement strategy to build authentic and equitable relationships that will help us meaningfully incorporate Indigenous knowledges systems into our work.

CADTH’s work on Indigenous knowledges has influenced our understanding of the biases embedded in Western-based evidence and its potential impact on health policy decisions that affect all equity-deserving populations.

Embracing equity within CADTH’s library sciences
Developing new approaches to find evidence on equity topics is another area of focus.

Typically, library science delivers a framework for finding evidence that can be applied to any subject; however, there could be bias embedded in the framework and the evidence provided for a review. Adapting for inequities in data sources, the data itself, and the systems that analyse data is essential to make better decisions about the evidence. Who has access to the data is another consideration, as is evaluating what’s measured, what’s considered evidence and what may be missing.

Incorporating equity considerations in CADTH’s reports and recommendations
At CADTH, evaluating equity in the evidence helps ensure that healthcare interventions are assessed and implemented fairly. In addition, it ensures that health system leaders have the information they need to make policy and practice decisions that result in the best health outcomes for everyone.

CADTH’s review of Peer Support Programs for Youth Mental Health was our first project to use the equity checklist for HTA and include equity considerations throughout.

The equity checklist for HTA is a framework used to assess equity-related issues in healthcare decision-making, especially during the assessment of new health technologies. The checklist can be consulted at each phase of an assessment to ensure equity is being considered.

We’ve been testing and evaluating how this checklist and other guides can help make HTA more equitable and better position HTA as an enabler of health equity in Canada. Ethical considerations in CADTH’s reviews help us assess equity and ethical implications by examining how:

• the evidence may be biased against, or not account for, equity-deserving groups or their interests
• implementation may address, create or reinforce health system inequities
• inequities may occur in access to treatment, care, outcomes or use of therapy for patients, caregivers and providers.

Ethical considerations are especially important when evaluating complex therapies like chimeric antigen receptor (CAR) T-cell therapies for haematological cancers or first-in-class drugs for rare diseases. They support health system leaders in considering the ethical and equity implications whenever novel therapeutic options are introduced.

The way forward
Considering equity in evidence will help CADTH foster health systems that reflect the diverse people of Canada and respond to the self-identified priorities and cultural practices of Indigenous peoples. We’ll continue to integrate equity considerations into our evidence by adapting our methodologies and analyses to include additional perspectives like environmental and patient perspectives. This fall, CADTH will release a series of reports about emergency department overcrowding in Canada that will include important equity and ethical considerations.

Early in my career, I saw how inequities directly affected people, their families and their health outcomes. Today, I’m confident that, by considering equity in the evidence CADTH assesses upfront, and not as an afterthought, we can help improve health equity in Canada.

Disclaimer
The views expressed in this World EBHC Day Blog, as well as any errors or omissions, are the sole responsibility of the author and do not represent the views of the World EBHC Day Steering Committee, Official Partners or Sponsors; nor does it imply endorsement by the aforementioned parties.