Aiming for health equity: the bullseye of the quadruple aim

In 2014, Drs. Bodenheimer and Sinsky introduced the Quadruple Aim into our health system improvement lexicon (1). Building off of the Triple Aim articulated by Dr. Berwick (2), an early pioneer of quality improvement in health systems and healthcare, the Quadruple Aim expanded the goals of enhancing patient experience, reducing cost and optimizing population health to include improvements to the work-life and experience of clinicians and care teams that provide care to patients. Immediately after and further catalyzed by emerging literature on the enormous financial, clinical and workforce impact of clinician burnout (3), evolving clinical settings focused on population health and national alternative payment models for advancing primary care delivery in new ways, and the true north for optimal health system performance was codified—it was now reflected in the Quadruple Aim. In fact, the addition of this 4 aim effectively eclipsed the other aims, because optimization of the initial Triple Aim was now considered impossible without the additional focus on clinician and workforce wellness, resilience and satisfaction. However, what became apparent was that a stringent focus on checking the boxes to the Quadruple Aim was insufficient, in and of itself, to reduce health disparities. The notion that global improvements in quality and delivery of care would improve health disparities and achieve health equity is explicitly false (4). In fact, the opposite is true. The health system in the United States is one of the most inequitable when compared to peer developed nations. Despite enormous spending on health care per capita, in fact spending more per capita than all other nations in the Organization for Economic Cooperation and Development combined, the United States has staggering and disappointing outcomesranking 28 out of 34 countries in life expectancy, 33 in infant mortality and 1 in poverty (5,6). In the landmark Mirror, Mirror International Comparison report done by the Commonwealth Fund, the United States ranked last on performance overall, and ranked last or near last on the Access, Administrative Efficiency, Equity, and Health Care Outcomes domains (7). While this performance certainly challenges the health system to rethink its focus, perhaps more confronting is the growing body of evidence about significant health and health care disparities based on race, ethnicity, income, zip code, education and other social determinants (8). For example, in the state of Ohio, known for its alarmingly high rates of infant mortality, numerous initiatives led to an overall decrease in infant mortality from 2009 to 2018, an average decrease of 1.1% per year. However, regardless of these global improvements spurred by advocacy and education initiatives as well as clinical and population health efforts, the Black infant mortality rate has not changed significantly since 2009 and Black infants still die at rates 2.5–3 times higher than White infants (9). Additional complexities are created by the foundational concept of intersectionality (10), so intersectional analyses must be considered in any examination of health disparities in the United States (11). As an example, interlocking systems of oppression for Black women have resulted in Black women in the US having the shortest healthy life expectancy of all racial/ethnic gender groups, even shorter than Black men. Inequities based on race are significantly Editorial Commentary