Making the social determinants of health the focus for healthcare improvement efforts

Quality improvement efforts must start to focus on the environments in which humans are “born, grow, live, work, and age,” argues Kaveh G Shojania

Well known quality improvement (QI) interventions, such as computerised decision support and performance report cards, typically increase the proportion of patients receiving recommended care by just 5%.[1][2] Even for conditions such as diabetes, the impacts of decades of improvement efforts on intermediate outcomes, like glycemic control and cardiovascular risk factors, tend to be tiny.[3]

In patient safety, which launched the interest in QI 20 years ago, the effectiveness of the two most famous success stories, surgical checklists and the bundle to prevent central line associated bloodstream infections, still remains unclear.[4][5][6] We have more names for this area of study—improvement science, implementation science, knowledge translation, diffusion, and innovation—than we have effective interventions.  

It is tempting to regard this as a failure of the field. Yet marginal gains apply to most of the biomedical enterprise, not just QI. Biomedical research has chased after “magic bullets” since Paul Ehrlich coined the phrase over a century ago. Most products of the massive investments in this enterprise fall far short of that goal. For instance, even in patients with established coronary artery disease, 30-100 patients need to take a statin for 10 years to avert one adverse cardiac event or death in a single patient.[7]      

A version of the London tube map with values for the average life expectancy in each neighbourhood shows striking differences, such as a 20 year difference in life expectancy between those born near Oxford Circus and others born close to some stations on the Docklands Light Railway.[8] These striking differences do not reflect differential provision of statins or any other aspect of healthcare delivery. 

Many have commented over the years that the major advances in health enjoyed by wealthy countries in the 20th century reflect advances in hygiene, nutrition, and public health, not the therapeutic advances that have consumed so much time and money over the subsequent decades. And, as Tudor Hart pointed out 50 years ago with his Inverse Care Law,[9] the people who typically receive these therapeutic advances often need them the least. The covid-19 pandemic has revealed the adverse consequences of these inverted investments, with poor public health capacity and socioeconomic disparities giving rise to so many health problems in wealthy countries, while lower and middle income countries, like Vietnam, with solid investment in public health infrastructure, have had strikingly low death rates.  

We invest billions to develop new drugs for cardiovascular disease, type 2 diabetes, cancer, etc. but little to address the reasons they became common in the first place. We invest massively in developing and evaluating the effectiveness of bariatric surgery, but spend orders of magnitude less on public health and policy interventions to reduce obesity. An explosion of new inhalers for asthma and chronic obstructive pulmonary disease have appeared over the past 20 years. Yet we have invested almost nothing in reducing air pollution or climate crisis induced wildfires, both of which produce detectable effects on rates of hospitalisation and even all cause mortality.[10][11]

We face multiple major crises: covid-19, the climate crisis, ever worsening economic inequalities, and ongoing violence against racialised groups, epitomised by Black Lives Matter in the US and calls for justice for Indigenous peoples, which are equally important in many countries. As an increasing number of people and organisations’ voices have pointed out, “We are not all in the same boat, just the same storm.”  

In the face of such challenges as we face—in healthcare and the world in general—“realism and radicalism are not so far apart.”[12] In that context, we must move away from chasing after marginal increases in the proportions of patients receiving guideline concordant care, reducing readmissions, and other routine QI targets. Instead, we must focus on the environments in which humans are “born, grow, live, work, and age”—the so called social determinants of health.[6] 

What might turning our attention to such factors look like? It might include initiatives to screen patients for basic unmet needs such as food and housing,[13] and assigning social workers or health advocates to these patients to help them gain these resources. It might also include interventions that directly address these challenges on a larger scale, such as with interventions to provide housing to homeless people with mental health problems,[14] or even broader projects such as providing universal basic income on a large scale.[15] 

Such efforts may seem very far from the plan-do-study-act (PDSA) cycles involved in projects aiming to remove unnecessary urinary catheters and other common QI targets.[16] Yet the idea underlying PDSA cycles is iterative refinement. And, complex interventions—whether the complexity lies with the intervention itself, the target of the intervention, or the context in which it will operate—typically require iterative refinement.[17]

All of biomedicine needs to focus more on the obvious causes of poor health, such as poverty, air quality, food security, structural racism, and the effects of the climate crisis. And those who work in healthcare quality need to collaborate with those working in public health, schools, and other social sectors  to develop, refine, and evaluate changes that achieve substantial improvements in health for large segments of society.  

This article was commissioned by The BMJ to coincide with THIS Institute’s annual conference, THIS Space 2020, which The BMJ is a media partner for. Kaveh Shojania is a keynote speaker at the event.

Kaveh G Shojania is professor and vice chair (quality & innovation) in the Department of Medicine at the University of Toronto. He was the former editor in chief of BMJ Quality & Safety. His research has focused on identifying effective strategies for improving healthcare quality. More recently, he has become interested in addressing obvious threats to health, such as poverty, systemic racism, and the climate crisis. Twitter @kgshojania

Competing interests: None declared.


[1] Kwan JL, Lo L, Ferguson J, Goldberg H,  et al. Computerised clinical decision support systems and absolute improvements in care: meta-analysis of controlled clinical trials. BMJ 2020;370:m3216.
[2] Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, et al. Audit and feedback: effects on professional practice and healthcare outcomes. The Cochrane database of systematic reviews 2012;6:Cd000259.
[3] Tricco AC, Ivers NM, Grimshaw JM, et al. Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis. Lancet 2012;379(9833):2252-61.
[4] Urbach DR, Dimick JB, Haynes AB, Gawande AA. Is WHO’s surgical safety checklist being hyped? BMJ 2019;366:l4700.
[5] Marang-van de Mheen PJ, van Bodegom-Vos L. Meta-analysis of the central line bundle for preventing catheter-related infections: a case study in appraising the evidence in quality improvement. BMJ Qual Saf 2016;25(2):118-29.
[6] Shojania KG. Beyond CLABSI and CAUTI: broadening our vision of patient safety. BMJ Qual Saf 2020;29(5):361-364
[7] Rosenson RS, Hayward RA, Lopez-Sendon, J.  Management of low density lipoprotein cholesterol (LDL-C) in the secondary prevention of cardiovascular disease.  In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA.
[8] Dangerfield A. Tube map used to plot Londoners’ life expectancy. BBC News. 2012 July 20. 
[9] Hart JT. The inverse care law. Lancet 1971;1(7696):405-12.
[10] Liu C, Chen R, Sera F, Vicedo-Cabrera AM, Guo Y, Tong S, et al. Ambient Particulate Air Pollution and Daily Mortality in 652 Cities. N Engl J Med 2019;381(8):705-15.
[11] McCormick E. Doctors alarmed by surge in hospital visits as toxic smoke engulfs west coast. The Guardian 2020; 18 Sept 
[12] The New Yorker Endorses a Biden Presidency. New Yorker. 2020 September 28, 2020:Available at
[13] Berkowitz SA, Hulberg AC, Hong C, Stowell BJ, Tirozzi KJ, Traore CY, et al. Addressing basic resource needs to improve primary care quality: a community collaboration programme. BMJ Qual Saf 2016;25(3):164-72 
[14] Stergiopoulos V, Hwang SW, Gozdzik A, et al. Effect of scattered-site housing using rent supplements and intensive case management on housing stability among homeless adults with mental illness: a randomized trial. JAMA 2015;313(9):905-15.
[15] Arnold C. Pandemic speeds largest test yet of universal basic income. Nature 2020;583(7817):502-3.
[16] Leis JA, Shojania KG. A primer on PDSA: executing plan-do-study-act cycles in practice, not just in name. BMJ Qual Saf 2017;26(7):572-7.
[17] Campbell NC, Murray E, Darbyshire J, Emery J, Farmer A, Griffiths F, et al. Designing and evaluating complex interventions to improve health care. BMJ 2007;334(7591):455-9.