Operationalizing Health Equity Through a Systems Reliability Framework: A Cross-Sectional Ecological Frontier Analysis of Health System Performance in the Pacific Northwest

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Presentation

Presentation Date

7-14-2026

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Presentation: 49:20

Abstract

The United States spends more on healthcare than any other high-income nation yet produces inequitable outcomes that current measurement frameworks describe but do not hold systems accountable for. Existing equity measures evaluate populations rather than the performance of the systems that serve them, and lack instruments capable of separating structural disadvantage from operational drift across organizational scales. The purpose of this study was to develop and empirically test a system-performance framework that reconceptualizes health equity as a measurable property of healthcare delivery rather than a demographic characteristic of populations. A two-phase ecological design was employed: a county-level pilot across 35 Washington counties, followed by an extended census-tract analysis spanning 2,554 tracts across Washington and Oregon. Social complexity was measured through a five-indicator principal-components Social Complexity Index (SCI), and geographic accessibility through a Spatial Capacity Accessibility Index derived from a population-weighted gravity model using OSRM-routed travel times to 142 hospitals, inverted to produce a Geographic Access Burden (GAB) measure. An output-oriented variable-returns-to-scale Data Envelopment Analysis treated SCI and GAB as non-discretionary inputs against three accepted Medicare outcomes, yielding tract-level Equity Drift Index (EDI) values. Second-stage inference compared Simar-Wilson bootstrap, naive OLS, cluster-robust OLS, and county fixed-effects estimators. SCI and GAB were empirically uncorrelated (r = 0.041), confirming geographic access as a structural dimension distinct from social complexity. SCI predicted EDI principally at the between-county scale (β = 0.0077, p = .065 cluster-robust; p = .013 with GAB and state), while bootstrap inference under independence assumptions overstated precision 2.7-fold. These findings support measuring health equity as multidimensional system drift; inference must be cluster-aware, and durable accountability requires institutional infrastructure, proposed here as an Equity Reliability Board, to translate measurement into governance.

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English

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