An Overview of the Impact of Health and Healthcare Disparities In the United States and the BRONX

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• An Overview of the Impact of Health and
  Healthcare Disparities In the United States and
  the BRONX
• Evelyn L. Lewis, MD, MA, FAAFP
  Consultant PI, Uniformed Services
  University Center for Health Disparities Research
  and Education World Wide Public
  Affairs and Policy Policy, Pfizer Inc

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• Healthcare Disparities
• What is healthcare disparity?
• Factors leading to health disparities
• Why is it important?
• What you must do to change the course of events

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Healthcare Disparity

• DisparityThe condition or fact of being unequal
• When the differences in higher rates of morbidity
  and mortality in minorities is a result of them
  being less likely than whites to receive needed
  services including clinically necessary
  procedures
• When Racial and Ethnic minorities receive lower
  quality healthcare than whites, even when insured
  to the same degree and healthcare access issues
  are the same

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National Institutes of Health
Minorities are less likely to be given
appropriate cardiac medications or to undergo
bypass surgery
African-Americans suffer strokes as much as 35
percent higher than whites do, but they are less
likely to receive major diagnostic and
therapeutic interventions
Less likely to be on waiting lists for
transplants or to receive dialysis.
Less likely to receive appropriate medications
to manage chronic symptoms
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Potential Sources of Disparities

• Patient-level factors patient preferences,
  refusal of treatment, poor adherence, biological
  differences, cultural considerations
• Health systems-level factors financing,
  structure of care, cultural and linguistic
  barriers, cultural competency and compliance
• Clinical encounter stereotyping, bias, and
  clinical uncertainty, cultural competency

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Factors Leading To Inequities

• Different underlying rates of illness (genetics)
  
• Local environmental conditions
• Lifestyle choices

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Factors Leading To Inequities

• Differences in care seeking behaviors
• cultural beliefs
• linguistic barriers
• trust of health providers
• predisposition to seeking timely care

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Factors Leading To Inequities

• Availability of care
• ability to pay
• location, management, and delivery of
• health care services
• clinical uncertainty
• health care provider beliefs

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Genetic Polymorphisms and Drug Metabolism

• Polymorphisms small differences in enzymatic
  ability to metabolize drugs
• Most drugs are degraded to metabolites in the
  liver by the cytochrome (CYP) P450 system
• CYP P450 activity exhibits a racial variation

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Genetic Polymorphisms

• Acetylation is another hepatic process in which
  alcohol and other toxins and medications are
  broken down
• Acetylation may be slow or rapid. Caucasians are
  generally slow acetylators, causing drugs to
  remain longer in the circulation, with more
  intense and possibly toxic effects. Blacks are
  rapid acetylators, with less optimal drug
  effectiveness. Classic example Isoniazide (INH)

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Historic Perspective

• 1895 Booker T. Washington at Atlanta Exposition
  Meeting discussed deficiencies in Negro health
  care
• 1899 W.E.B. Dubois The Philadelphia Negro A
  Social Study a sociological study of Negroes
  including health
• 1903 W.E.B. Dubois Souls of Black Folk
  discussed declining health of Negroes post
  slavery
• 1968 Kerner Commission Report speaks of gains
  in Black Americans social welfare, however
  health inequalities remain severe and troubling
• 1976 National Medical Association met in
  Washington, D.C. and discussed access, morbidity
  and mortality disparities between Blacks and
  Whites

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Historic Perspective (continued)

• 1980 Black Congress on Health Law and
  Economics met in Dallas, Texas and discussed
  strategies for bridging health care gaps between
  Blacks and Whites
• 1985 Report of the HHS Secretarys Task Force
  on Black and Minority Health (Heckler-Malone)
  identified the continuing existence of health
  disparities
• 1999 IOM Report Unequal Burden of Cancer,
  Alfred Haynes Brian Smedley, Editors cancer as
  experienced by ethnic minorities and medically
  underserved

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Historic Perspective (continued)

• 2002 IOM Report Confronting Racial and Ethnic
  Disparities in Health Care Brian Smedley,
  Adrienne Stith, Alan Nelson, Editors race and
  ethnicity remain as significant predictors of
  health care quality

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Well-documented disparities in the U.S

• An African-American baby boy born in the U.S.
  today lives 7 fewer years than a white baby boy.
• People of color account for 80 percent of new HIV
  infections, with African Americans accounting for
  50 percent and Hispanics, 30 percent.
• The diabetes death rate in Hispanics is 40
  percent higher than for non-Hispanic whites.
• Cancer deaths are 35 percent higher among African
  Americans than whites.
• African American, Hispanic and Asian American
  women wait twice as long as white women for
  diagnostic tests following abnormal mammograms

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Data Sources

• National Health and Nutrition Examination Survey
  (NHANES)
• NHANES III (19881994)
• Blacks 4,709
• Whites 7,121
• National Hospital Discharge Survey (NHDS)
• NHDS 1992
• Blacks 23,508
• Whites 124,775
• National Health Interview Survey (NHIS)
• NHIS 1997
• Blacks 4,941
• Whites 23,639
• NIH Institute of Medicine Report, March 2002
• Maryland CVD Surveillance Report, 1999

• NHANES 19992000
• Blacks 861
• Whites 1,986

• NHDS 2000
• Blacks 31,843
• Whites 128,876

• NHIS 2001
• Blacks 4,475
• Whites 21,392

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Cancer Death Rate, 2002
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Diabetes-Related Death Rate, 2002
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Cardiovascular Disease Death Rate, 2002Deaths
per 100,000 population
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Cardiac Catheterizations per 1,000 Circulatory
Disorders Hospital Discharges by Race and Age
NHDS 2000
NHDS I992
Number per 1,000 Discharges
2044
4564
65
Age
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CABG Procedures per 1,000 Circulatory Disorders
Hospital Discharges by Race and Age
NHDS 2000
NHDS I992
Number per 1,000 Discharges
2044
4564
65
Age
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Source NHANES III, Scott Levin, PDDA
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Patients experiencing symptoms of heart
disease, from Schulman et al. (1999)
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Patients experiencing symptoms of heart
disease, from Schulman et al. (1999)
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Neighborhood Areas hard hit by health
disparities

• Central Bronx
• Highbridge
• Morrisania
• Hunts Point
• Mott Haven
• South East Bronx

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Complex interplay of root causes

• cultural and environmental factors
• behavioral influences
• socioeconomic conditions
• healthcare access and quality issues.
• Richard F. Daines, M.D., New York State
  Commissioner of Health , June 2007

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Neighborhood Composition

• Hispanics account for the largest population
  group ranging from a high of 73 percent of the
  population in Hunts Point and Mott Haven to a low
  of 43 percent in South East Bronx.
• African Americans constitute the second- largest
  group ranging from 38 percent in Highbridge and
  Morrisania to 21 percent in South East Bronx.
• Whites are the third-largest group ranging from
  28 percent in South East Bronx to a low of 1
  percent in Highbridge, Morrisania, Hunts Point,
  and Mott Haven.
• Immigrants represent a significant portion of the
  residents of the entire area

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Level of Acculturation may have a Negative
Impact on Health

• Low Acculturation (New immigrants)
• Lower Access to Accurate Health info
• Lower disease awareness and symptom recognition
• Lower understanding of Prevention
• Less concerned about silent diseases as
  hypertension or dyslipidemia

• High Acculturation (US-born)
• Poor nutrition
• Difficulty with disease management and continuity
  of care
• High-risk behavior (drinking, smoking, drug use)
• Increased risk of chronic conditions as
  depression

De la Torre, 2001. US Census Bureau,
2001 Aguirre-Molina, 2001
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Leading causes of morbidity and mortality in the
Bronx Neighborhoods

• heart disease
• Cancer
• AIDS
• accidents and injuries
• Diabetes
• Pneumonia
• stroke.

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Black New Yorkers die at younger ages from heart
disease (New York Citys biggest killer) than
White New Yorkers.
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Rates of People Living w/HIV AIDS in the Bronx
vs. NYC vs. US, 2001
Figures as of 12/31/01
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HIV infection rates
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AIDS mortality
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AIDS deaths and income
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Black New Yorkers die at younger ages from heart
disease (New York Citys biggest killer) than
White New Yorkers.
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Percent of NYC Residents with Diagnosed Diabetes,
by Borough, 2003
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DIABETES
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A tale of two neighborhoods diabetes in Upper
ManhattanPercent of adults with
diabetesWashington Heights and Inwood 12Upper
West Side 4Percents are age-adjustedSource
NYC Community Health Survey, 2002
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Changing the course of events
Three primary tools

• Health insurance identified as one of the key
  determinants of disparities in obtaining
  consistent access to healthcare services.
• Quality indicators create a patient-centered
  system that emphasizes primary and preventive
  care
• Health information technology patient medical
  histories, clinical data, and decision-making
  support tools can be available at all points of
  delivery and can be viewed in the aggregate for
  outcomes measurement and reporting among multiple
  clinicians, providers, and payers

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Clinical Imperative


RR2
Diabetes Mellitus
RR2.2
Major Depression
RR3
Bipolar
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Bronx Uninsured by Neighborhood

• Neighborhood Stats Uninsured
• Kingsbridge Percent 15
• Population 10,000
• North East Bronx Percent 18
• Population 23,000
• Fordham-Bronx Pk Percent 18
• Population 34,000
• Pelham-Throgs Neck Percent 16
• Population 34,000
• South Bronx Percent 22
• Population 75,000

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Hospitalizations for conditions that potentially
can be prevented through early intervention and
good outpatient care

• residents of the section of the Bronx south of
  Fordham Road are much more likely than residents
  in the rest of the state to experience serious
  health complications
• rate of hospitalization for asthma is nearly 400
  percent higher among residents of this Bronx area
  than the rest of the state.
• rate of lower-extremity amputations a serious
  complication of diabetes is 105 percent higher
  in this area than the state average

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Causes of premature/preventable death
vary by racial group
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• Of all the forms of inequality, injustice in
  health is the most shocking and the most
  inhuman.
• The Rev. Martin Luther King
  
  2nd National Convention of the Medical
  Committee
  for Human Rights, 1966