Health Disparities and Medicine

1
Health Disparities and Medicine

• John R. Wheat MD, MPH
• College of Community Health Sciences
• School of Medicine-Tuscaloosa Program
• The University of Alabama

2
Basic Concepts Related Terms

• Health disparities
• Healthcare inequities
• Unequal treatment
• Synonyms inequality, disproportion,
  difference, unlikeness

3
Basic Concepts Ethical Basis

• Allare created equal with inalienable
  rightslife, liberty, pursuit of happiness
• Equality under the law
• Healthcare as a right?
• Secondary social gain? (military, employment,
  decreased societal costs)

4
(No Transcript)
5
Basic Concepts Statistical Basis 1

• Random vs. systematic variation (Hookworms)
• Group comparisons (Representativeness)
• Whole group
• Systematic sample
• Random sample

6
Basic Concepts Statistical Basis 2

• Variables
• Outcome or dependent, e.g. health measure
• Independent
• Study factor (policy or intervention
  factor) Control factors (co-variants,
  correlates)
• Theory of multiple causation Health is a
  function of many factors

7
Epidemiologic Model for Health(adapted from
Dever)
Age, Gender, Genetics, Illnesses
Biology
Public health Prevention Primary care Advanced
care Home health Nursing home EMS Insurance
Physical Psychological Social
HEALTH
Healthcare
Environment
Lifestyle
Consumptive, work, recreation
SES Education, Income, Resources, Culture
8
Socioeconomic Status and
Health Green, PH Reports 118 306,
2003
9
SES and Health Disparity Shishehbor et al. JAMA
295 784, 2006.

• Biology (Age, Gender, Race?, Medical
  Hx.)
• Envr. 1. Functional
  Capacity Healthcare
  (Hosp. distance) 2. Mortality
  (Medications, Insurance)
• _
• Lifestyle (BMI, Smk, Work)
• SES (Block income, house value,
  interest/dividends/rent,
• education, professional status)

10
Alabama Geographic Health Disparities

• Selected Urban and Rural Division Mortality Rates
  Per 100,000 Population
• 
  Heart Chronic
  Prostate
• Division Hypertension Diabetes
  Stroke disease lung disease
  cancer
• Urban 5.5 26.1 61.8
  293.4 40.2 30.3
• (21 counties)
• Rural North 4.7
  27.5 79.0 407.8
  50.2 31.9
• (21 counties)
• Rural South 6.3 31.7
  79.4 361.7 40.9
  38.1
• (25 counties)
• Bold indicates statistically higher than others
  in column.

11
Some Associated Independent Factors

• Selected Data for Urban and Rural Division
  Counties of Alabama
• Mean Mean
  Mean Mean Median
• Division Population Minority
  65 Pop./doctor
• Urban 67.8 26.6
  12.9 28.7 10.8
  285
• (21 counties)
• Rural North 17.5 13.0
  15.2 27.7 13.0
  714
• (21 counties)
• Rural South 14.7 41.1
  14.0 31.6 21.6
  743
• (25 counties)
• Total Alabama population estimated 4,447,100.

12
Health Disparity Correlates

• Demonstrated
• Geography (Environment?)
• Minority Status (Culture, Genetics?)
• Age (Biology)
• SES
• Physician Access (Healthcare)
• But what about other factors related to
• Biology
• Environment
• Lifestyle
• SES
• Healthcare

13
Roles In Addressing Health Disparity

• For which of these factors, and in what way,
• Do physicians bear responsibility?
• Do individuals bear responsibility?
• Do governments bear responsibility?
• Do medical schools bear responsibility?

14
Disparity in Healthcare Summary Statement

• A disparity is an inequality. In the United
  States, we believe that
• healthcare should not differ by race, ethnicity,
  socioeconomic
• status, or geographic location. When these
  differences do exist,
• they are referred to as disparities.
• We see this when racial and ethnic minorities
  receive lower
• quality healthcare than whites. It is important
  to understand that
• differences in race and ethnicity (among other
  things) will always
• exist it is wrong, however, when these
  differences lead to
• unequal care. AMSA, 2006

15
Disparity in Quality of HealthCare

• Populations with Equal Access
  to Health Care

16
Opinions about Healthcare Disparities
17
African Americans, Cardiovascular Disease, and
Cardiac Catheterization
Green, PH
Reports 118 304, 2003
18
Example Heart Disease Treatment
19
Social Determinants of Healthcare Green, PH
Reports 118 306, 2003
20
Example HIV Treatment
21
Health Behavior And Preventive Care Of Minorities
Green, PH Reports 118 304, 2003
22
Example Vaccinations of Older Adults (
65)Singleton et al. AJPM 29 412, 2005.

• Biology (Age, Gender)
• Race (W vs. B H)
• Envr. 1. Flu
  Vaccine Healthcare
  (Region) 2. Pneumo vac
  (MD visit, Site, MD rec, Mcare)
• Lifestyle (BMI, Smk, Work)
• SES, Education
• (Education level, Knowledge, Language)

23
Race and Health CareGeiger. NEJM 335 815,
1996Burchard et al. NEJM 348 1170, 2003

• Health Status
• Patient Race (-) Access to Care
• As Minority Scope of Care
• Quality of Care
• Bias?, Communication?,
• SES?, Culture?,
  Environment?
• Lifestyle?, Genetics?

24
African Americans and Renal Transplant
Green,
PH Reports 118 304, 2003
25
Latinos and Diabetic Complications
Green, PH Reports 118 305, 2003
26
Minorities and Analgesia for Long-Bone
Fractures Green, PH Reports 118 305,
2003
27
Healthcare Factors in Racial DisparitiesEpstein,
NEJM 351 603, 2004 Bach et al. NEJM 351575,
2004

• Patient Factors
  Doctor Factors
• Ability to afford care
  Cultural
  sensitivity
• Knowledge and beliefs
  Certification
• Preferences
  Referral
  opportunity
• 
  Racial
• Disparity
• Doctor-Patient
  Delivery System
• Relationship
  Factors
• Patient education
  
  Location of care
• Trust Type of clinic
• 
  

28
Doctor FactorsKomaromy et al. NEJM 3341305,
1996 Rabinowitz et al. AJPH 901225,
2000Cantor et al. Inquiry 33)167, 1996 Moy,
Bartman JAMA 2731515, 1995.

• Minority patients
• Minority physicians serve more
  Indigent patients
• Underserved
  communities
• Minority patients choose more
  Same race, same more satisfied with
  ethnic physicians

29
More Representatives of Underserved Populations
in Medical Education Wheat et al. J Rural Health
19 181, 2003.

• Student-student interactions to
  create new cross-cultural
  understandings, and
• 
  better doctor-patient relationships.
• Diversity among
• medical school class
• Diverse population of doctors,
  thus more opportunity for patients
  to choose doctor understanding
  their cultural cues.

30
First Rural Health Scholars to Graduate from
Medical School May, 2001 Program Co-founders
Cynthia Moore and Dr. Bob Garner (on left) and
John Wheat, MD, MPH (right) with new MDs Kris
Cummings, Aprile Brown, and Joey Gasson
31
Front  Mark Christensen, Madison County Robert
Martin, Houston County Ashley Poe, Winston
County LaRea Kelly, Walker County  Alabama
Senator Jeff Sessions from Wilcox County Adam
Shaw, Etowah County Brent Ballard, Marion
County.  Back  Dana Todd, Hale County Dr. Jerry
Harrison of Winston County, AAFP President James
Henderson, Escambia County and Chris Clayton,
Madison County.