Map the Gap: Creating a roadmap for eliminating health disparities

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Map the Gap Creating a roadmap for eliminating
health disparities

• Mitchell D. Wong, MD PhD
• David Geffen School of Medicine at UCLA

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Acknowledgements

• Martin Shapiro
• Susan Ettner
• John Boscardin
• Teresa Seeman
• Eileen Crimmins
• Nazleen Bharmal
• Andrea Carter

3
Funding Sources

• K08 award from NIA
• UCLA/USC Center on Biodemography
• UCLA Department of Medicine STAR program
• Pfizer Faculty Scholar Award in Epidemiology
• Doris Duke Foundation
• American Cancer Society

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Chapin, AJPH 1924
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Differences Life Expectancy
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Trends in Life Expectancy
White Women
Black Women
White Men
Black Men
Harper et al. JAMA. 2007297(11)1224-1232.
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Trends in Racial Gap in Life Expectancy
Men
Women
Harper et al. JAMA. 2007297(11)1224-1232.
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Life expectancy and chronic diseases

• Depression 6.5 years
• Reynolds et al. Am J Geriatr Psychiatry 2008)
• Diabetes 7-8 years
• Franco et al. Arch Intern Med. 2007
  1671145-1151
• High vs Low CHD risk patients 6-9 years
• Stamler et al., JAMA 1999

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Cross National Comparisons of Life Expectancy
among Men(2000)
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Cross National Comparisons of Life Expectancy
among Women (2000)

• African American Male 68.2
• African American Female 74.9
• White Male 74.8
• White Female 80.0

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Differences in Disease Incidence and Cause
Specific Mortality
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Trends in CHD Mortality Rates 1990-2001
Murray et al. Circulation. 2006
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Incident myocardial infarction by race, gender
and age
Source NHLBI ARIC Surveillance study
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Incidence stroke by race, gender, and age
Kissela, Stroke 2004
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Incidence intracranial hemorrhage by race,
gender, and age
Kissela et al., Stroke 2004
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Incident Diabetes
Source Brancati, JAMA 2000.
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Relative risk of Colorectal Cancer Deathfor
African Americans Compared to Whites
Marcella et al., J Clin Epidemiol, 2004.
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Relative risk of Colorectal Cancer for African
Americans Compared to Whites
Marcella et al., J Clin Epidemiol, 2004.
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Age adjusted death rates for CHD, stroke, lung
and breast cancer
Source CDC/NCHS
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Differences in Care
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Cholesterol Screening and Treatment
plt0.001



Source Nelson, Mangione et al. Arch Intern Med.
2002
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Glycemic Control
plt0.05



No Medication
Yes Medication
Source Heisler et al. Arch Intern Med. 2007
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Cancer Treatment
Gross et al., Cancer 2008
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Relative Odds of Delay in Breast Cancer Diagnosis
and Treatment
Gorin et al., Arch Intern Med, 2006.
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Renal Transplant
Ayanian et al., NEJM 1999
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Diffusion of Technology
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Proportion of asthma visits with inhaled
steroids 1985 to 1997
Ferris et al, Med Care 2006.
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HIV Mortality Rate Ratio for African American
compared to white men before and after 1996
Levine et al., AJPH, 2007.
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HIV Mortality Rate Ratio for African American
compared to white women before and after 1996
Levine et al., AJPH, 2007.
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HIV Mortality Rate Ratio for African Americans
compared to whites before and after 1996
Levine et al., AJPH, 2007.
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Reasons for disparities in care

• Health Insurance
• Health care system

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Disparities exist among those with Medicare HMO
insurance
Schneider et al., JAMA, 2002.
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African Americans have lower mortality among VA
patients
Jha, Hosmer et al., JAMA, 2001.
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African Americans have lower mortality among VA
patients
Jha, Hosmer et al., JAMA, 2001.
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Reasons for disparities in care

• Patient factors

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Confidence to manage cardiovascular disease
Blustein et al., Med Care 2008.
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Distrust in the healthcare system
Armstrong et al., J Gen Intern Med 2008.
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Reasons for disparities in care

• Is health care segregated?

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Racial/ethnic minorities often receive worse care
and have worse health outcomes compared to whites
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Do racial/ethnic minority patients tend to go to
physicians who tend to provide worse care?
Between-physician variations
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Do racial/ethnic minority patients tend to worse
care even compared to white patients who share
the same physician?
Within-physician variations
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Bach et al., NEJM 2007
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Lorenz Curves Distribution of Female Cancer
Patients Among Cancer Specialists
Line of Perfect Equality
Women
Carter, Wong, et al.
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Lorenz Curves Distribution of White and Black
Cancer Patients Among Cancer Specialists
Line of Perfect Equality
Whites
African Americans
Carter, Wong, et al.
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Differences in physicians caring for white and
black patients
Bach et al., NEJM 2007
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Quality of care by volume of African American
patients
Jha et al., Arch Intern Med, 2007.
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Quality of care by volume of African American
patients
Jha et al., Arch Intern Med, 2007.
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Quality of care by volume of African American
patients
Jha et al., Arch Intern Med, 2007.
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Racial differences in the perceptions of quality
of care between and within physician disparities
Rodriguez H, et al. J Gen Intern Med 2008.
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Reasons for disparities in care

• Are physicians biased?

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Racial differences in referral rates
Ayanian et al., NEJM, 1999.
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Racial differences in referrals for cardiac
catheterization
Schulman, Escarce et al., NEJM, 1999.
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Racial differences in referrals for cardiac
catheterization
Schulman, Escarce et al., NEJM, 1999.
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Racial differences in referrals for cardiac
catheterization
Schulman, Escarce et al., NEJM, 1999.
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Framework for Eliminating Disparities
DETECTING Identify which disparities exist
UNDERSTANDING Determine why disparities occur
REDUCING Identify how disparities can be
eliminated
Kilbourne, et al. AJPH 2006.
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Determinants of health and health disparities
Kilbourne, et al. AJPH 2006.
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Alternative Framework for Eliminating Disparities
Identify which disparities exist
Identify how disparities can be eliminated
Determine which disparities matter most
Determine why disparities occur
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Contribution of specific causes of death to
racial disparity in life expectancy
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Contribution of causes of death to racial
differences in years of life lost
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Difference due to Cancer
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White African American difference in average
life expectancy (years) attributable to all
cancers combined
Scenario
1 Incidence 3.6 1.1 7.8 0.4
2 Stage 4.5 0.2 7.9 0.3
3 Survival 4.5 0.2 7.9 0.3
4 Total 3.2 1.5 7.3 0.9
Base Case 4.7 -- 8.2 --
Men Race difference in LE Comparison to base
case Women Race difference in LE Comparison to
base case
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Change in Racial Difference in Life Expectancy
Men
Lung

Prostate


Esophagus
Head and Neck

Colorectal
Stomach

Change due to incidence
Liver

Change due to stage
Thyroid
Change due to survival
Pancreas

plt0.05
Hematologic
Bladder/Kidney
Brain
Melanoma

-0.2
-0.1
0
0.1
0.2
0.3
0.4
0.5
0.6
Change in life expectancy (years per person)
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Change in Racial Difference in Life Expectancy
Women
Breast


Colorectal
Cervix
Pancreas

Stomach

Lung

Bladder/Kidney
Head and Neck
Change in LE due to incidence
Esophagus

Change in LE due to stage
Liver
Change in LE due to survival
Hematologic
Thyroid
plt0.05
Uterine/Ovary

Melanoma

Brain
-0.10
-0.05
0
0.05
0.10
0.15
0.20
0.25
Change in life expectancy (years per person)
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State variations in disparities
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White-Black Difference in Life Expectancy Males
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Top Causes to LE Disparity Male States with
Greatest Disparity (gt10 yrs)
Maine, New Hampshire, Rhode Island, Vermont
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Top Causes to LE Disparity Male Other Selected
States
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Top 3 Contributors to LE Disparity Male
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White-Black Difference in Life Expectancy Females
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Top Causes to LE Disparity Female States with
Greatest Disparity (gt9 yrs)
Idaho, Montana, North Dakota, South Dakota,
Utah, Wyoming
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Top 3 Reasons for LE Disparity Female
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Cardiovascular Risk Factors by Race
Carnethon et al. Arch Intern Med. 2006
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IOM Framework for Disparities
Gomes and McGuire, 2001