HEALTH DISPARITIES:

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• HEALTH DISPARITIES
• Why the States MUST Answer the Call to Action
• Evelyn L. Lewis, MD, MA
  Adjunct Associate Professor
• Deputy Director, USU Center for Health
  Disparities Research and Education
  

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• Healthcare Disparity
• What is healthcare disparity?
• Why is it important?
• What is the impact?

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Healthcare Disparities

• Among the nations most serious health care
  problems (IOM 2002)
• Approximately 30 percent of Americans are racial
  or ethnic minorities and even greater diversity
  of the US is expected.
• Healthcare quality and health outcomes across
  ethnic and racial populations is disturbing

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Healthcare Disparity

• 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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Cancer Death Rate, 2002
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Cardiovascular Disease Death Rate, 2002Deaths
per 100,000 population
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Diabetes-Related Death Rate, 2002
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STATE OF MARYLAND Case Study

• 6th Wealthiest State (per capita income)
• Age lt65 population 88.5
• African Americans population 28
  -Hispanic and other population 7.2
• 84 Graduate HS, 35 Advance Degree
• 890 million per year hospitalization cost for
  CVD

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Leading Causes Of
Death In MD, 1998

• 6. Diabetes
• 7. Unintentional injury
• 8. Septicemia
• 9. Homicide
• 10. HIV

• 1. Heart Disease
• 2. Cancer
• 3. CVD
• 4. COPD
• 5. Pneumonia and influenza

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• Healthcare Disparity
• Clinical Imperative
• Economic Imperative
• Political Imperative

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Clinical Imperative

• CVD Leading cause of death among black adults
  (Maryland- 66
  of all CVD deaths are African Americans)
• CVD First leading cause of death among black men
  ages 45-64. Second leading cause of death among
  black women ages 20-64
• Treatment rates Low for hyperlipidemia higher
  for hypertension and diabetes mellitus.
• Treatment not likely to result in control of
  hyperlipidemia, hypertension and diabetes
  mellitus.
• Ischemic heart disease, congestive heart failure,
  stroke occur at a younger age, higher
  prevalence among black adults than non-blacks

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Clinical Imperative


RR2
Diabetes Mellitus
RR2.2
Major Depression
RR3
Bipolar
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• Economic Imperative

• Highest Prevalence of Chronic Diseases
• African-American Men Have a 40 Higher Rate of
  Heart Disease and 2X Rate of Strokes
• Hispanics, Aged 35-64, Have a 1.3 X Higher
• Risk of Stroke Deaths

National Business Group On Health
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Health Disparities and Chronic Conditions
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By 2008, 41.5 of Workforce Will Be Ethnic
Minorities
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Political Imperative

• 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

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Congressional Proposals

• Comprehensive Health Disparities Legislation
  Introduced in the Senate by Majority Leader
  Frist and Senator Mary Landrieu (D-LA)
• Currently there are no plans for companion
  legislation to be introduced in the House of
  Representatives. Additionally, Senator Gregg has
  said he will not support the Frist- Landrieu
  legislation
• The Healthcare Equality and Accountability Act
• Introduced in the Senate by Tom Daschle (D-SD)
  and in the House of Representatives by Rep.
  Elijah Cummings
• The Hispanic Health Improvement Act
• Introduced in the Senate by Jeff Bingaman (D-NM)
  and in the House of Representatives by Ciro
  Rodriquez (D-TX)
• The Native Hawaiian Health Care Improvement
  Reauthorization.
• Introduced in the Senate by Daniel Inouye (D-HI)
  and in the House of Representatives by Rep. Neil
  Abercrombie (D-HI)

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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 competency
• Health systems-level factors financing,
  structure of care, cultural and linguistic
  barriers, cultural competency
• Clinical encounter stereotyping, prejudice, and
  clinical uncertainty, cultural competency

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Level of Healthcare Satisfaction
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Language, Communication and Health Disparities

• 37 million adults in the U.S. speak a language
  other than English
• 18 million people (48 percent) speak English less
  than "very well."
• Language and communication can affect the amount
  and quality of health care received.
• Rural vs Urban vs inner city vs social classes
• Center on an Aging Society analysis of data from
  the 2000 Census, QT-P17, Ability to speak
  English. Washington, DC U.S. Bureau of the
  Census, Census Summary File 3 ? Sample Data.9.
  Fiscella, K., Franks, P., Doescher, M. P.,
  Saver, B. G. 2002. Disparities in health care by
  race, ethnicity and language among the insured
  Findings from a national sample. Medical Care,
  40(1), 52-59.10. Collins et al. 2002.

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Disparities in the Clinical Encounter The Core
Paradox

• Bias No evidence shows that providers are more
  likely than the general public to express biases,
  but evidence suggests that unconscious biases may
  exist
• Uncertainty When providers treat patients that
  are dissimilar in cultural or linguistic
  background
• Stereotyping Evidence suggests that physicians,
  like everyone else, use these cognitive
  shortcuts

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Patients ExperiencingSymptoms of Heart Disease
(Schulman et al., 1999)