Eliminating Health Disparities

1
Eliminating Health Disparities

• Michael A. Rodriguez, MD, MPH
• Associate Professor
• David Geffen School of Medicine at UCLA
• May 10, 2006

2
Moving Forward

• Advancements in biomedical sciences and medical
  practices

3
Public Interest
Public Health
Community
4
Health Disparities in perspective

• Identify risk factors
• Quantify consequences
• Discover and disseminate solutions

5
Daily ReportingBasic Questions

• Who? Name, Age, Ethnicity, Gender
• What? Type of condition, Outcome
• When? Date
• Where? Environment, House, Hospital
• Why/How? What prompted the Incident

6
Daily ReportingAdditional Questions

• Perspective What type of condition is this? How
  typical is this type of condition in this
  community?
• Employment Education Do the people have jobs?
  How much does the individual earn? What level of
  education?
• Environment How much does the environment
  contribute to the condition?
• Health Costs How much do these preventable ER
  visits and hospitalizations cost?
• Consequences to Family What happens to the
  families and homes of the individual?
• Solutions What is being done to address this
  problem?

7
Overview

• Background
• Contributing Factors
• Efforts to Address

8
Health Disparities

• Health disparities are differences in the
• incidence, prevalence, mortality, and burden of
• diseases and other adverse health conditions
• that exist among specific population groups in
• the United States

Institute of Medicine. Unequal Treatment
Confronting Racial and Ethnic Disparities in
Health Care, 2002
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Racial/Ethnic Disparities in Virtually all Health
Domains

• Premature mortality including infant mortality
• Morbidity
• Chronic disease (cancer, diabetes)
• Communicable disease
• Physiological risk factors
• Hypertension
• Obesity/overweight
• Functional limitations and disability

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Leading Health Disparities

• Cardiovascular Disease
• Cancer
• Diabetes
• HIV/AIDS
• Asthma
• Mental Health

Institute of Medicine. Unequal Treatment
Confronting Racial and Ethnic Disparities in
Health Care, 2002.
11
Diabetes

• Type 2 diabetes is more prevalent in Mexican
  Americans (13) than in non-Latino Whites (8)
  (Hertz et al.)
• Latinos in the US are almost twice as likely to
  die from diabetes as compared to non-Latino
  Whites
• (Multicultural Medicine and Health Disparities,
  2005)

12
Mental Health

• Individuals with mental health illness have high
  co-morbidity and mortality rates
• Over 26 of Latinos in Los Angeles over age 60
  reported major depression or dysphoria
• (U.S. Department of Health and Human
  Services, 2001)
• Latinos are less likely than Non Latino Whites to
  seek treatment for mental health.
  (Cooper-Patrick, 1999)

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What causes these disparities in health?
Health Disparities
Social Determinants
Access To Care
Quality Of Care
14
What causes these disparities in health?

• Social Determinants

15
Factors leading to disparitiesSocial
Determinants

• Low Levels of Education
• Low Socioeconomic Status
• Behavior and Environment

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Social DeterminantsThe Latino Case Example

• Education
• Latino children have highest high school drop out
  rates
• Environment
• Latino children have greater exposure to
  pollutants, waste sites, pesticides, lead
  mercury
• 3 of 5 largest landfills in Latino AA
  communities (Kaiser Network)
• Employment
• Latinos are well represented in the workforce,
  but work in low wage and disproportionately
  higher risk jobs.

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What causes these disparities in health?

• Social Determinants
• Access to Care

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Health Insurance

• Health insurance facilitates entry into the
  health care system
• The uninsured are more likely to die early have
  poor health status because they are diagnosed at
  later disease states
• Higher costs, poor outcomes, and greater
  disparities are observed among individuals
  without a usual source of care

19
Access to Care The Latino Case Example

• 40 of Latinos under 65 are uninsured
  (National Health Care
  Disparities Report, 2005)
• Latino children make up 29 of uninsured children
  (Flores et al., 2005)
• One quarter of the nations uninsured are Latino
  (11 of 44 million Americans) (Goldstein,
  2000)
• Reasons include lack of employer-based health
  insurance and low income

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What causes these disparities in health?

• Social Determinants
• Access to Care
• Health Care

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Racial/Ethnic Disparities inHealth Care

• Within Medicare
• Differential utilization based on race for
• Mammography (Gornick et al.)
• Amputations (Gornick et al.)
• Influenza vaccination (Gornick et al.)
• Lung Cancer Surgery (Bach et al.)
• Renal Transplantation (Ayanian et al.)
• Cardiac catheterization angioplasty (Harris et
  al, Ayanian et al.)
• Coronary artery bypass graft (Peterson et al.)
• Treatment of chest pain (Johnson et al.)
• Referral to cardiology specialist care (Schulman
  et al.)
• Pain management (Todd et al.)

22
Language Barriers

• Quality of health care requires effective
  communication between patient and physician
• Communication problems lead to lower patient
  adherence to medications and decreased
  participation in medical decision-making

23
Language Barriers

• Spanish speakers are less likely to be discharged
  from the ER with an understanding of their
  medications, special instructions, and plans for
  follow-up care (Crane 1997)
• Spanish-speaking Latinos are less likely to have
  physician visits, flu shots, or mammograms as
  compared to English-speaking Latinos or
  non-Latino Whites (Fiscella 2002)

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Efforts to Address Disparities in Health
25
Steps Towards Translating HealthDisparities
Research Into Policy

• Set The Agenda
• 2) Build The Case
• 3) Beware of Politics in Science
• 4) Develop Comprehensive Approaches
• 5) Recognize that Public Policies Are
  Complementary To Health

26
Set The Agenda

• Healthy People 2010- Clinton Administration
• Goal Eliminate Health Disparities

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Set The Agenda

• Achieving Equity The Healthy People
  Perspective
• HP 2010 recognizes that communities, states, and
  national organizations will need to take a
  multidisciplinary approach to achieving health
  equity that involves improving health, education,
  housing, labor, justice, transportation,
  agriculture, and the environment.
• (HP2010 Vol. 1, p. 16)

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Build The Case

• Institute Of Medicine Report (2002)
• Unequal Treatment Confronting Racial And Ethnic
• Disparities In Health Care (www.nap.edu)
• Physicians For Human Rights Report
• The Right To Equal Treatment
• Numerous Health Research Policy Publications
  
• Health Affairs The Determinants Of Health
  (3/2003)
• American Journal Of Public Health, Eliminating
  Health
• Inequalities, October 2003
• Milbank Quarterly A Journal for Population
  Health And
• Health Policy, Volume 1, 2004
• Numerous Books on Health Disparities And Social
  Justice
• Health For All Californias Strategic Approach
  To
• Eliminating Racial And Ethnic Health Disparities
  (11/2003)

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Politics And Science in Federal Reports

• This first report clearly demonstrates that
  racial,
• ethnic and socioeconomic disparities are national
• problems that affect health care at all points in
• the process, at all sites of care, and for all
• medical conditions in fact, disparities in the
• health care system are pervasive.
• -National Health Disparities Report, as submitted
  to the
• Department Of Health And Human Services (DHHS) by
  the
• Agency for Healthcare Research And Quality
  (AHRQ), July 2003

30
Politics And Science in Federal Reports

• This first report finds that, while most
• Americans receive exceptional quality of
• health care and have excellent access to
• needed services, some socioeconomic,
• racial, and ethnic differences exist.
• - National Healthcare Disparities Report, as
  released by the DHHS, December 2003

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Differences Between the Two Reports

• Deletes most uses of the word disparity
• Eliminates the conclusion that healthcare
• disparities are national problems
• Removes findings on the social costs of
• disparities and replaces them with a
• discussion of success
• Omits key examples of healthcare disparities

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Comprehensive and Integrated Approaches

• Does health disparities legislation address
• Social Determinants and Environment?
• Health Care System?
• Individual Factor?

33
A Commitment to Document Disparities

• Collect and report data on health conditions and
  health care access by ethnicity, SES and primary
  language
• Include measures of racial and ethnic disparities
  in performance measurements
• Report racial and ethnic data by use of
  subpopulation groups where possible

34
Recognition that Health and OtherSocial Policies
are Complementary

• Invest in young children
• Provide services and opportunities for the
• neediest, including health care
• Strengthen support at the community level
• Improve the work environment
• Create a more equal economic environment
• Assess the effects of economic and social
• action on health

35
Resources

• CDC Media Relations-Hispanic Disparities Press
  Kit
• http//www.cdc.gov/od/oc/media/presskits/hhd.htm
• The Office of Minority Health
• http//www.omhrc.gov/
• The National Center for Minority Health
• http//ncmhd.nih.gov/

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Summary

• There is a significant body of evidence that has
  identified disparities in health and health care
  for Latinos and other underserved populations.
• To eliminate disparities, partnerships, research,
  advocacy and more comprehensive policy approaches
  will be required