Creating a Culture of Health Equity: A Public Health Approach to America s Pressing Health Needs

Transcription

1 Creating a Culture of Health Equity: A Public Health Approach to America s Pressing Health Needs Ali S. Khan, MD, MPH Professor and Dean, College of Public Health, UNMC Assistant Surgeon General (Ret.), USPHS HHS Region VII Public Health Meeting September 28, 2017

2 It is more important to know what sort of person has a disease than to know what sort of disease a person has. - Hippocrates

3 Where Are We Going? How Are We Getting There? Region VII Health: Where Are We?

4 Region VII Health: Where Are We?

5 HHS Region 7: 2016 Population by State (in millions) 7,000,000 6,000,000 5,000,000 4,000,000 3,000,000 Total Population Urban Rural 2,000,000 1,000,000 0 Iowa Nebraska Kansas Missouri Source: State fact sheets, USDA, Economic Research Service (2017):

6 Region 7 Population: Urban vs Rural (2016) Rural, 8,464,070 Total, 14,042,098 Urban, 5,578,028 Source: State fact sheets, USDA, Economic Research Service (2017):

7 HHS Region 7 States 2016 Population by Race/Ethnicity (%) Black AI/AN Asian Hispanic 2 0 Iowa Nebraska Kansas Missouri Source: Quick Facts: United States Census Bureau (2016):

8 Percentage of Minorities in Region 7 Black AI/AN Asian Hispanic 44% 37% 14% 5% Source: Quick Facts: United States Census Bureau (2016):

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10 Region 7: Opioid Overdose Deaths by Type of Opioid (2015) Heroin Methadone Iowa Nebraska Kansas Missouri Synthetic Opioids (e.g. fentanyl, tramadol) Natural and Semisynthetic Opioids (e.g. oxycodone, hydrocodone) Source: Kaiser Family Foundation

11 Drug deaths (per 100,000): Region 7 States Compared to National Average National Iowa Nebraska Kansas Missouri Source:

12 Opioid Overdose Death rate trend per 100,000, Source:

13 Opioid Overdose Deaths by Race/Ethnicity: Trends Timeframe Source:

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15 Region 7: Percent of Adults Reporting Poor Mental Health Status (2015) Iowa Nebraska Kansas Missouri National Source: Kaiser Family Foundation

16 Region 7: Percentage of Adults Reporting Serious Mental Illness in the Past Year (2015) Iowa Nebraska Kansas Missouri National Source: Kaiser Family Foundation

17 Mental Health America Adult Ranking The 7 measures that make up the Adult Ranking include: 1. Adults with Any Mental Illness (AMI) 2. Adults with Dependence or Abuse of Illicit Drugs or Alcohol 3. Adults with Serious Thoughts of Suicide 4. Adults with AMI who Did Not Receive Treatment 5. Adults with AMI Reporting Unmet Need Source: 6. Adults with AMI who

18 Mental Health America Youth Ranking The 7 measures that make up the Youth Ranking include: 1. Youth with At Least One Past Year Major Depressive Episode (MDE) 2. Youth with Dependence or Abuse of Illicit Drugs or Alcohol 3. Youth with Severe MDE 4. Youth with MDE who Did Not Receive Mental Health Services 5. Youth with Severe MDE who Received Some Consistent Treatment 6. Children with Private Insurance that Did Not Cover Mental or Emotional Problems Source: 7. Students Identified with

19 Percent of Adults Reporting Poor Mental Health Status, by Race/Ethnicity (2015) White Black Hispanic Asian/Pacific Islander American Indian Other Source:

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21 Region 7: Percentage of Obese Children by State (2011) Iowa Nebraska Kansas Missouri Source:

22 Region 7: Childhood Obesity Trends by State Iowa Nebraska Kansas Missouri National Source:

23 Percent Region 7: Percent of WIC children aged 2 to 4 years who have obesity Iowa Kansas Nebraska Missouri Source:

24 CURRENT OBESITY RATES AMONG CHILDREN BY RACE AND ETHNICITY ( ) All Children Black Latino White Source:

25 The State of Obesity in Nebraska shows disparities in Obesity rates Nebraka Obesity Rates by Age-2015 Overall Adult Obesity steadily increased from Adult Obesity Rate in 2015= 34.4% WOMEN MEN 15.1% 28.1% 32.0% 31.6% 37.4% Nebraska Obesity Rates by HISPANICS AMERICAN INDIAN-NH WHITE-NH 32.8% 13.8% 42.1% 35.9% 28.7% Nebraska Obesity Rates by Gender- 29.2% Source:

26 PARADOX Phenomenal scientific achievements Steady improvement in overall health status Persistent, significant health inequalities exist

27 Thomas F. Malone: Chairman, Heckler Report Task Force 1985 Heckler Report Secretary Margaret M. Heckler s report on minority health in the U.S. The first time the DHHS has consolidated minority health issues into one report Legitimization of health disparities as an area of research Focus on biomedical factors Just as individual well-being is not static, the health needs of minority populations are changing. They are influenced by a diverse set of factors of which disease is but one aspect

28 Age-Adjusted Death Rates by Cause, Race, and Sex United States, 1980 (Rate per 100,000 Population) White Male Black Male White Female Black Female 50 0 Heart Disease Cancer Stroke HomicideAccidents Cirrhosis Diabetes

29 Age-Adjusted Death Rates by Cause, Race, and Sex United States, 2013 (Rate per 100,000 Population) White Males Black Males White Females Black Females 50 0 Heart Disease Cancer Stroke Homcide Accidents Cirrhosis Diabetes

30 Zip Code as Predictor of health Source: City of Portland, Oregon, Office of Health Equity and Human Rights

31 Health Disparities in Omaha, NE

32 Disparity in Health Status 32nd 41st 22nd 6th HI #1 14.8* * Difference in the percentage of adults with vs. without a high school degree who self-reported that their health was very good or excellent Source: American s Health Ranking,

33 Infant Mortality 14th MA #1 4.3* 3rd 33rd 30th * Difference in the percentage of adults with vs. without a high school degree who self-reported that their health was very good or excellent Source: American s Health Ranking,

34 Infant Mortality, U.S 2016 Nebraska s infant mortality is 5.2 per one thousand live births compared to 5.9 of the U.S. Healthy People 2020 target is 6.0 infant deaths per 1000 live births

35 Infant Mortality, by Race, in Nebraska Nebraska Department of Health and Human Services (2015) Nebraska Title V 2015 Needs Assessment. Retrieved on Jan. 16 th, 2016 from dhhs.ne.gov/publichealth/mchblockgrant/documents/infantsoutcomes.pdf

36 Mounting evidence indicates that sexual and gender minority populations have less access to health care and higher burdens of certain diseases, such as depression, cancer, and HIV/AIDS, For example, research shows that sexual and gender minorities who live in communities with high levels of anti-sgm prejudice die sooner 12 years on average than those living in more accepting communities. -Dr. Eliseo J. Perez- Stable- Director of the NIMHD

37 Life Expectancy by Race/Ethnicity and Sex White Male White Female Black Male Black Female Hispanic Male Hispanic Female French Male French Female Source: CDC National Center for Health Statistics

38 The Hispanic Paradox Hispanics have the lowest rates of cardiovascular and cancer deaths in Nebraska. Cardiovascular Deaths Cancer Deaths Source: America s Health Rankings, 2014

39 Region VII Health: Where Are We Going?

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41 Shift to a Majority-Minority Source: Pew Research Center

42 Percentages Uninsured For Adults Ages 18 64, By Race And Ethnicity, Stacey McMorrow et al. Health Aff doi: /hlthaff by Project HOPE - The People-to-People Health Foundation, Inc.

43 Survival Comparison of Patients With Cystic Fibrosis in Canada and the United States Median age of survival over time Unadjusted univariate subgroup analysis comparing the risk for death in Canada versus the United States overall and in several subgroups ( ). Stephenson A.L., Sykes J.Stanojevic S. Quon B.S. Marshall B.C Petren K Goss C.H.(2017). Survival Comparison of Patients With Cystic Fibrosis in Canada and the United States- A Population-Based Cohort Study. Accessed on 04/25/2017

44 Disparities in Healthcare Sociodemographic characteristics of patients can influence Physicians' perceptions of patients (Ryn and Burke,2000) Perceptions can influence treatment recommendations, independent of clinical factors

45 Disparities in Healthcare Evidence point to implicit and explicit bias among doctors against overweight patients Physicians view obesity as largely a behavioral problem reinforcing negative societal stereotypes Negative perceptions results in decline in health service utilization Studies show obese persons are less likely to undergo ageappropriate screenings for breast, cervical, and colorectal cancer. Source Obesity (2009) 17, doi: /oby

46 Our Life Expectancy vs. Cost, 2013 us! It seems like one of the central goals of health care is to keep people not dead longer... not the ONLY goal but a big one. The Incidental Economist blog

47 Trends in Premature Mortality in the US by Race, Sex and Ethnicity ( ) Estimates of annual percentage changes in mortality using cause-of-death and demographic data from death certificates shows racial and age disparities in US premature mortality. Premature mortality in Canada and in England and Wales declined by up to 3% per year in both men and women across nearly all age groups In US, premature mortality decreased for some age groups but increased for othersnotably, women aged years The largest increases in white individuals but also seen in American Indians and Alaska Natives in those aged years, particularly in women. Shiels, M.S et al( (2017). Trends in premature mortality in the USA by sex, race, and ethnicity from 1999 to 2014: an analysis of death certificate data. Lancet 2017; 389: S (17)

48 Estimated annual percentage change in all-cause mortality by age and sex in (A) Canada, (B) England and Wales, (C) the USA, and (D H) various racial and ethnic groups in the USA, Shiels et al(2017). Trends in premature mortality in the USA by sex, race, and ethnicity from 1999 to 2014: an analysis of death certificate data. S (17)

49 Social Determinants of Health Race/Ethnicity Culture Neighborhood Education Social Economic Status Geographic Location Occupation Gender Sexual Orientation

50 Health Equity Source: City of Portland, Oregon, Office of Health Equity and Human Rights

51 How Are We Getting There?

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53 Moving to Healthcare 3.0 AHCos

54 THE CASE FOR AN ACCOUNTABLE HEALTH COMMUNITY 9 SOCIOECONOMIC FACTORS Access to health foods Access to preventive care Employment Equality Connected/Accessible transportation Livable median wage Quality Education Relationships/support network Safe/affordable housing Safe Community There are multiple factors that impact our health. By working together to address them, we can improve quality of life and reduce the number of deaths linked to chronic disease in our community 4 HEALTH BEHAVIORS Lack of physical activity llll11111d Poor diet Substance use and binge drinking Tobacco use Behavi oral Factor s 30% Physical Environment socioeconomic factors 40% Clinical Factors 20% 4 CHRONIC DISEASES Cancer Heart disease and stroke Lung disease Type 2 diabetes INFLUENCE LEAD TO CAUSING THESE SOCIOECONOMIC FACTORS, HEALTH BEHAVIORS AND CHRONIC DISEASES IMPACT OUR QUALITY OF LIFE 94,000 OR 1 IN 6 Douglas county residents report having to limit their daily activity due to emotional, physical or mental health 41% of these residents live in NE and in SE Douglas County 78% OF EARLY DEATHS IN DOUGLAS COUNTY Leading cause of death linked to chronic diseases Source: Live Well Omaha

55 Accountable Health Community (AHCo) Model how population health can be advanced through collaborative, multiinstitutional efforts to improve health and health systems on a community basis. First one in Akron, Ohio

56 How do we create healthier communities? We can involve citizens in local delivery system reform and stewardship of their financial resources promote shared responsibility for the health of the community focus on the social determinants of health, clinical-community linkages, and whole person care. Source: Magnan et al, Achieving Accountability for Health and Health Care. July 2012

57 The greatest medicine of all is teaching people how not to use it. - Hippocrates

58 Acknowledgements Kushal Karan

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