Eliminating Barriers: Health Disparities and Solutions for African Americans
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1 Eliminating Barriers: Health Disparities and Solutions for African Americans Gregory L. Hall, MD Chairman, Ohio Commission on Minority Health Member, Cuyahoga County Board of Health Ass t Clinical Professor, CWRU School of Medicine Ass t Clinical Professor, NEOMED College of Medicine
2 Health Disparities 1985 Brought to national attention in report in by Margaret Heckler, Secretary of the Department of Health and Human Services under President Reagan. She took note of startling disparities in health status for Blacks and other minorities.
3 Secretary s Task Force on Black and Minority Health The work of the Secretary s Task Force on Black and Minority Health documented the myriad of reasons for these disparities and set forth a number of behavioral, systemic, workforce and resource allocation recommendations to eliminate this historic and persistent problem.
4 Ohio Commission on Minority Health The need for a deliberate, focused effort to address this problem led to the creation of the Ohio Commission on Minority Health in July of Representative Ray Miller convinced the governor of it s importance. It was the first state agency in the nation charged with addressing disparities in the health status between minority and majority populations.
5 Ohio Commission on Minority Health 1987
6 Mission The Ohio Commission on Minority Health is dedicated to eliminating disparities in minority health through: 1. Innovative Strategies and Financial Opportunities 2. Public Health Promotion 3. Legislative Action, Public Policy and Systems Change.
7 Ohio Demographics (2016) Race 13% 4% White African American Hispanic Latino Asian Pacific Islanders American Indian/Alaskan 81%
8 Ohioans with Medicare 6 13 White African American 83 Hispanic Latino
9 Ohioans with Medicaid 1% 3% 28% 67% White African American Hispanic Latino Other
10 The difference is health disparities Ohio Racial Demographics Ohioans with Medicaid 1% White 3% 13% 4% 81% African American Hispanic Latino 28% 67% White African American Hispanic Latino Other
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14 Mortality Rate
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19 Ten Top Causes of Death (US) 1. Heart Disease 2. Cancer 3. Chronic Lower Respiratory Disease 4. Accidents 5. Stroke 6. Alzheimer s Disease 7. Diabetes 8. Influenza / Pneumonia 9. Kidney Disease 10.Suicide
20 Ten Top Causes of Death (US) 1. Heart Disease 2. Cancer 3. Chronic Lower Respiratory Disease 4. Accidents 5. Stroke 6. Alzheimer s Disease 7. Diabetes 8. Influenza / Pneumonia 9. Kidney Disease 10.Suicide
21 The Worst Oxford Dictionary Of the poorest quality or the lowest standard; least good or desirable. Be in the least advantageous position; suffer the most.
22 African American Clinical Care Outcomes Worst death from Cardiovascular disease outcomes: 321 per 100,000 African American 245 per 100,000 European American 188 per 100,000 Hispanic Latino 178 per 100,000 American Indian 137 per 100,000 Asian Pacific Islanders
23 African American Clinical Care Outcomes Worst death from Diabetes outcomes: 50 per 100,000 African American 22 per 100,000 European American 36 per 100,000 Hispanic Latino 45 per 100,000 American Indian 17 per 100,000 Asian Pacific Islanders
24 African American Clinical Care Outcomes in Cancer Worst outcomes in: Lung cancer Breast cancer Ovarian cancer Cervical cancer Colon cancer Prostate cancer Pancreatic cancer Liver cancer Thyroid cancer Head & neck cancers
25 Age-Adjusted Death Rates for Top Five Causes of Cancer Death (CDC)
26 Is it related to insurance?
27 Social Determinants of Health?
28 Social Determinants of Health Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.
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34 ... shocking & inhumane
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36 Physician-Driven Disparities Lower physician-ordered cholesterol screens Lower physician-ordered diet/nutrition counseling Lower physician-ordered exercise counseling Lower physician-ordered use of Alzheimer disease medications Lower physician-ordered antidepressant medication in the diagnosis of depression
37 Clinician-Driven Disparities Lower physician-ordered cholesterol-lowering medications (statins) after stroke. Lower physician-ordered blood thinners with atrial fibrillation. Lower physician ordered bone marrow transplant (curative treatment) in multiple myeloma. And much more...
38 Poor provider care Poor clinical care by providers Cultural Incompetence Poor medical research application Poor adherence to recommendations
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40 Cultural Competence In 1998 Jeffrey T. Berger, MD wrote "Culture and Ethnicity in Clinical Care" for the Journal of the American Medical Association and stressed the importance of "physician recognition of the cultural context of patients' illnesses (that) can be essential to a successful therapeutic relationship.
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52 Prostate Cancer
53 Prostate Cancer Mortality Whites: 19 per 100,000 persons Blacks: 44 per 100,000 persons
54 Age-Adjusted Death Rates for Top Five Causes of Cancer Death (CDC)
55 The course of prostate cancer has been shown to be different in African American men prostate cancer volume is greater in African American men and advanced metastatic prostate cancer occurs at a 4:1 ratio.
56 Prostate Cancer The risk of death from prostate cancer in African Americans was consistently higher than in whites in all socioeconomic status strata. Among patients with the same socioeconomic status, cancer screening with a PSA was more common in Whites than African Americans, and cancer detection was earlier in Whites.
57 More watchful waiting % of African Americans were in watchful waiting, compared to only 7.2% of Whites (P<0.001).
58 Prostate Cancer African American patients are more likely to have elevated PSA levels in the presence of prostate cancer. The PSA is better as a prostate cancer screen in African Americans.
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60 Prostate Cancer Screens All African American men should have an annual PSA drawn.
61 Cardiovascular Differences 2 to 3-fold increased risk for stroke 2-fold increased risk for heart failure 1.5 to 2 fold increased risk for coronary heart disease 1.4 fold increased risk for hypertension 1.7 fold increased risk for diabetes 1.5 fold increased risk for obesity 4 fold increased risk for end stage renal disease
62 Salt Sensitivity African Americans have a salt-sensitive gene that may make hypertension worse.
63 Salt Sensitivity 75% of all African American patients with hypertension are salt sensitive compared to 50% across all races with hypertension. Salt sensitivity increases with age and is more common in patients that are obese, and have renal insufficiency leading to failure... all of which are increased in African Americans. Salt-sensitivity alone is associated with increased mortality, even in salt-sensitive people without hypertension.
64 Salt-Reduction Counseling A modest reduction in salt intake (half normal consumption: 5 to 6 grams) for a month has been shown to make significant and sustained reductions in blood pressure. African Americans showed the most pronounced blood pressure reductions in response to salt restriction with a drop of 8 mm Hg systolic over 4 mm Hg diastolic averaged across as array of studies.
65 Hypertension
66 ALLHAT Trial (42,000 enrollees) Thiazide-type diuretic was better at reducing blood pressure and preventing cardiovascular events than other meds in African Americans.
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68 ALLHAT Trial (42,000 enrollees) Calcium channel blockers (amlodipine) have also shown greater efficacy in African Americans as first line antihypertensives.
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70 Hypertension & African Americans Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blocker (ARB) medications are less effective in African Americans for blood pressure control and are associated with worse outcomes.
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72 Hypertension & African Americans Treatment of hypertension appears to be inconsistent with the prevailing treatment guidelines for nearly one-third of the aged African Americans."
73 Do NOT Stop your Medicine!! Consult your physician!!
74 Stroke
75 Strokes in African Americans Nearly 44% of African American men and 48% of African American women have some form of cardiovascular disease that includes heart disease and stroke. About 2 out of every 5 African American adults have high blood pressure, and less than half of them have it under control. African-Americans are twice as likely to die from stroke as Whites and their rate of first strokes is almost double that of Whites.
76 Ohio Department of Health Burden of Stroke Report 2006
77 Causes of Strokes 1. High Blood Pressure (Hypertension) 2. Tobacco (smoking or chewing) 3. Heart Disease (valves and/or atrial fibrillation) 4. Diabetes 5. Obesity & Lack of Exercise 6. Medications (blood thinners, hormone therapy, BCP & smoking) 7. Family history (strokes or sickle cell)
78 ABCs A - Take aspirin as directed by your health care provider. B - Control your blood pressure. C - Manage your cholesterol. S - Don't smoke.
79 Aspirin Everyone age 50 and older should be on Aspirin 81mg daily unless they have an increased risk for bleeding or cannot tolerate.
80 Blood Pressure Everyone age 50 and older should measure their own blood pressure.
81 Smoking Everyone should stop smoking!!
82 Menthol Cigarettes Studies have also shown a higher propensity among African Americans to smoke mentholated cigarettes (80% vs 5% white) Menthol smokers absorb more nicotine and metabolize it slower. The anesthetizing effect of menthol makes you inhale more deeply and hold smoke in the lungs longer.
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84 Menthol Cigarettes Higher risk of stroke in menthol smokers. Smoking cessation among menthol cigarette smokers is harder in both African American and Latino smokers, and for those who stopped fewer were able to remain abstinent.
85 Diabetes
86 Racial Differences: Diabetes
87 Racial Differences: Diabetes African Americans with Sickle Cell Trait have much lower HbA1c at any level: HbA1c cannot be trusted in patients with Sickle Cell trait or disease.
88 Racial Differences: Diabetes Compared to non-hispanic whites, HbA1c levels among African Americans typically average 0.4% higher than Whites at similar blood glucose levels. African Americans and Hispanics with normal fasting plasma glucose levels had significantly higher HbA1c values than whites.
89 African Americans should subtract 0.4 from your HbA1c.
90 Diabetes Control Studies have repeatedly shown that: increased diabetes knowledge and understanding have been positively associated with better glucose (sugar) control and increased education leads to elevated confidence in the patient's ability to achieve control.
91 Racial Differences: Colon Cancer Screening Colonoscopies begin at what age? Colonoscopy is indicated at age 45 in African Americans due to earlier onset and faster growing tumors. Sigmoidoscopy...
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93 Racial Differences: Colon Cancer Colon polyps more often occur on the left side of the colon and can be reached by sigmoidoscopy... Except in African Americans when they occur more often on the right side, out of sight and reach of the sigmoidoscope. Sigmoidoscopy is NOT preferred for African Americans.
94 American College of Gastroenterology
95 African Americans should begin colon screening at age 45 and NEVER have a sigmoidoscopy.
96 Dietary Differences
97 Dietary Differences
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100 Thirsty? Drink water.
101 Racial Differences: Hypertension prevalence and treatment Cardiovascular disease prevalence and treatment Diabetes prevalence and treatment Smoking prevalence and treatment Cancer detection and treatment And much more...
102 Racial & Cultural Differences Exist They impact patient engagement. They impact patient outcomes. They impact patient care quality. They impact patient mortality. To ignore them and treat everyone according to one set of guidelines is completely unadvisable and could be interpreted as a sign of... Clinical incompetence.
103 These poor outcomes cost... Racial health disparities are associated with substantial annual economic losses nationally, including an estimated: $35 billion in excess health care expenditures $10 billion in illness-related lost productivity
104 These poor outcomes cost... Lost hope and aspirations. Lost companionship and leadership. Lost opportunities and accomplishments.
105 Patient-centered care is culturally, racially, and clinically competent care.
106 Thank You
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