Conceptual framework! Definitions of race and ethnicity Census Questions, Genetics! Social Class, migration, language proficiency! Patient-physician communication! Clinical Research Examples! Options for Interventions!
Source: McGinnis JM, Russo PG, Knickman, JR. Health Affairs, April 2002. Contextual Physical environment Social environment! Health care system Technical aspects of health care Communication with clinicians Economic resources Individual-level Demographics - age, gender, race, ethnicity, education, income Psychosocial - beliefs, attitudes, adherence, coping, personality Behavior - exercise, diet, alcohol, smoking, sexual behavior, substance use! Biological - genetics, stress, allostatic load, opiate receptors, metabolism, telomeres Race is a social construct Geographic origin of racially classified groups data compelling Contrast of White and Black simple One-drop rule (1/16th Black = Black) Gradations of pigmentation Colonial Spanish America table
Ethnicity refers to self-identity with a group defined in part by racial admixture, geographic origin, culture, religion and/or language! Characterized by sharing nonphenotypic characteristics!
100% 90% 80% 3.0% 15% Percent Ancestral Contribution Admixture 70% 60% 50% 40% 30% 20% 52% 24% 45% 61% African Indigenous European 10% 0% Mexican American Puerto Rican Education years of schooling! Annual household income per capita! Occupation: control or autonomy! Life course childhood exposure! Parental occupation and education! Self-perceived standing on a ladder! It all comes down to wealth or assets! Explain independent variance in outcomes that varies by population Strong association between the two constructs Gradient of health exists across all levels of social class Paradox of good health despite adverse social class status
Use of jargon, health literacy Race/ethnicity of clinician as an independent predictor of outcomes Cultural competence or factors that affect communication Racism (usually institutional) and discrimination experiences may affect behavior
Measure by asking Census question plus preference for health care LEP status patient with discordant MD trumps low health literacy in communication domains Retrospective review of registry of 7023 hospitalized patients 2001-2003 8% Chinese, 4% Spanish, 4% Russian Similar LOS, cost, mortality LEP patients had higher adjusted odds of readmission: OR = 1.3 (1.0-1.7) Chinese and Spanish speaking LEP patients had increased odds (1.7 and 1.5) of readmission Karliner L, et al. J Hosp Med 2010; 5: 276-282
System, Biology, Behavior, Environment Disparities by race/ethnicity and social class exist at a broad level across the health care spectrum: HIV, access, cancer Most marked race differences involve obtaining technical procedures CAD care, early cancer surgery, renal transplantation evaluation, other! Disparities are most evident (and most data exist) for Blacks compared to Whites!
SEER registries, US
183,813 Af Ams, Japanese-Am, Latino, Native Hawaiian, Whites; age 45-75, in California and Hawaii 1979 cases lung cancer, identified through SEER, from 1993-2001; 1135 in men African Americans as referent group Stratify by smoking intensity Relative risk of Lung Cancer by race/ ethnicity within smoking level Haiman CA, et al. N Engl J Med. 2006;354(4):333-42 Haiman CA, et al. N Engl J Med. 2006;354(4):333-42
African Americans have 50% more lung cancer and higher cotinine levels per cigarette despite fewer cigarettes/day Total and renal clearance of cotinine were 20% lower in African Americans Nicotine intake per cigarette was 30% greater in African Americans JAMA 1999;280:152-56
African American Latino All AAPI Chinese Japanese Filipino Pacific Islander South Asian African American Latino All AAPI Chinese Japanese Filipino Pacific Islander South Asian *Adjusted for Demographics (age as the timescale, gender, educational level, ADC site, current marital status, living situation), MMSE Score, and age at first dementia symptom
Medicare data, 2002-2005, from markets with top-ranked cardiac hospitals Evaluate role of race, SES of area, distance to hospital Black with acute MI more likely to go to top ranked hospitals (OR = 1.12; 1.08-1.16) No difference in care for CABG Blacks from disadvantaged zip codes were less likely to go to top ranked hospitals (OR = 0.75; 0.64 0.86) Popescu, Arch Intern Med 2010; 170: 1209 Percent Tested White 64 Black 62 Asian / PI 56 AI / AN 54 Latino 50 < High School 46 High School / GED 58 Some College / Tech 64 College Graduate 71 MMWR 2010; 59: 810
Practice in areas with fewer doctors and with higher percent minorities Provide care for more uninsured and Medicaid patients Cultural and linguistic competency Medical School graduates in 2008: 65% White, 20% Asian, 7% Black, 7% Latino, 1% Am Indian, 0.2% Native Hawaiian/PI CDC Health Disparities and Inequalities Report United States, 2011, MMWR, Volume 60, January 14, 2011!