Health Disparities Research Kyu Rhee, MD, MPP, FAAP, FACP Chief Public Health Officer Health Resources and Services Administration Outline on Health Disparities Research What is a health disparity? (DETECT) What are some? (DETECT) What causes them? (UNDERSTAND) What can be done? (ELIMINATE) Primary Sources Minority Populations and Health: An Introduction to Health Disparities in the United States by Thomas LaVeist, 2005 Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, Institute of Medicine, 2002 1
General Public Perceptions: How do you think the average African American compares to whites in access to health care? 70 60 50 40 30 20 10 0 Whites Blacks Better off As well off Worse off No opinion Source: Washington Post/Kaiser Family Foundation Physicians on Health Care Disparities: How often do you think our health care system treats people unfairly based on race? 60 50 40 30 20 10 0 Very Often Somewhat Rarely Never Nearly 70% of physicians believe that minorities are rarely or never treated unfairly Source: Kaiser Family Foundation Physicians on Health Care Disparities Percent saying minorities are very or somewhat often unfairly treated 80 70 60 50 Black 40 Latino 30 Asian White 20 10 0 Over ¾ of African American physicians believe minorities are very or somewhat often treated unfairly only ¼ of white physicians believe this. Source: Kaiser Family Foundation 2
What is a Health Disparity? What is a Health Disparity? Disparity = What type of difference? Youth v. elderly Men v. women Unjust or inequitable Who is the Reference Group? Specific group v. overall population Compare specific groups Minority v. Non-minority Subgroup v. Subgroup Subgroup v. Minority Compare a specific group internally 3
Public Law 106-525 (2000) A population is a health disparity population if there is a significant disparity in the overall rate of disease incidence, prevalence, morbidity, mortality or survival rates in the population as compared to the health status of the general population. What is a Health Disparity? Health Status Disparity Differences in health status Morbidity Mortality Functional status Health Care Disparity Differences in access, use, quality, outcomes How we define Health? What are some population demographics where Health Disparities iti exist? 4
Health Disparities amongst groups defined by Race and ethnicity Socioeconomic status Income, Wealth, Poverty Education, Occupation Geographic status t Insurance status Immigration status Health literacy status NIH has defined health disparity populations in the following categories: (1) racial and ethnic minorities; (2) low-income; (3) rural. Black and White Differences in Specialty Procedure Utilization Among Medicare Beneficiaries Age 65 and Older, 1993 Angioplasty (procedures per 1,000 beneficiaries per year) Coronary Artery Bypass Graft Surgery (procedures per 1,000 beneficiaries per year) Mammography (procedures per 100 women per year) Hip Fracture Repair (procedures per 100 women per year) Amputation of All or Part of Limb (procedures per 1,000 beneficiaries per year) Bilateral Orchiectomy (procedures per 1,000 beneficiaries per year) Source: Gornick et al., 1996 Black White Black-to- White Ratio 2.5 5.4 0.46 1.9 4.8 0.40 17.1 26.0 0.66 2.9 7.0 0.42 6.7 1.9 3.64 2.0 0.8 2.45 Among Medicare Beneficiaries Enrolled in Managed Care Plans, African Americans Receive Poorer Quality of Care (Schneider et al., JAMA, March 13, 2002 ving Services Percent Recei 80 70 60 50 40 30 20 Breast Screening Eye Exams Beta Blockers Health Service Follow-up Whites Blacks 5
African American Health Issues Major Health Risks and Health Issues Poverty and Low Socioeconomic Status HIV/AIDS Homicide Obesity Maternal and Child Health Smoking American Indian and Alaska Native Health Issues Major Health Risks Poverty and Low Socioeconomic Status Language and Culture as Barriers to Care Accidents (Unintentional Injuries) Alcohol Asian and Pacific Islander Health Issues Model Minority Myth Major Health Issues Language and Culture as Barriers to Care Culturally Related Beliefs and Values Acculturation and Health 6
Hispanic/Latino Health Issues By 2042, will be the largest group Major Health Issues Poverty and Low Socioeconomic Status Occupational Health HIV/AIDS Acculturation and Health Hispanic Epidemiologic Paradox What are some health conditions where Health Disparities exist? Health Disparities are in Cardiovascular Care Cancer Analgesia Diabetes Renal Transplantation HIV/AIDS 7
Cardiovascular Care Some of the strongest and most consistent evidence for the existence of racial and ethnic disparities in care is found in studies of cardiovascular care. Cerebrovascular Disease African Americans have a higher risk for stroke; however the preponderance of studies finds generally lower rates of diagnostic and therapeutic procedures among African Americans with cerebrovascular disease. Cancer Many studies indicate that ethnic minorities are diagnosed at later stages of cancer progression. 8
Diabetes African Americans, Hispanics, and Native Americans experience 50-100% higher burden of illness and mortality due to diabetes than white Americans; yet it is more poorly managed among minority patients. Renal Transplantation African Americans are at greater risk for end-stage renal disease (ESRD); however, they are less likely than similar white patients to receive a kidney transplant, to be referred for transplantation, and to appear on waiting lists within the first year of Medicare eligibility. HIV/AIDS HIV infection continues to spread more rapidly among African American and Hispanic populations than any other racial/ethnic group in the US; however, even after adjusting for age,,g gender, education, and insurance coverage, African Americans with HIV infection are less likely to receive antiretroviral therapy, less likely to receive prophylaxis for pneumocystic pneumonia (a common cause of death for HIV-positive patients), and less likely to receive protease inhibitors (one of the basic medications to treat HIV and prevent AIDS) than nonminorities with HIV. 9
Analgesia Given the role of cultural and linguistic factors in both patients perceptions of pain and in physicians ability to accurately assess patients pain, healthcare disparities might be greater in pain treatment than in treatment of objectively verifiable disease. What causes Health Disparities? Causes of Health Disparities Ecological Framework Medical Care Framework Unequal Treatment Framework Unequal Treatment Framework Biogenetic/Physiological Theories 10
Ecological Framework Medical Care Framework From Unequal Treatment: Differences, Disparities, and Discrimination in Populations with Equal Access to Health Care Patient-Provider Communication Patient Preferences Non-Minority Minority Difference The Operation of Healthcare Systems and the Legal and Regulatory Climate Discrimination: Biases and Prejudice, Stereotyping, and Uncertainty Disparity Populations with Equal Access to Health Care 11
Biogenetic/Physiological Theories Lack scientific support No racial/ethnic-specific alleles Race/ethnicity are socio-political constructs What can be done? WHO Commission on SDH Three overarching recommendations to tackle the "corrosive effects of inequality of life chances": (1) Improve daily living conditions, including the circumstances in which people p are born,,g grow, live, work and age. (2) Tackle the inequitable distribution of power, money and resources the structural drivers of those conditions globally, nationally and locally. (3) Measure and understand the problem and assess the impact of action. 12
Institute of Medicine www.iom.edu Unequal Treatment Findings Racial and Ethnic disparities in healthcare exist and, because they are associated itdwith worse outcomes in many cases, are unacceptable. Unequal Treatment Findings Many sources including health systems, health care providers, patients, and utilization managers contribute to racial and ethnic disparities in health care. 13
Unequal Treatment Findings Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in healthcare. Unequal Treatment Findings A small number of studies suggest that racial and ethnic minority patients are more likely than white patients to refuse treatment differences in refusal rates are generally small and that minority patient refusal does not fully explain healthcare disparities. Evidence of Racial and Ethnic Disparities in Healthcare Literature Review Only studies that provided some control or adjustment for racial and ethnic differences in insurance status were included 14
Overview of Studies Only a handful of the several hundred studies reviewed find no racial and ethnic difference in care. Insurance status is the key predictor of the quality of care that patients receive. When sources of insurance are controlled, race and ethnicity remain as significant predictors of quality of care. Racial and ethnic minorities receive lower quality of care. Health care systems may serve an important role. Military and VA systems have fewer and lower racial and ethnic healthcare disparities. What are the Recommendations? General Recommendation 2-1, 2-2 Increase awareness of racial and ethnic disparities in healthcare among the general public and key stakeholders. Increase healthcare providers awareness of disparities. 15
Legal, Regulatory, and Policy Interventions Recommendations 5-1, 5-2, 5-3 Avoid fragmentation of health plans along socioeconomic lines. Strengthen the stability of patient- provider relationships in publicly funded health plans. Increase the proportion of underrepresented U.S. racial and ethnic minorities among health professionals. Health System Interventions Recommendation 5-6, 5-7, 5-8, 5-9 Promote the consistency and equity of care through the use of evidence-based guidelines. Structure payment systems to ensure an adequate supply of services to minority patients, and limit provider incentives that may promote disparities. Enhance patient-provided communication and trust by providing financial incentives for practices that reduce barriers and encourage evidence-based practice. Support the use of interpretation services where community need exists. Health System Interventions Recommendation 5-10, 5-11 Support the use of community health workers. Implement multidisciplinary treatment and preventive care teams. 16
Patient Education and Empowerment Recommendation 5-12 Implement patient education programs to increase patients knowledge of how to best access care and participate p in treatment decisions. Cross-Cultural Education in the Health Professions Recommendation 6-1 Integrate cross-cultural education into training of all current and future health professionals. Data Collection and Monitoring Recommendation 7-1, 7-2, 7-3, 7-4 Collect and report data on health care access and utilization by patients race, ethnicity, socioeconomic status, and where possible, primary language. Include measures of racial and ethnic disparities in performance measurement. Monitor progress toward the elimination of healthcare disparities. Report racial and ethnic data by OMB categories, but use subpopulation groups where possible. 17
Research Needs Recommendation 8-1, 8-2 Conduct further research to identify sources of racial and ethnic disparities and assess promising intervention strategies. Conduct research on ethical issues and other barriers to eliminating disparities. Better Data and Research Improved data collection and reporting Subgroups Primary Language Immigrant status Country of Origin Socioeconomic status Further research in weak areas and intervention strategies NIH Health Disparities Summit Recommendations Intersections between Science, Practice, and Policy Partnerships and Collaborations, especially Media Research Capacity-Building/Infrastructure Development AJPH, Transdisciplinary Research, February 10, 2010, e7-e13 18
3 Ts of Health Disparities Research Innovation AJPH, Transdisciplinary Research, February 10, 2010, e1-e7 19