HCMC Family Medicine Clinic August 6, 2008 Population Disparities in Health and Health Care Yiscah Bracha, M.S. Research D...
Definitions <ul><li>Disparity:  “…a  population-specific  difference in the presence of disease, health outcomes, or acces...
Population vs. Individual Health:  <ul><li>Philosophy questions: </li></ul><ul><ul><li>What is a ‘population’? What is the...
Population “ontology” <ul><li>How are populations typically differentiated? </li></ul><ul><ul><li>By race, culture, ethnic...
Examples of population health measures: <ul><li>Rates of death from heart disease </li></ul><ul><li>Breast cancer incidenc...
Population measures of access to care: <ul><li>Percent uninsured </li></ul><ul><li>Number of family practitioners per capi...
Population measures of medical care: <ul><li>Percent of AMI patients receiving beta blockers </li></ul><ul><li>Percent of ...
What we know: <ul><li>In the U.S., population measures of health, of access to care, and of medical care, are lower for: <...
Documented evidence <ul><li>DuBois (1906).   The Health and Physique of the Negro American.  Documents racial inequalities...
… continued <ul><li>Margaret Heckler, Secretary of DHHS (January 1984).   Health, United States,1983. “ … a continuing dis...
Healthy People 2010 <ul><li>Decennial goal-setting document of the U.S. Department of Health and Human Services </li></ul>...
Environmental reasons for disparities <ul><li>Access to safe spaces for exercise </li></ul><ul><li>Access to healthy food ...
Cultural reasons for disparities: <ul><li>Culturally developed and reinforced beliefs about: </li></ul><ul><ul><li>Sexual,...
Social reasons for disparities: <ul><li>Immediate social (e.g. friends, family, neighbors, faith community) reinforcement ...
Individual reasons for disparities: <ul><li>Availability of resources </li></ul><ul><ul><li>Discretionary income </li></ul...
Health care reasons for disparities <ul><li>Quality of patient-provider encounter: </li></ul><ul><ul><li>Level of trust </...
It all cumulates … <ul><li>“ Social causation [is] the primary explanation for health disparities … [through] cumulative e...
Upstream Interventions: <ul><li>Diffuse targets, multiple populations: </li></ul><ul><ul><li>Built environment </li></ul><...
<ul><li>Focused targets, specific populations. </li></ul><ul><ul><li>Community outreach and partnership: </li></ul></ul><u...
Downstream interventions: <ul><li>In the clinic and/or health system, manage  populations  using EHRs </li></ul><ul><ul><l...
Exam room interventions: <ul><li>Target:  Individual patient and patient’s immediate social environment (spouse, children,...
Philosophy revisited: <ul><li>A population is a set of individuals sharing physical, behavioral, lifestyle, life history, ...
Questions? Yiscah Bracha [email_address]
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Population disparities in health & health care

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Presentation to culturally diverse group of family practice residents, on viewing disparities from a population perspective

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Transcript of "Population disparities in health & health care"

  1. 1. HCMC Family Medicine Clinic August 6, 2008 Population Disparities in Health and Health Care Yiscah Bracha, M.S. Research Director Center for Urban Health
  2. 2. Definitions <ul><li>Disparity: “…a population-specific difference in the presence of disease, health outcomes, or access to care”. </li></ul><ul><li>Health Resources and Services Administration. Carter-Pokras and Baquet 2002: 430 </li></ul>
  3. 3. Population vs. Individual Health: <ul><li>Philosophy questions: </li></ul><ul><ul><li>What is a ‘population’? What is the difference between a ‘population’ and an ‘individual’? </li></ul></ul><ul><ul><li>Do populations have “properties” distinctly different from their individual members? </li></ul></ul>
  4. 4. Population “ontology” <ul><li>How are populations typically differentiated? </li></ul><ul><ul><li>By race, culture, ethnicity, country of origin, language spoken at home. </li></ul></ul><ul><ul><ul><li>Extra credit question: What is the difference between these terms? </li></ul></ul></ul><ul><ul><li>By geographic area </li></ul></ul><ul><ul><li>By age group </li></ul></ul><ul><ul><li>By income level </li></ul></ul>
  5. 5. Examples of population health measures: <ul><li>Rates of death from heart disease </li></ul><ul><li>Breast cancer incidence rates among women aged 25-40. </li></ul><ul><li>Life expectancy for males at age 65 </li></ul><ul><li>Among cancer patients, rates of death within five years of diagnosis. </li></ul>
  6. 6. Population measures of access to care: <ul><li>Percent uninsured </li></ul><ul><li>Number of family practitioners per capita </li></ul><ul><li>Percent who report making financial choices between medication and food. </li></ul><ul><li>Average distance from home to tertiary care hospital </li></ul>
  7. 7. Population measures of medical care: <ul><li>Percent of AMI patients receiving beta blockers </li></ul><ul><li>Percent of ED patients with long bone fractures receiving pain medication </li></ul><ul><li>Percent of patients with asthma prescribed daily controller medications </li></ul><ul><li>Percent of ESRD patients placed on transplant waiting list </li></ul>
  8. 8. What we know: <ul><li>In the U.S., population measures of health, of access to care, and of medical care, are lower for: </li></ul><ul><ul><li>Low income vs. high income populations </li></ul></ul><ul><ul><li>Among those born in the US, African- compared to European American populations </li></ul></ul><ul><ul><li>In general, populations of all races, ethnicities, cultures other than American-born White. </li></ul></ul>
  9. 9. Documented evidence <ul><li>DuBois (1906). The Health and Physique of the Negro American. Documents racial inequalities in health. </li></ul><ul><li>1964 Civil Rights Act. Prohibits racial discrimination in any programs receiving federal assistance; 1965 passage of Medicare/Medicaid makes most hospitals potential recipients of federal funds </li></ul>
  10. 10. … continued <ul><li>Margaret Heckler, Secretary of DHHS (January 1984). Health, United States,1983. “ … a continuing disparity in the burden of death and illness experienced by Blacks and other minority Americans as compared with our nation’s population as a whole” </li></ul><ul><li>US Office of Civil Rights (1999). The Health Care Challenge: Acknowledging Disparity, Confronting Discrimination, and Ensuring Equality. </li></ul><ul><li>Institute of Medicine (2003). Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. </li></ul>
  11. 11. Healthy People 2010 <ul><li>Decennial goal-setting document of the U.S. Department of Health and Human Services </li></ul><ul><li>Calls for the elimination of all health disparities: </li></ul><ul><ul><li>Race or ethnicity </li></ul></ul><ul><ul><li>Gender </li></ul></ul><ul><ul><li>Education or income </li></ul></ul><ul><ul><li>Disability </li></ul></ul><ul><ul><li>Geographic location </li></ul></ul><ul><ul><li>Sexual orientation </li></ul></ul><ul><ul><li>(U.S. Department of Health and Human Services 1998). </li></ul></ul>
  12. 12. Environmental reasons for disparities <ul><li>Access to safe spaces for exercise </li></ul><ul><li>Access to healthy food </li></ul><ul><li>Exposure to environmental toxins in soil, air, building materials </li></ul><ul><li>Stress induced by unstable housing, fear of deportation, violence, discriminatory treatment, inability to communicate </li></ul>
  13. 13. Cultural reasons for disparities: <ul><li>Culturally developed and reinforced beliefs about: </li></ul><ul><ul><li>Sexual, child-rearing practices </li></ul></ul><ul><ul><li>Food, cleanliness, purity </li></ul></ul><ul><ul><li>Reasons for illness; notions of “disease” </li></ul></ul><ul><ul><li>Proper time to seek medical care </li></ul></ul><ul><ul><li>Consequences of referring to death/disease </li></ul></ul><ul><ul><li>Consequences of treatments for disease </li></ul></ul>
  14. 14. Social reasons for disparities: <ul><li>Immediate social (e.g. friends, family, neighbors, faith community) reinforcement for “healthy behaviors”: </li></ul><ul><ul><li>Abstention from smoking </li></ul></ul><ul><ul><li>Screening for detectable disease (e.g. mammogram, prostate exam) </li></ul></ul><ul><ul><li>Diet </li></ul></ul><ul><li>Social reinforcement for preventive measures: </li></ul><ul><ul><li>Immunizations </li></ul></ul><ul><ul><li>Well-baby exams </li></ul></ul>
  15. 15. Individual reasons for disparities: <ul><li>Availability of resources </li></ul><ul><ul><li>Discretionary income </li></ul></ul><ul><ul><li>Transportation & child care </li></ul></ul><ul><ul><li>Stable housing </li></ul></ul><ul><ul><li>Generous insurance </li></ul></ul><ul><ul><li>Knowledge </li></ul></ul><ul><ul><li>Flexible and supportive employer (e.g. time available during work day for medical appts) </li></ul></ul><ul><ul><li>English comprehension, literacy, numeracy </li></ul></ul>
  16. 16. Health care reasons for disparities <ul><li>Quality of patient-provider encounter: </li></ul><ul><ul><li>Level of trust </li></ul></ul><ul><ul><li>Communication: Language, individual words, explanations, stories </li></ul></ul><ul><ul><li>Prior beliefs and expectations; doc unconscious stereotyping </li></ul></ul><ul><ul><li>Amount of time available to deal with number of and seriousness of problems </li></ul></ul>
  17. 17. It all cumulates … <ul><li>“ Social causation [is] the primary explanation for health disparities … [through] cumulative effects of social disadvantage across stages of the life cycle and across environments (e.g., fetal, family, educational, occupational, and neighborhood).…” </li></ul><ul><li>Kevin Fiscella MD, MPH, and David R. Williams, PhD, MPH. Health Disparities Based on Socioeconomic Inequities: Implications for Urban Health Care. Academic Medicine . 2004; 79:1139-1147. </li></ul>
  18. 18. Upstream Interventions: <ul><li>Diffuse targets, multiple populations: </li></ul><ul><ul><li>Built environment </li></ul></ul><ul><ul><ul><li>Safe parks, playgrounds, walking and bicycle paths </li></ul></ul></ul><ul><ul><ul><li>Suppression of environmental toxins </li></ul></ul></ul><ul><ul><li>Public education </li></ul></ul><ul><ul><ul><li>Healthy behaviors </li></ul></ul></ul><ul><ul><ul><li>Prevention </li></ul></ul></ul><ul><ul><ul><li>Screening </li></ul></ul></ul><ul><ul><li>Coverage and reimbursement reform to make health care more accessible & affordable </li></ul></ul>
  19. 19. <ul><li>Focused targets, specific populations. </li></ul><ul><ul><li>Community outreach and partnership: </li></ul></ul><ul><ul><ul><li>Advertisements about healthy behaviors, screening, prevention, using media accessed by members of at-risk populations </li></ul></ul></ul><ul><ul><ul><li>Encourage patient self-management & self-efficacy through collaborations between health care providers and: </li></ul></ul></ul><ul><ul><ul><ul><li>Schools </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Worship communities </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Community centers </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Community elders </li></ul></ul></ul></ul>Midstream interventions:
  20. 20. Downstream interventions: <ul><li>In the clinic and/or health system, manage populations using EHRs </li></ul><ul><ul><li>Monitor population health stats </li></ul></ul><ul><ul><li>Monitor population receipt of appropriate care </li></ul></ul><ul><ul><ul><li>Compare across clinics </li></ul></ul></ul><ul><ul><ul><li>Compare across docs (gasp!) </li></ul></ul></ul><ul><ul><ul><li>Compare across time points </li></ul></ul></ul><ul><ul><li>Identify at-risk individual patients; target for: </li></ul></ul><ul><ul><ul><li>Intensive medical intervention </li></ul></ul></ul><ul><ul><ul><li>Community health worker support </li></ul></ul></ul>
  21. 21. Exam room interventions: <ul><li>Target: Individual patient and patient’s immediate social environment (spouse, children, parents, caregivers, close friends) </li></ul><ul><li>Actions: </li></ul><ul><ul><li>Coming up, from Dr. Eliason! </li></ul></ul><ul><li>Effects on population health and thus disparities: </li></ul>
  22. 22. Philosophy revisited: <ul><li>A population is a set of individuals sharing physical, behavioral, lifestyle, life history, environmental exposure, characteristics </li></ul><ul><li>Measures of population health improve when averages over individuals improve and when variability of measures among individuals decrease </li></ul><ul><li>Targeted interventions in the exam room thus can reduce population disparities. </li></ul>
  23. 23. Questions? Yiscah Bracha [email_address]
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