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Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD
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Mobilizing to Eliminate Health Disparities - Carolina Reyes, MD

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  • A variety of innovations in health promotion and disease prevention have been presented, not to mention advances in diagnosis and treatment. As a result of these interventions , the overall health of Americans has improved dramatically. Yet despite these interventions, minorities continue to display worse health outcomes than their counterpart majority populations. This has resulted in racial/ethnic disparities in health. Two areas in the literature are highlighted here in which disparities have been evident: Health care utilization Health outcomes
  • A variety of innovations in health promotion and disease prevention have been presented, not to mention advances in diagnosis and treatment. As a result of these interventions , the overall health of Americans has improved dramatically. Yet despite these interventions, minorities continue to display worse health outcomes than their counterpart majority populations. This has resulted in racial/ethnic disparities in health. Two areas in the literature are highlighted here in which disparities have been evident: Health care utilization Health outcomes
  • Medicare Services Study showed variation in health care utilization based on race/ethnicity for: Mammography Amputations Influenza vaccination Summary point of study: “Providing health insurance is not enough to ensure that the program is used effectively and equitably by all beneficiaries.”
  • A variety of innovations in health promotion and disease prevention have been presented, not to mention advances in diagnosis and treatment. As a result of these interventions , the overall health of Americans has improved dramatically. Yet despite these interventions, minorities continue to display worse health outcomes than their counterpart majority populations. This has resulted in racial/ethnic disparities in health. Two areas in the literature are highlighted here in which disparities have been evident: Health care utilization Health outcomes
  • A variety of innovations in health promotion and disease prevention have been presented, not to mention advances in diagnosis and treatment. As a result of these interventions , the overall health of Americans has improved dramatically. Yet despite these interventions, minorities continue to display worse health outcomes than their counterpart majority populations. This has resulted in racial/ethnic disparities in health. Two areas in the literature are highlighted here in which disparities have been evident: Health care utilization Health outcomes
  • A variety of innovations in health promotion and disease prevention have been presented, not to mention advances in diagnosis and treatment. As a result of these interventions , the overall health of Americans has improved dramatically. Yet despite these interventions, minorities continue to display worse health outcomes than their counterpart majority populations. This has resulted in racial/ethnic disparities in health. Two areas in the literature are highlighted here in which disparities have been evident: Health care utilization Health outcomes
  • Transcript

    • 1.  
    • 2. The California Endowment A Partner for Healthier Communities
    • 3. Mobilizing to Eliminate Health Disparities 2003 Ethnic Physician Summit Carolina Reyes, MD The California Endowment
    • 4. <ul><li>Racial/Ethnic Disparities in Health </li></ul><ul><li>The IOM Report on Racial/Ethnic Disparities in Health Care: “Unequal Treatment” </li></ul><ul><li>Major Findings and Recommendations </li></ul>Outline
    • 5. <ul><li>Among the nation’s most serious health care problem (IOM 2002) </li></ul><ul><li>Approximately 30 percent of Americans are racial or ethnic minorities and even greater diversity of the US is expected. </li></ul><ul><li>Healthcare quality and health outcomes across ethnic and racial populations is disturbing. </li></ul>Disparities in Health Care
    • 6. <ul><li>Despite health interventions that have improved the overall health of the majority of Americans, minorities have benefited less from these advances (NHLHI) </li></ul>Racial/Ethnic Disparities in Health
    • 7. Cardiovascular Disease Death Rate, 1999 Deaths per 100,000 population
    • 8. Cancer Death Rate, 1999 Deaths per 100,000 population
    • 9. Diabetes-Related Death Rate, 1999 Deaths per 100,000 population
    • 10. <ul><li>Social Determinants </li></ul><ul><ul><li>Education, geography, environment, housing, employment </li></ul></ul><ul><li>Access to Care </li></ul><ul><ul><li>Insurance, continuity of care </li></ul></ul><ul><li>Health Care </li></ul><ul><ul><li>Health systems and the medical encounter </li></ul></ul>What Leads to Disparities in Health?
    • 11. <ul><li>Within Medicare: </li></ul><ul><ul><li>Differential utilization based on race for: </li></ul></ul><ul><ul><ul><li>Mammography (Gornick et al.) </li></ul></ul></ul><ul><ul><ul><li>Amputations (Gornick et al.) </li></ul></ul></ul><ul><ul><ul><li>Influenza vaccination (Gornick et al.) </li></ul></ul></ul><ul><ul><ul><li>Lung Ca Surgery (Bach et al.) </li></ul></ul></ul><ul><ul><ul><li>Renal Transplantation (Ayanian et al.) </li></ul></ul></ul><ul><ul><ul><li>Cardiac catherization & angioplasty (Harris et al, Ayanian et al.) </li></ul></ul></ul><ul><ul><ul><li>Coronary artery bypass graft (Peterson et al.) </li></ul></ul></ul><ul><ul><ul><li>Treatment of chest pain (Johnson et al.) </li></ul></ul></ul><ul><ul><ul><li>Referral to cardiology specialist care (Schulman et al.) </li></ul></ul></ul><ul><ul><ul><li>Pain management (Todd et al.) </li></ul></ul></ul>Racial/Ethnic Disparities in Health Care
    • 12. <ul><li>Private, independent non-profit Institute of National Academy of Sciences </li></ul><ul><li>Examines issues related to health policy, health care, education and research </li></ul><ul><li>Convenes “mixed” expert panel for deliberations (6-24 months) and findings to Congress and the public </li></ul>Congressional Action: Institute of Medicine Report
    • 13. <ul><li>Study Charge </li></ul><ul><li>Determine presence and extent of racial/ethnic disparities in health care not attributable to access </li></ul><ul><li>Evaluate potential sources of disparities including the role of bias, discrimination, and stereotyping at the individual, institutional, and health systems level </li></ul><ul><li>Provide recommendations regarding interventions to eliminate racial/ethnic disparities </li></ul>IOM’s Unequal Treatment
    • 14. <ul><li>Eliminating disparities in health has become a national priority of the NIH, DHHS </li></ul><ul><li>Any effort to eliminate disparities will be hindered by an incomplete understanding of the social context of individuals. </li></ul>Why Study Ethnic Racial Bias?
    • 15. <ul><li>Neglecting study of the health impact of bias, discrimination means that explanations for and interventions to alter population distributions of health, disease, and well-being will be incomplete, if not outright harmful. </li></ul>Why Study Racial Bias?
    • 16. <ul><li>This area of work is fraught with controversy because the exposure raises important themes of accountability and human rights. </li></ul><ul><li>It is no more less germane than for research on any other social determinant. </li></ul><ul><li>It is political and unscientific to exclude this study from legitimate scientific inquiry and discourse. </li></ul>Why Study Racial Bias?
    • 17. <ul><li>Explicitly naming a long-standing problem long recognized by those affected has the potential to galvanize or catapult inquiry and action </li></ul><ul><ul><li>“ The Battered Child Syndrome” by C. Henry Kempe </li></ul></ul><ul><ul><li>Domestic Violence </li></ul></ul>The Unnamable Is Named
    • 18. <ul><li>Once named it becomes less nebulous and more tangible </li></ul><ul><li>Bolstered with the belief that with more rigorous documentation, analysis and resources – it could ultimately be rectified </li></ul>The Unnamable Is Named
    • 19. Non-Minority Minority Difference Clinical Appropriateness and Need Patient Preferences The Operation of Healthcare Systems and the Legal and Regulatory Climate Discrimination: Biases and Prejudice, Stereotyping, and Uncertainty Disparity Quality of Health Care Defining the Issues: Differences, Disparities, and Discrimination in Populations with Equal Access to Health Care Populations with Equal Access to Health Care
    • 20. <ul><li>Sources of Data </li></ul><ul><li>Literature Search </li></ul><ul><ul><li>Over 600 papers reviewed </li></ul></ul><ul><li>Commissioned Papers </li></ul><ul><ul><li>Disparities, Legal Issues, Ethical Issues, Data Issues, etc. </li></ul></ul><ul><li>Expert Testimony </li></ul><ul><ul><li>Technical expertise and representation </li></ul></ul><ul><li>Public Workshop </li></ul><ul><ul><li>Professional and Advocacy Perspectives </li></ul></ul><ul><li>Focus Groups </li></ul><ul><ul><li>Both providers and patients </li></ul></ul><ul><li>18 Month Process </li></ul>IOM’s Unequal Treatment
    • 21. <ul><li>Major Finding </li></ul><ul><li>Racial/Ethnic disparities consistently found across a wide range of health care settings (managed care, public/private hospitals, teaching/community, etc.), disease areas (CVD, Ca, HIV, DM, etc.) and clinical services, even when various confounders are controlled for (i.e. SES, stage of presentation, comorbidities) </li></ul>IOM’s Unequal Treatment (www.nap.edu)
    • 22. <ul><li>Specific Findings </li></ul><ul><li>Racial and ethnic disparities in health care exist and, because they are associated with worse outcomes in many cases, are unacceptable. </li></ul><ul><li>They occur in the context of broader historic and contemporary social and economic inequality, and evidence of persistent racial and ethnic discrimination in many sectors of American life. </li></ul><ul><li>Many sources – health systems, health care providers, patients, and utilization managers – contribute to racial and ethnic disparities in health care. </li></ul>IOM’s Unequal Treatment (www.nap.edu)
    • 23. <ul><li>Specific Findings </li></ul><ul><li>Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in healthcare. </li></ul><ul><li>Racial and ethnic minority patients are more likely than white patients to refuse treatment, but differences in refusal rates are generally small, and do not fully explain healthcare disparities. </li></ul>IOM’s Unequal Treatment (www.nap.edu)
    • 24. “ Sociocultural differences between patient and physician influence communications and clinical decision-making.” Eisenberg, 1979 Physician-Patient Communication
    • 25. Linking Communication to Outcomes <ul><li>How do we link communication to outcomes? </li></ul><ul><ul><li>Communication </li></ul></ul><ul><ul><li>Patient Satisfaction </li></ul></ul><ul><ul><li>Adherence </li></ul></ul><ul><ul><li>Health Outcomes </li></ul></ul>
    • 26. “ Medical decision-making can be as much a function of who the patient is as much as what the patient has. ” Mckinley et al., 1996 Physician Decision-Making
    • 27. <ul><li>Focuses on questions such as: </li></ul><ul><ul><li>How do we develop perceptions and judgments of others? </li></ul></ul><ul><ul><li>What factors influence the way we form beliefs? </li></ul></ul><ul><ul><li>How do we use “social knowledge” to make decisions? </li></ul></ul>Physician Decision-Making Social Cognition
    • 28. <ul><li>Characteristics of the Patient </li></ul><ul><ul><li>Age, Sex, SES, Race/Ethnicity, Insurance, Individual patient factors </li></ul></ul><ul><li>Characteristics of the Physician </li></ul><ul><ul><li>Specialty, Level of Training, Background </li></ul></ul><ul><li>Features of the Practice Setting </li></ul><ul><ul><li>Organization of Practice, Compensation, and expectations of productivity </li></ul></ul>Factors Affecting Physician Decision-Making
    • 29. <ul><li>Automatic aspects; group  individual </li></ul><ul><li>“ Cognitive Misers”  cognitive shortcuts to save resources; principle of “least effort” </li></ul><ul><li>Primal->race, gender, age </li></ul><ul><li>Activated most when: </li></ul><ul><ul><li>Stressed </li></ul></ul><ul><ul><li>Under time constraints </li></ul></ul><ul><ul><li>Multitasking </li></ul></ul>Social Cognitive Theory: Stereotyping
    • 30. <ul><li>Built on the IOM report on Crossing the Quality Chasm in 2001 </li></ul><ul><ul><li>One of the six goals to raising the overall quality of the nation’s healthcare </li></ul></ul><ul><li>Clearly stated that racial discrimination is intolerable by law </li></ul><ul><li>Contrary to the moral creed and health care ethic </li></ul>Disparities in Health Care
    • 31. <ul><li>Arguments date back a century and a half ago </li></ul><ul><li>The task at hand is to bring the knowledge and methods available in our generation to the pressing explicit public health problem of persistent racial/ethnic health care disparities. </li></ul>Is This Inquiry New?
    • 32. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care Institute of Medicine
    • 33. <ul><li>Insanity is when we keep doing the same thing and expecting a different result. </li></ul><ul><li>-Albert Einstein </li></ul>How Do We Begin To Address These Disparities?
    • 34. <ul><li>Lack a robust tool bag of interventions </li></ul><ul><li>Significant disparity in the racial ethnic diversity among health professionals. </li></ul><ul><li>Language barriers are a major challenge. </li></ul>Tool Bag of Interventions
    • 35. <ul><li>General Recommendations: </li></ul><ul><li>Increase awareness of racial and ethnic </li></ul><ul><li>disparities in health care among the general </li></ul><ul><li>public and key stakeholders </li></ul><ul><li>Increase health care providers’ awareness </li></ul><ul><li>of disparities. </li></ul><ul><li>  </li></ul>Summary of Recommendations
    • 36. <ul><li>De-fragmentation of Healthcare Financing </li></ul><ul><li>and Delivery </li></ul><ul><li>Avoid fragmentation of health plans along </li></ul><ul><li>socioeconomic lines </li></ul>Legal, Regulatory and Policy Recommendations
    • 37. <ul><li>Strengthening Doctor-Patient Relationships: </li></ul><ul><li>– Take measures to strengthen the stability </li></ul><ul><li>of patient-provider relationships in publicly </li></ul><ul><li>funded health plans </li></ul>Legal, Regulatory and Policy Recommendations
    • 38. <ul><li>Improve the Diversity of the Workforce: </li></ul><ul><li>Increase in the proportion of underrepresented </li></ul><ul><li>U.S. racial and ethnic minorities among health professionals; </li></ul>Legal, Regulatory and Policy Recommendations
    • 39. <ul><li>Patient Protections: </li></ul><ul><li>Apply the same managed care protections to publicly funded HMO enrollees that apply to private HMO enrollees </li></ul>Legal, Regulatory and Policy Recommendations
    • 40. <ul><li>Civil Right Enforcement: </li></ul><ul><li>Provide greater resources to the U.S. DHHS Office of Civil Rights to enforce civil rights laws. </li></ul>Legal, Regulatory and Policy Recommendations
    • 41. Evidence-Based Cost Control: Promote the consistency and equity of care through the use of evidence-based guidelines     Health Systems Interventions
    • 42. <ul><li>Financial Incentives in Health Care: </li></ul><ul><li>Structure payment systems to ensure an adequate supply of services to minority patients, and limit provider incentives that may promote disparities; </li></ul><ul><li>Provide financial incentives for practices that Enhance patient-provider communication Encourage evidence-based practice </li></ul>Health Systems Interventions
    • 43. <ul><li>Interpretation Services: </li></ul><ul><li>Promote the use of interpretation services where community need exists </li></ul><ul><li>Community Health Workers </li></ul><ul><li>Support the use of community health workers </li></ul>Health Systems Interventions
    • 44. <ul><li>Multidisciplinary Teams: </li></ul><ul><li>Implement multidisciplinary treatment and preventive care teams that help coordinate and streamline care </li></ul>Health Systems Interventions
    • 45. Patient Education and Empowerment: Patient education programs should be implemented to increase patients’ knowledge of how to best access care and participate in treatment decisions. Cross-Cultural Education in Health Professions:   Integrate cross-cultural education into the training of all current and future health professionals. Health Systems Interventions
    • 46. DATA COLLECTION AND MONITORING: Collect and report data on health care access and utilization by patients’ race, ethnicity, socio-economic status, and where possible, primary language; Include measures of racial and ethnic disparities in performance measurement;   Health Systems Interventions
    • 47. <ul><li>DATA COLLECTION AND MONITORING: </li></ul><ul><li>  </li></ul><ul><li>Monitor progress toward the elimination of health care disparities; </li></ul><ul><li>Report racial and ethnic data by OMB categories, but use subpopulation groups where possible </li></ul>Health Systems Interventions
    • 48. NEEDED RESEARCH: Conduct further research to identify sources of racial and ethnic disparities and assess promising intervention strategies, and;   Conduct research on ethical issues and address barriers to research of disparities in care Health Systems Interventions
    • 49. <ul><li>Acutely aware of the value laden and sensitive nature of the subject </li></ul><ul><li>Disparities in healthcare may be reflective of inequalities in other aspects of American life </li></ul><ul><li>The real challenge is embracing and acting on these recommendations </li></ul><ul><li>Requires a broad and sustained commitment from all of us </li></ul>Conclusions
    • 50. <ul><li>National dialogue </li></ul><ul><ul><li>Professional organizations </li></ul></ul><ul><ul><li>Catalyst for adding cultural competency under the rubric of quality care </li></ul></ul><ul><ul><li>Health plans are developing strategies to address race/ethnicity disparities </li></ul></ul>What has been the Impact of the IOM report to date?
    • 51. <ul><li>Equity is defined as “providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status” </li></ul><ul><li>For populations, equity means reducing disparities in the use of health care services that are related to personal characteristics </li></ul>Guiding the National Healthcare Disparities Report
    • 52. <ul><li>Health Care Quality </li></ul><ul><ul><li>Safety </li></ul></ul><ul><ul><li>Effectiveness </li></ul></ul><ul><ul><li>Patient Centeredness </li></ul></ul><ul><ul><li>Timeliness </li></ul></ul>Guiding the National Healthcare Disparities Report
    • 53. <ul><li>Severe morbidity and mortality from disease is always a tragedy. </li></ul><ul><li>Preventable morbidity and mortality is unjust. </li></ul>Guiding the National Healthcare Disparities Report
    • 54. <ul><li>Immense challenges to improving our healthcare system for many populations experiencing unequal treatment. </li></ul><ul><li>Immense commitment </li></ul><ul><ul><li>Strategize with colleagues </li></ul></ul><ul><ul><li>Create new partnerships </li></ul></ul><ul><ul><li>Explore our own role towards elimination of disparities </li></ul></ul>Conclusion
    • 55. <ul><li>Teamwork across expertise </li></ul><ul><ul><li>Building coalitions </li></ul></ul><ul><ul><li>Trusting relationships </li></ul></ul><ul><li>Tenacity </li></ul><ul><li>Realistic </li></ul><ul><li>Hopeful </li></ul><ul><li>Keep our attention focused on the possible </li></ul>Sustained Policy Change
    • 56. The California Endowment A Partner for Healthier Communities
    • 57.  

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