DGH Lecture Series: Leo Morales


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Department of Global Health Lecture Series

Leo Morales
December 16, 2008
'Perspectives and Research on Minority Health and Health Disparities'

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  • DGH Lecture Series: Leo Morales

    1. 1. Perspectives and Research on Minority Health and Health Disparities Leo S. Morales, MD, PhD Associate Professor Division of General Internal Medicine and Health Services Research, UCLA
    2. 2. Education and Training <ul><li>Education </li></ul><ul><ul><li>BS, Chemistry, University of Washington (1984) </li></ul></ul><ul><ul><li>MPH, Health Services, University of Washington (1990) </li></ul></ul><ul><ul><li>MD, University of Washington (1990) </li></ul></ul><ul><ul><li>PhD, Policy Studies, RAND Graduate School (2000) </li></ul></ul><ul><li>Clinical Training </li></ul><ul><ul><li>Internship and residency in primary care internal medicine, UCSF/San Francisco General Hospital (1990-1993) </li></ul></ul><ul><li>Fellowship Training </li></ul><ul><ul><li>UCLA-NRSA Fellowship (1995-1998) </li></ul></ul>
    3. 3. Professional Experience <ul><li>Community Health Center Provider (SFDPH) 1993-1995 </li></ul><ul><li>Interim Medical Director for Managed Care (SFDPH) 1994-1995 </li></ul><ul><li>Health Policy Analyst (RAND) 1995- </li></ul><ul><li>Clinical Instructor (UCLA) 1995-1998 </li></ul><ul><li>Assistant Professor (UCLA) 1998-2005 </li></ul><ul><li>Associate Professor (UCLA) 2006- </li></ul>
    4. 4. Areas of Research <ul><li>Disparities in healthcare </li></ul><ul><ul><li>Patient reports about care (CAHPS) </li></ul></ul><ul><ul><li>Cultural and linguistic barriers to care </li></ul></ul><ul><li>Minority and immigrant health </li></ul><ul><ul><li>Acculturation and health among Latinos </li></ul></ul><ul><ul><li>US-Mexico binational research </li></ul></ul><ul><li>Measurement of patient-reported outcomes </li></ul><ul><ul><li>Health-related quality of life </li></ul></ul><ul><ul><li>Psychometric research </li></ul></ul>
    5. 5. The Changing Demographics of United States: Population Projections 2000-2100 Source: US Census Bureau Projections, Middle Series, 2000
    6. 6. Population Trends in California (2005) Source: American Community Survey, 2004
    7. 7. Immigration Trends, 1850-2000
    8. 8. Origins of Immigrants to United States (1900)
    9. 9. Origins of Immigrants to United States (2000) Latin America 51.7%
    10. 10. Hispanics Are Younger than Whites Aging Labor
    11. 11. Age Distribution of Mexican-American Population by Generational Status FIGURE 1. Age-sex composition of Mexican-origin population by generation, 1998-2002. Note. Males on the right and females on the left. First generation are immigrants; second generation are US-born with at least one foreign-born parent; third generation and higher are US-born with US-Born parents. Source: Hispanics and the Future of America , National Research Council, 2006. Females Males Aging Immigrants Patterns of Assimilation – 2 nd Generation
    12. 16. Results from a study using the National CAHPS Benchmarking Database 1.0 (NCBD 1.0) Racial and Ethnic Differences in Patents’ Assessments of Pediatric Care in Medicaid Managed Care (Weech-Maldonado et al., HSR, 2001) Disparities in Healthcare
    13. 17. Research Questions <ul><li>What is the association between race/ethnicity and patients’ experiences with care? </li></ul><ul><li>What is the association between language spoken at home and patients’ experiences with care, when race and ethnicity is accounted for? </li></ul>
    14. 18. Linking Patients’ Experiences of Health Care to Health Outcomes Health Care Delivery System Patients’ Experiences of Care Patients Seek Care Patients’ Assessments of Care Health Outcomes Adherence & Utilization
    15. 19. Data Source <ul><li>National CAHPS Benchmarking Database 1.0 </li></ul><ul><ul><li>Pediatric CAHPS surveys (n=9,871) </li></ul></ul><ul><ul><ul><li>Medicaid HMOs n=33 </li></ul></ul></ul><ul><ul><ul><li>Response rates among health plans </li></ul></ul></ul><ul><ul><ul><ul><li>mean=42% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>median=42% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>range 30% to 57% </li></ul></ul></ul></ul>
    16. 20. The CAHPS ® Surveys <ul><li>Purpose: to develop reliable and valid surveys to capture aspects of quality of health care for which patients are the best and only source of information. </li></ul><ul><li>Developed with funding from AHRQ and HCFA </li></ul><ul><ul><li>CAHPS I: CAHPS 1.0 and 2.0 surveys (1995-2000) </li></ul></ul><ul><ul><li>CAHPS II: CAHPS 3.0 surveys (2001-2007) </li></ul></ul><ul><li>Adapted for many settings: </li></ul><ul><ul><li>Adult and pediatric patients </li></ul></ul><ul><ul><li>Commercial and Medicaid HMOs </li></ul></ul><ul><ul><li>FFS, PPOs and IPAs </li></ul></ul><ul><li>Wide-spread use: </li></ul><ul><ul><li>Results made available to more than 90 million in 1999 </li></ul></ul><ul><ul><li>Adopted by Medicare managed care and FFS, NCQA, OPM, many state Medicaid programs and others </li></ul></ul>
    17. 21. Capturing Patients’ Experiences with Care: The CAHPS Survey Measures <ul><li>Single-item global ratings: </li></ul><ul><ul><li>Personal doctor </li></ul></ul><ul><ul><li>Specialists </li></ul></ul><ul><ul><li>Health care </li></ul></ul><ul><ul><li>Health plan </li></ul></ul><ul><li>Multiple-item composites of reports: </li></ul><ul><ul><li>Access to care (4 items) alpha=0.62 </li></ul></ul><ul><ul><li>Timeliness of care (4 items) alpha=0.68 </li></ul></ul><ul><ul><li>Doctor communication (4 items) alpha=0.89 </li></ul></ul><ul><ul><li>Office staff courtesy and respect (2 items) r=0.67 </li></ul></ul><ul><ul><li>Health plan customer services (3 items) alpha=0.63 </li></ul></ul>
    18. 22. Example Global Rating Item 0 Worst Possible Health Care 1 2 3 4 5 6 7 8 9 10 Best Possible Health Care How Would You Rate Your Child’s Health Care?
    19. 23. Example of Multiple-Item Composite: Patient-Provider Communication <ul><li>In the last 12 months, how often did your child’s doctors: </li></ul><ul><ul><li>Explain things in a way you could understand? </li></ul></ul><ul><ul><li>Listen to you carefully? </li></ul></ul><ul><ul><li>Show respect for what you had to say? </li></ul></ul><ul><ul><li>Spend enough time with you? </li></ul></ul><ul><li>Response Options: Never, Sometimes, Usually, Always </li></ul>
    20. 24. Independent Variables <ul><li>Parent’s race and ethnicity </li></ul><ul><li>Parent’s age </li></ul><ul><li>Parent’s gender </li></ul><ul><li>Parent’s education </li></ul><ul><li>Child’s age </li></ul><ul><li>Child’s health status </li></ul><ul><li>Language spoken at home </li></ul><ul><li>Health plan membership </li></ul>
    21. 25. Analyses <ul><li>Separate regression model for each rating and composite measure </li></ul><ul><li>Non-response weights </li></ul><ul><li>Adjusted standard errors for clustering of patients within health plans </li></ul>
    22. 26. Selected Sample Characteristics
    23. 27. Regression Results: Minority Patients Report Worse Experiences with Care  Indicate significantly differences compared with whites at p<0.05 level. Models control for parents’ age, gender, education and child’s health status.
    24. 28. Regression Results w/Home Language  Indicate significantly differences compared with whites at p<0.05 level. Models control for parents’ age, gender, education and child’s health status.
    25. 29. Regression Results w/Home Language  Indicate significantly differences compared with whites at p<0.05 level. Models control for parents’ age, gender, education and child’s health status.
    26. 30. Conclusions <ul><li>Asian/Pacific Islanders, Hispanics, Blacks and American Indians/Native Alaskans report worse care compared with Whites </li></ul><ul><li>Language preferences largely account for disparities between Whites and Asian/Pacific Islanders and Hispanics </li></ul><ul><li>Reports and global ratings do not provide consistent findings </li></ul>
    27. 31. Impact of interpreters on parents' experiences with ambulatory care for their children. Morales LS, Elliott M, Weech-Maldonado R, Hays RD. Med Care Res Rev. 2006 Feb;63(1):110-28. Disparities in Healthcare
    28. 32. Research Question <ul><li>What is the impact of providing interpreters on parents’ experiences with care for their children? </li></ul>
    29. 33. Data Sources <ul><li>2000 and 2001 California State Health Families Program CAHPS® surveys </li></ul><ul><li>28 health plans </li></ul><ul><li>Administered in 5 languages (n=26,671) </li></ul><ul><ul><li>English (n=11,231) </li></ul></ul><ul><ul><li>Spanish (n=12,458) </li></ul></ul><ul><ul><li>Cantonese (n=1,374) </li></ul></ul><ul><ul><li>Korean (n=979) </li></ul></ul><ul><ul><li>Vietnamese (n=629) </li></ul></ul><ul><li>Response rates: 2000 (58%), 2001 (60%) </li></ul>
    30. 34. Outcome Measures <ul><li>Three multiple-item composites: </li></ul><ul><ul><li>Provider communication (4 items; alpha=0.78) </li></ul></ul><ul><ul><li>Access to care (4 items; alpha=0.77) </li></ul></ul><ul><ul><li>Timeliness of care (4 items; alpha=0.67) </li></ul></ul><ul><li>Three single-item global ratings: </li></ul><ul><ul><li>Personal doctor </li></ul></ul><ul><ul><li>Specialists </li></ul></ul><ul><ul><li>Health Care </li></ul></ul>
    31. 35. Main Explanatory Variable
    32. 36. Other Explanatory Variables <ul><li>Parents’ age </li></ul><ul><li>Parents’ gender </li></ul><ul><li>Parents’ education </li></ul><ul><li>Parents’ race and ethnicity </li></ul><ul><li>Children’s health status </li></ul><ul><li>Children’s age, </li></ul><ul><li>Survey language </li></ul><ul><li>Survey year. </li></ul>
    33. 37. Analyses <ul><li>Separate OLS regression models for each CAHPS® measure </li></ul><ul><li>Non-response weights based on plan membership, length of enrollment, child’s age and survey language. </li></ul><ul><li>Huber/White standard errors adjusting for clustering within plan. </li></ul>
    34. 38. Sample Characteristics 8 2207 Other 18 4639 Asian/Pacific Islander 9 2623 White % (weighted) N (unweighted) 7 1,926 <25 years 44 11,469 25-34 years 41 10,680 35-44 years 9 2,199 ≥ 45 year Parents’ Education 20 5,206 0-8 Grade 15 3,941 9-11 Grade 30 7,811 12 Grade 34 9,103 >12 Grade Parents’ Race/Ethnicity 63 16729 Hispanic 2 473 African American Parents’ Age
    35. 39. Sample Characteristics 24 6,268 Good 37 9,697 Excellent % (weighted) N (unweighted) 41 11,231 English 47 12,458 Spanish 6 1,374 Cantonese 4 979 Korean 3 629 Vietnamese Child Age 34 9,006 0-5 Years 41 10,921 6-9 Years 25 6,744 10-13 Years Child Health Status 7 1,800 Fair/Poor 32 8,412 Very Good Survey Language
    36. 40. Access to Interpreters by Need Source: Morales et al., 2006 N=26,671
    37. 41. Effect of Interpreters on Reports About Care Source: Morales et al, 2006 * * * * * * * Note: OLS regressions controlling for respondent’s age, respondent’s education, child’s health status, child’s age, survey language, plan membership, year.
    38. 42. Effect of Interpreters on Ratings of Care Source: Morales et al., 2006 * * * * * * * Note: OLS regressions controlling for respondent’s age, respondent’s education, child’s health status, child’s age, survey language, plan membership, year.
    39. 43. Variation in Access to Interpreters by Health Plan Source: Morales et, 2006
    40. 44. Conclusions <ul><li>15% of patients surveyed needed an interpreter but only 7% were always provided an interpreter. </li></ul><ul><li>Interpreter services have a significant effect on patients’ experiences with care: </li></ul><ul><ul><li>Patients who needed an interpreter and never or sometimes had one reported worst care </li></ul></ul><ul><ul><li>Patients who didn’t need interpreters and patients who needed interpreters and usually had one reported intermediate care </li></ul></ul><ul><ul><li>Patients who needed interpreters and always had one reported best care </li></ul></ul><ul><li>No health plan is regularly providing interpreters to patients who need them and there is significant variation among health plans in the provision of interpreters. </li></ul>
    41. 45. Recently Completed Research on Disparities in Healthcare <ul><li>Moreno, Turin, Morales . Impact of Interpreters on the Receipt of New Prescription Medication Information for Spanish-Speaking Latinos. Submitted to: Med Care. </li></ul><ul><li>Morales , Lai, Mazhar et al., Self-Reported Utilization of Eye Care among Latinos in the Los Angeles Latino Eye Study (LALES). Submitted to Am. J. Ophthalmol. </li></ul>
    42. 46. Item and Scale Differential Functioning in the Mini Mental Status Examination Assessed Using the DFIT Framework Morales LS et al. Med Care. 2006 Nov;44(11 Suppl 3):S143-51. Patient-Reported Outcomes
    43. 47. Self-Reported Vision by Racial/Ethnic Group Among Persons Visual Acuity of 20/25 or Better
    44. 48. Purpose of Study <ul><li>To evaluate the Spanish version of the MMSE for differential functioning at the item and scale level (relative to the English version) using item response theory (IRT) models. </li></ul>
    45. 49. The Mini Mental Status Examination <ul><li>Cognitive impairment affects 10% population over 65 and 50% of population over 85. </li></ul><ul><li>MMSE is one of the most familiar and widely used cognitive screening tests worldwide. </li></ul><ul><li>Selected characteristics of MMSE: </li></ul><ul><ul><li>Provider administered </li></ul></ul><ul><ul><li>Seventeen (17) items </li></ul></ul><ul><ul><li>Takes 5 to 10 minutes to administer. </li></ul></ul><ul><ul><li>Multiple translations in existence including Spanish, Chinese, Danish, French German, Russian, … </li></ul></ul>
    46. 50. Data Source <ul><li>Northern Manhattan Aging Project </li></ul><ul><ul><li>13 adjacent census tracks in Northern Manhattan </li></ul></ul><ul><ul><li>9,349 individuals 65 years of age and older </li></ul></ul><ul><li>Dementia Registry </li></ul><ul><ul><li>Survey of representative sub-samples </li></ul></ul><ul><ul><li>Reporting network </li></ul></ul><ul><li>Analytical file of 1,578 completed surveys </li></ul><ul><ul><li>913 English-language respondents </li></ul></ul><ul><ul><li>665 Spanish-language respondents </li></ul></ul>
    47. 51. MMSE Instrument <ul><li>17 items assessing five areas of cognitive functioning including: </li></ul><ul><ul><li>Orientation </li></ul></ul><ul><ul><li>Attention </li></ul></ul><ul><ul><li>Memory </li></ul></ul><ul><ul><li>Recall </li></ul></ul><ul><ul><li>Language </li></ul></ul>
    48. 52. MMSE Spanish Translation <ul><li>Blind independent forward translations </li></ul><ul><li>Reconciliation of new translations and with previous translations </li></ul><ul><li>Pilot test and cognitive interviews (n=50) </li></ul>
    49. 53. MMSE Items 1-11 Categories Content Item 4 Name 3 objects MMSE11 2 Name of type of place MMSE10 2 Name floor of building MMSE9 2 Name 2 nearby streets MMSE8 2 Name city MMSE7 2 Name state MMSE6 2 Name month MMSE5 2 State day of week MMSE4 2 State day of month MMSE3 2 State season MMSE2 2 State year MMSE1
    50. 54. MMSE Items 12-21 2 Copy design MMSE21 2 Write sentence MMSE20 4 Instructions w/paper MMSE19 2 Close eyes MMSE18 2 Repeat phrase MMSE17 2 Name wristwatch MMSE16 2 Name pencil MMSE15 4 Recall 3 objects MMSE14 6 Spell WORLD MMSE13 6 Serial 7s MMSE12 Categories Content Item
    51. 55. Sample Characteristics (n=1,578) 1 6 Asian 18 82 1 <1 98 17 39 44 76 Spanish (n=665) 54 46 32 62 5 31 42 28 75 English (n=913) 9+ years 0 – 8 years <0.001 Education White African American Latino <0.001 Race/Ethnicity 85+ years 75 – 84 years <0.001 <75 years Age 0.82 Female P-Value Gender
    52. 56. Statistical Analysis <ul><li>Test IRT Model Assumptions </li></ul><ul><ul><li>Dimensionality </li></ul></ul><ul><li>Evaluate Item and Scale Differential Functioning </li></ul><ul><ul><li>Estimate item parameters </li></ul></ul><ul><ul><li>Evaluate item and scale differential functioning </li></ul></ul>
    53. 57. Testing Model Assumptions <ul><li>Evaluate dimensionality and local independence for English and Spanish samples separately : </li></ul><ul><ul><li>Item-scale correlation </li></ul></ul><ul><ul><li>Internal reliability consistency (Alpha) </li></ul></ul><ul><ul><li>Confirmatory factor analysis </li></ul></ul>
    54. 58. Item-Scale Correlation and Alpha 0.87 0.89 Alpha 0.43-0.68 0.48-0.72 Range 0.62 0.67 Median 0.58 0.63 Mean Item-Test Correlations Spanish English MMSE
    55. 59. Results from CFA 1-Factor Solution 0.06 0.99 0.97 English 0.06 0.99 0.97 Spanish Root Mean Square Error of Approximation Rec: <0.05 Tucker-Lewis Index Rec >0.90 Comparative Fit Index Rec >0.90 MMSE
    56. 60. Evaluating Differential Item and Test Functioning
    57. 61. Testing for Differential Functioning <ul><li>Item-level differential functioning: </li></ul><ul><ul><li>Chi-square statistics </li></ul></ul><ul><ul><li>Non-compensatory DIF (NC-DIF) </li></ul></ul><ul><li>Scale-level differential functioning: </li></ul><ul><ul><li>Chi-square statistics </li></ul></ul><ul><ul><li>Differential test functioning (DTF) </li></ul></ul><ul><li>Raju, van der Linden, Fleer (1995) IRT-Based Internal Measures of Differential Functioning of Item and Tests. Applied Psych Measurement 19(4): 353-368. </li></ul>
    58. 62. 2-Parameter Models I am unhappy some of the time I don’t care what happens to me I cry easily Severe Happy True  b = 0.25 b = 1.33 b = -0.23 a = 2.83 a = 1.11 a = 2.20
    59. 63. MMSE 2: Name Season NCDIF: 0.060 Cutoff: 0.006
    60. 64. MMSE 17: Repeat Phrase NCDIF: 0.098 Cutoff: 0.006
    61. 65. MMSE 8: Name 2 Nearby Streets NCDIF: 0.005* Cutoff: 0.006
    62. 66. MMSE 14: Recall 3 Objects NCDIF: 0.106 Cutoff: 0.054
    63. 67. MMSE 19: Instructions with Paper NCDIF: 0.087 Cutoff: 0.054
    64. 68. MMSE Scale Response Functions Spanish English DTF: 0.215 Cutoff: 0.558
    65. 69. Differential Test Functioning
    66. 70. Impact of DIF on MMSE Scale Scoring 0.09 DIF-Adjusted IRT Scores Constrained: 1,4-5,8-16,20-21 Unconstrained: 2-3,6-7,17-19 0.05 Change in Group Mean Difference 0.04 Fully Constrained IRT Scores Group Mean Score Difference: English-Spanish Model Assumptions
    67. 71. Summary of Findings <ul><li>Item-Level Findings: </li></ul><ul><ul><li>Based on chi-square statistics, all items show DIF. </li></ul></ul><ul><ul><li>Based on NC-DIF cutoffs, 9 items show DIF (MMSE2, MMSE3, MMSE6, MMSE7, MMSE8, MMSE14, MMSE17, MMSE18, MMSE19). </li></ul></ul><ul><li>Scale-Level Findings: </li></ul><ul><ul><li>Based on chi-square statistics, MMSE shows DF </li></ul></ul><ul><ul><li>Based on DTF cutoff, the MMSE does not shows differential test functioning </li></ul></ul><ul><ul><li>The group mean score difference due to bias is probably not “clinically significant” </li></ul></ul>
    68. 72. Conclusions <ul><li>Some Spanish and English items in the MMSE show different measurement characteristics. </li></ul><ul><li>Comparisons between respondents to English and Spanish versions of MMSE are probably unbiased, whether using IRT to account for items with DIF or not. </li></ul>
    69. 73. Ongoing Research on Patient-Reported Outcomes <ul><li>Development of obesity-specific HRQOL measure for overweight adolescents (NKDDK) </li></ul><ul><li>Psychometric research </li></ul><ul><ul><li>Analyses of Medicare-CAHPS items– DIF by sex, racial-ethnic group, language (Claude Setodji, PhD - NIA - UCLA-RCMAR) </li></ul></ul><ul><ul><li>Analyses of CES-D 11 items– DIF by language (Sylvia Paz, MS - PhD dissertation) </li></ul></ul>
    70. 74. Ongoing Research on Immigrant and Minority Health <ul><li>Cardiovascular risk factors in first and second generation Mexican-Americans in HHANES and NHANES 1999-2004 (Supported by the Russell Sage Foundation: PI Escarce and Morales) – Submitted to: J Immigr Minor Health. </li></ul><ul><li>Inflammatory and hemostasis cardiovascular risk factors among immigrants in MESA (Supported by USC-UCLA Biodemography Center [NIA]: PI Morales) </li></ul><ul><li>Binational research UCLA and IMSS: cardiovascular and liver disease risk factors in Mexican Nationals and Mexican-Americans (Supported by PIMSA: PI Morales and Flores) </li></ul><ul><li>Cardiometabolic risk factors among Mexican-Americans (NHANES) and Mexicans (MHAS) (Supported by UCLA-RCMAR: PI Emma Aguila) </li></ul>
    71. 75. Mentoring and Teaching <ul><li>Mentoring of Junior Faculty, Fellows and Graduate Students </li></ul><ul><ul><li>UCLA-RWJ Clinical Scholars Program </li></ul></ul><ul><ul><li>UCLA Resource Center for Minority Aging Research </li></ul></ul><ul><ul><li>Drew-UCLA Project Export </li></ul></ul><ul><ul><li>RWJ Network for Multicultural Research on Health and Healthcare </li></ul></ul><ul><ul><li>UCLA School of Public Health </li></ul></ul><ul><li>Teaching </li></ul><ul><ul><li>HS 206: Seminar in Latino Health </li></ul></ul><ul><ul><li>Invited lectures and seminars </li></ul></ul>
    72. 76. Potential Research Agenda for Global Health <ul><li>Immigrant Health Studies </li></ul><ul><ul><li>Immigrant populations living in the Northwest </li></ul></ul><ul><ul><li>Collaborations with Latin American researchers in countries of immigrant sending countries </li></ul></ul><ul><li>Minority Health Studies </li></ul><ul><ul><li>Disparities in health and healthcare </li></ul></ul><ul><ul><li>Obesity and cardiometabolic disease and risk factors </li></ul></ul><ul><li>Measurement in Multicultural Populations </li></ul><ul><ul><li>Measure development and evaluation (PROMIS) </li></ul></ul><ul><ul><li>Psychometric evaluation of existing measures </li></ul></ul><ul><li>Teaching and Mentoring </li></ul>
    73. 77. Vision Statement <ul><li>To develop collaborations with investigators interested in multicultural health – locally, nationally and internationally. </li></ul><ul><li>To develop collaborations with researchers in Latin American immigration - focusing on Mexico first. </li></ul><ul><li>To provide mentorship to students and junior faculty interested in disparities and minority health </li></ul><ul><li>To provide leadership at the University of Washington and the greater community on issues related to multicultural health </li></ul>
    74. 78. 2-Parameter Model (Dichotomous Outcomes)