Reasons for Disparities in Health and HealthCare


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Draws attention to population health, and ways to assess differences between populations in health and health care. Presented to an ethnically diverse group of residents at a family practice clinic in Minneapolis. August 08.

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Reasons for Disparities in Health and HealthCare

  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]