Eliminating Health Eliminating Health Disparities Disparities Michael A. Rodriguez, MD, MPH Michael A. Rodriguez, MD, MPH Associate Professor Associate Professor David Geffen School of Medicine David Geffen School of Medicine at UCLA at UCLA May 10, 2006 May 10, 2006
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Eliminating Health Disparities Michael A. Rodriguez, MD, MPH Associate Professor David Geffen School of Medicine at UCLA May 10, 2006.
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Eliminating Health Eliminating Health DisparitiesDisparities
Michael A. Rodriguez, MD, MPHMichael A. Rodriguez, MD, MPHAssociate ProfessorAssociate ProfessorDavid Geffen School of Medicine at David Geffen School of Medicine at UCLAUCLAMay 10, 2006May 10, 2006
Moving ForwardMoving Forward
Advancements in Advancements in biomedical biomedical
sciences and sciences and medical practicesmedical practices
Public Interest Public Health
Community
Health Disparities Health Disparities in perspectivein perspective
Identify risk factorsIdentify risk factors Quantify consequencesQuantify consequences Discover and disseminate solutionsDiscover and disseminate solutions
Perspective: What type of condition is this? How Perspective: What type of condition is this? How typical is this type of condition in this community?typical is this type of condition in this community?
Employment & Education: Do the people have jobs? Employment & Education: Do the people have jobs? How much does the individual earn? What level of How much does the individual earn? What level of education?education?
Environment: How much does the environment Environment: How much does the environment contribute to the condition?contribute to the condition?
Health Costs: How much do these preventable ER Health Costs: How much do these preventable ER visits and hospitalizations cost? visits and hospitalizations cost?
Consequences to Family: What happens to the Consequences to Family: What happens to the families and homes of the individual?families and homes of the individual?
Solutions: What is being done to address this Solutions: What is being done to address this problem?problem?
OverviewOverview
Background Background
Contributing FactorsContributing Factors
Efforts to Address Efforts to Address
Health DisparitiesHealth Disparities
““Health disparities are differences in theHealth disparities are differences in the
incidence, prevalence, mortality, and burden incidence, prevalence, mortality, and burden of of
diseases and other adverse health diseases and other adverse health conditions conditions
that exist among specific population groups that exist among specific population groups in in
the United States”the United States”Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, 2002
Racial/Ethnic Disparities Racial/Ethnic Disparities in Virtually all Health in Virtually all Health DomainsDomains Premature mortality including infant Premature mortality including infant
Functional limitations and disabilityFunctional limitations and disability
Leading Health DisparitiesLeading Health Disparities
Cardiovascular Cardiovascular DiseaseDisease
CancerCancer DiabetesDiabetes HIV/AIDSHIV/AIDS AsthmaAsthma Mental HealthMental Health
Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, 2002.
DiabetesDiabetes
Type 2 diabetes is more prevalent in Type 2 diabetes is more prevalent in Mexican Americans (13%) than in Mexican Americans (13%) than in non-Latino Whites (8%) non-Latino Whites (8%) (Hertz et al.)(Hertz et al.)
Latinos in the US are almost twice as Latinos in the US are almost twice as likely to die from diabetes as likely to die from diabetes as compared to non-Latino Whitescompared to non-Latino Whites((Multicultural Medicine and Health DisparitiesMulticultural Medicine and Health Disparities, 2005), 2005)
Mental HealthMental Health
Individuals with mental health illness have Individuals with mental health illness have high co-morbidity and mortality rateshigh co-morbidity and mortality rates
Over 26% of Latinos in Los Angeles over Over 26% of Latinos in Los Angeles over age 60 reported major depression or age 60 reported major depression or dysphoriadysphoria
(U.S. Department of Health and Human Services, 2001)(U.S. Department of Health and Human Services, 2001)
Latinos are less likely than Non Latino Latinos are less likely than Non Latino Whites to seek treatment for mental Whites to seek treatment for mental health.health. (Cooper-Patrick, 1999)(Cooper-Patrick, 1999)
What causes these What causes these disparities in health?disparities in health?
Social Determinants
AccessTo Care
QualityOf Care
HealthDisparities
What causes these disparities What causes these disparities in health?in health?
Social DeterminantsSocial Determinants
Factors leading to disparities:Factors leading to disparities:Social DeterminantsSocial Determinants
Low Levels of EducationLow Levels of Education
Low Socioeconomic StatusLow Socioeconomic Status
Behavior and EnvironmentBehavior and Environment
Social Determinants:Social Determinants:The Latino Case The Latino Case ExampleExample
EducationEducation– Latino children have highest high school drop out rates Latino children have highest high school drop out rates
EnvironmentEnvironment– Latino children have greater exposure to pollutants, Latino children have greater exposure to pollutants,
waste sites, pesticides, lead & mercurywaste sites, pesticides, lead & mercury– 3 of 5 largest landfills in Latino & AA communities 3 of 5 largest landfills in Latino & AA communities
– Latinos are well represented in the workforce, but Latinos are well represented in the workforce, but work in low wage and disproportionately higher risk work in low wage and disproportionately higher risk jobs.jobs.
What causes these disparities What causes these disparities in health?in health?
Social DeterminantsSocial Determinants
Access to CareAccess to Care
Health InsuranceHealth Insurance
Health insurance facilitates entry into the Health insurance facilitates entry into the health care systemhealth care system
The uninsured are more likely to die early The uninsured are more likely to die early & have poor health status because they & have poor health status because they are diagnosed at later disease statesare diagnosed at later disease states
Higher costs, poor outcomes, and greater Higher costs, poor outcomes, and greater disparities are observed among disparities are observed among individuals without a usual source of careindividuals without a usual source of care
Access to Care: Access to Care: The Latino Case ExampleThe Latino Case Example
40% of Latinos under 65 are uninsured 40% of Latinos under 65 are uninsured
(National Health Care Disparities Report, 2005)(National Health Care Disparities Report, 2005)
Latino children make up 29% of uninsured children Latino children make up 29% of uninsured children (Flores et al., 2005) (Flores et al., 2005)
One quarter of the nation’s uninsured are Latino One quarter of the nation’s uninsured are Latino
(11 of 44 million Americans) (11 of 44 million Americans) (Goldstein, 2000)(Goldstein, 2000)
Reasons include lack of employer-based health Reasons include lack of employer-based health
insurance and low incomeinsurance and low income
What causes these disparities What causes these disparities in health?in health?
Social DeterminantsSocial Determinants
Access to CareAccess to Care
Health CareHealth Care
Racial/Ethnic Disparities inRacial/Ethnic Disparities inHealth CareHealth Care
Within Medicare:Within Medicare:– Differential utilization based on race for:Differential utilization based on race for:
MammographyMammography (Gornick et al.)(Gornick et al.)
AmputationsAmputations (Gornick et al.)(Gornick et al.)
Influenza vaccinationInfluenza vaccination (Gornick et al.)(Gornick et al.)
Lung Cancer SurgeryLung Cancer Surgery (Bach et al.)(Bach et al.)
Renal TransplantationRenal Transplantation (Ayanian et al.) (Ayanian et al.)
Cardiac catheterization & angioplasty Cardiac catheterization & angioplasty (Harris et al, Ayanian et al.)(Harris et al, Ayanian et al.) Coronary artery bypass graft Coronary artery bypass graft (Peterson et al.)(Peterson et al.)
Treatment of chest painTreatment of chest pain (Johnson et al.) (Johnson et al.)
Referral to cardiology specialist care Referral to cardiology specialist care (Schulman et al.)(Schulman et al.)
Pain management Pain management (Todd et al.)(Todd et al.)
Language BarriersLanguage Barriers
Quality of health care requires Quality of health care requires effective communication between effective communication between patient and physicianpatient and physician
Communication problems lead to Communication problems lead to lower patient adherence to lower patient adherence to medications and decreased medications and decreased participation in medical decision-participation in medical decision-makingmaking
Language BarriersLanguage Barriers
Spanish speakers are less likely to Spanish speakers are less likely to be discharged from the ER with an be discharged from the ER with an understanding of their medications, understanding of their medications, special instructions, and plans for special instructions, and plans for follow-up care follow-up care (Crane 1997)(Crane 1997)
Spanish-speaking Latinos are less Spanish-speaking Latinos are less likely to have physician visits, flu likely to have physician visits, flu shots, or mammograms as shots, or mammograms as compared to English-speaking compared to English-speaking Latinos or non-Latino Whites Latinos or non-Latino Whites (Fiscella 2002)(Fiscella 2002)
Efforts to Address Efforts to Address Disparities in HealthDisparities in Health
Steps Towards Translating HealthDisparities Research Into Policy
1) Set The Agenda
2) Build The Case
3) Beware of Politics in Science
4) Develop Comprehensive Approaches
5) Recognize that Public Policies Are Complementary To Health
Set The Agenda
Healthy People 2010- Clinton Administration
Goal: Eliminate Health Disparities
““Achieving Equity– The Healthy People Achieving Equity– The Healthy People Perspective”Perspective”– ““HP 2010 recognizes that communities, HP 2010 recognizes that communities,
states, and national organizations will states, and national organizations will need to take a multidisciplinary need to take a multidisciplinary approach to achieving health equity that approach to achieving health equity that involves improving health, education, involves improving health, education, housing, labor, justice, transportation, housing, labor, justice, transportation, agriculture, and the environment.”agriculture, and the environment.”
(HP2010 Vol. 1, p. 16)(HP2010 Vol. 1, p. 16)
Set The Agenda
Build The Case
• Institute Of Medicine Report (2002):Unequal Treatment: Confronting Racial And EthnicDisparities In Health Care (www.nap.edu)
• Physicians For Human Rights Report:The Right To Equal Treatment
• Numerous Health Research & Policy Publications –• Health Affairs The Determinants Of Health (3/2003)• American Journal Of Public Health, Eliminating Health
Inequalities, October 2003• Milbank Quarterly A Journal for Population Health And
Health Policy, Volume 1, 2004• Numerous Books on Health Disparities And Social Justice• Health For All: California’s Strategic Approach To
Eliminating Racial And Ethnic Health Disparities (11/2003)
Politics And Science in Federal Reports
“This first report clearly demonstrates that racial,ethnic and socioeconomic disparities are nationalproblems that affect health care at all points inthe process, at all sites of care, and for allmedical conditions – in fact, disparities in thehealth care system are pervasive.”-National Health Disparities Report, as submitted to the Department Of Health And Human Services (DHHS) by the Agency for Healthcare Research And Quality (AHRQ), July
2003
Politics And Science in Federal Reports
“This first report finds that, while mostAmericans receive exceptional quality ofhealth care and have excellent access toneeded services, some socioeconomic,racial, and ethnic differences exist.”- National Healthcare Disparities Report, as released by
the DHHS, December 2003
Differences Between the Two Reports
• Deletes most uses of the word “disparity”• Eliminates the conclusion that healthcare disparities are “national problems”• Removes findings on the social costs of disparities and replaces them with a discussion of “success”• Omits key examples of healthcare
disparities
Comprehensive and Integrated Approaches • Does health disparities legislation
address:
–Social Determinants and Environment?
– Health Care System?
– Individual Factor?
A Commitment to A Commitment to Document Disparities Document Disparities
Collect and report data on health Collect and report data on health conditions and health care access by conditions and health care access by ethnicity, SES and primary languageethnicity, SES and primary language
Include measures of racial and ethnic Include measures of racial and ethnic disparities in performance disparities in performance measurementsmeasurements
Report racial and ethnic data by use Report racial and ethnic data by use of subpopulation groups where of subpopulation groups where possiblepossible
Recognition that Health and OtherSocial Policies are Complementary• Invest in young children• Provide services and opportunities for the neediest, including health care• Strengthen support at the community level• Improve the work environment• Create a more equal economic
environment• Assess the effects of economic and social action on health
ResourcesResources
CDC Media Relations-Hispanic CDC Media Relations-Hispanic Disparities Press KitDisparities Press Kithttp://www.cdc.gov/od/oc/media/presskits/hhd.htmhttp://www.cdc.gov/od/oc/media/presskits/hhd.htm
The Office of Minority HealthThe Office of Minority Health
http://http://www.omhrc.govwww.omhrc.gov// The National Center for Minority The National Center for Minority
HealthHealth
http://http://ncmhd.nih.govncmhd.nih.gov//
SummarySummary
There is a significant body of evidence There is a significant body of evidence that has identified disparities in health that has identified disparities in health and health care for Latinos and other and health care for Latinos and other underserved populations. underserved populations.
To eliminate disparities, partnerships, To eliminate disparities, partnerships, research, advocacy and more research, advocacy and more comprehensive policy approaches will be comprehensive policy approaches will be requiredrequired