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

Daily ReportingDaily ReportingBasic QuestionsBasic Questions

Who?Who? Name, Age, Ethnicity, Gender Name, Age, Ethnicity, Gender

What?What? Type of condition, Outcome Type of condition, Outcome

When?When? Date Date

Where?Where? Environment, House, Environment, House, HospitalHospital

Why/How?Why/How? What prompted the What prompted the Incident Incident

Daily ReportingDaily ReportingAdditional QuestionsAdditional Questions

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

mortalitymortality

MorbidityMorbidity– Chronic disease (cancer, diabetes)Chronic disease (cancer, diabetes)– Communicable diseaseCommunicable disease

Physiological risk factorsPhysiological risk factors– HypertensionHypertension– Obesity/overweightObesity/overweight

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

(Kaiser Network)(Kaiser Network) EmploymentEmployment

– 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