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Reasons for Disparities in Health and HealthCare

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  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
    • Disparity:apopulation-specificdifference in the presence of disease, health outcomes, or access to care.
    • Health Resources and Services Administration. Carter-Pokras and Baquet 2002: 430
  3. 3. Population vs. Individual Health:
    • Philosophy questions:
      • What is a population? What is the difference between a population and an individual?
      • Do populations have properties distinctly different from their individual members?
  4. 4. Population ontology
    • How are populations typically differentiated?
      • By race, culture, ethnicity, country of origin, language spoken at home.
        • Extra credit question:What is the difference between these terms?
      • By geographic area
      • By age group
      • By income level
  5. 5. Examples of population health measures:
    • Rates of death from heart disease
    • Breast cancer incidence rates among women aged 25-40.
    • Life expectancy for males at age 65
    • Among cancer patients, rates of death within five years of diagnosis.
  6. 6. Population measures of access to care:
    • Percent uninsured
    • Number of family practitioners per capita
    • Percent who report making financial choices between medication and food.
    • Average distance from home to tertiary care hospital
  7. 7. Population measures of medical care:
    • Percent of AMI patients receiving beta blockers
    • Percent of ED patients with long bone fractures receiving pain medication
    • Percent of patients with asthma prescribed daily controller medications
    • Percent of ESRD patients placed on transplant waiting list
  8. 8. What we know:
    • In the U.S., population measures of health, of access to care, and of medical care, are lower for:
      • Low income vs. high income populations
      • Among those born in the US, African- compared to European American populations
      • In general, populations of all races, ethnicities, cultures other than American-born White.
  9. 9. Documented evidence
    • DuBois (1906). The Health and Physique of the Negro American.Documents racial inequalities in health.
    • 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
  10. 10. continued
    • 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 nations population as a whole
    • US Office of Civil Rights (1999). The Health Care Challenge:Acknowledging Disparity, Confronting Discrimination, and Ensuring Equality.
    • Institute of Medicine (2003). Unequal Treatment:Confronting Racial and Ethnic Disparities in Health Care.
  11. 11. Healthy People 2010
    • Decennial goal-setting document of the U.S. Department of Health and Human Services
    • Calls for the elimination of all health disparities:
      • Race or ethnicity
      • Gender
      • Education or income
      • Disability
      • Geographic location
      • Sexual orientation
      • (U.S. Department of Health and Human Services 1998).
  12. 12. Environmental reasons for disparities
    • Access to safe spaces for exercise
    • Access to healthy food
    • Exposure to environmental toxins in soil, air, building materials
    • Stress induced by unstable housing, fear of deportation, violence, discriminatory treatment, inability to communicate
  13. 13. Cultural reasons for disparities:
    • Culturally developed and reinforced beliefs about:
      • Sexual, child-rearing practices
      • Food, cleanliness, purity
      • Reasons for illness; notions of disease
      • Proper time to seek medical care
      • Consequences of referring to death/disease
      • Consequences of treatments for disease
  14. 14. Social reasons for disparities:
    • Immediate social (e.g. friends, family, neighbors, faith community) reinforcement for healthy behaviors:
      • Abstention from smoking
      • Screening for detectable disease (e.g. mammogram, prostate exam)
      • Diet
    • Social reinforcement for preventive measures:
      • Immunizations
      • Well-baby exams
  15. 15. Individual reasons for disparities:
    • Availability of resources
      • Discretionary income
      • Transportation & child care
      • Stable housing
      • Generous insurance
      • Knowledge
      • Flexible and supportive employer (e.g. time available during work day for medical appts)
      • English comprehension, literacy, numeracy
  16. 16. Health care reasons for disparities
    • Quality of patient-provider encounter:
      • Level of trust
      • Communication:Language, individual words, explanations, stories
      • Prior beliefs and expectations; doc unconscious stereotyping
      • Amount of time available to deal with number of and seriousness of problems
  17. 17. It all cumulates
    • 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).
    • 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.
  18. 18. Upstream Interventions:
    • Diffuse targets, multiple populations:
      • Built environment
        • Safe parks, playgrounds, walking and bicycle paths
        • Suppression of environmental toxins
      • Public education
        • Healthy behaviors
        • Prevention
        • Screening
      • Coverage and reimbursement reform to make health care more accessible & affordable
  19. 19.
    • Focused targets, specific populations.
      • Community outreach and partnership:
        • Advertisements about healthy behaviors, screening, prevention, using media accessed by members of at-risk populations
        • Encourage patient self-management & self-efficacy through collaborations between health care providers and:
          • Schools
          • Worship communities
          • Community centers
          • Community elders
    Midstream interventions:
  20. 20. Downstream interventions:
    • In the clinic and/or health system, managepopulationsusing EHRs
      • Monitor population health stats
      • Monitor population receipt of appropriate care
        • Compare across clinics
        • Compare across docs (gasp!)
        • Compare across time points
      • Identify at-risk individual patients; target for:
        • Intensive medical intervention
        • Community health worker support
  21. 21. Exam room interventions:
    • Target:Individual patient and patients immediate social environment (spouse, children, parents, caregivers, close friends)
    • Actions:
      • Coming up, from Dr. Eliason!
    • Effects on population health and thus disparities:
  22. 22. Philosophy revisited:
    • A population is a
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