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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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)
Prior beliefs and expectations; doc unconscious stereotyping
Amount of time available to deal with number of and seriousness of problems
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. 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.
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. 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. 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:
