population disparities in health & health care

www.CenterForUrbanHealth.org

HCMC Family Medicine ClinicAugust 6, 2008

Population Disparitiesin Health and Health Care

Yiscah Bracha, M.S.Research Director

Center for Urban Health


Definitions

• Disparity: “…a population-specific difference in the presence of disease, health outcomes, or access to care”.

Health Resources and Services Administration. Carter-Pokras and Baquet 2002: 430


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?


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


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.


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


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


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.


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


… 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 nation’s 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.


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).


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


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


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


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


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


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.


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


• 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:


Downstream interventions:

• In the clinic and/or health system, manage populations using 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


Exam room interventions:

• Target: Individual patient and patient’s immediate social environment (spouse, children, parents, caregivers, close friends)

• Actions: Coming up, from Dr. Eliason!

• Effects on population health and thus disparities:


Philosophy revisited:

• A population is a set of individuals sharing physical, behavioral, lifestyle, life history, environmental exposure, characteristics

• Measures of population health improve when averages over individuals improve and when variability of measures among individuals decrease

• Targeted interventions in the exam room thus can reduce population disparities.


Questions?Questions?Yiscah BrachaYiscah Bracha

[email protected]@CenterForUrbanHealth.org

population disparities in health & health care

Health & Medicine

health disparities

health care reasons

individual health

urban health care

population measures

health care challenge

department of health

health resources