william a. vega, phd provost professor executive director latino health and faculty development...
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William A. Vega, PhD
Provost Professor
Executive Director
Latino Health and Faculty Development Conference
Stanford University, July 22, 2010
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Brain Reward Pathways
Source: Messing RO. In: Harrison’s Principles of Internal Medicine. 2001:2557-2561.
•The VTA-nucleus accumbens pathway is activated by all drugs of dependence including alcohol
•This pathway is important not only in drug dependence, but also in essential physiological behaviors such as eating, drinking, sleeping, and sex
Ventral tegmental area (VTA)
Nucleus accumbens
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genomegenomeprotein expressionprotein expression
neural circuitsneural circuits
DRUGSDRUGSsocialsocial
conductconduct
Systems operating in the etiology ofdrug addiction and mental illnesses Systems operating in the etiology ofdrug addiction and mental illnesses
MENTAL MENTAL ILLNESSESILLNESSES
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Pathways for interactions among levels:
Social groups composed of individuals
Individuals composed of physiological
systems
Physiological systems composed of cells
Cells composed of molecules (DNA)
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Only 1 in 10 people who use illicit drugsbecome
dependent on them
Genetic susceptibility to complex disease
usually results from joint effects of many genes,
each with a small to moderate effect and often
with interaction among themselves (e.g.
regions) and the environment.
IOM (2006)
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“Schinka et al. have identified a functional Schinka et al. have identified a functional polymorphism within the opioid receptor polymorphism within the opioid receptor gene as a gene as a general general risk gene for substance risk gene for substance dependence. Substance abuse and dependence. Substance abuse and dependence phenotypes that emerge only dependence phenotypes that emerge only after exposure to the environment.”after exposure to the environment.”
Licinio, J (2002) Gene-environment interactions in Molecular Psychiatry.
Molecular Psychiatry 7:123-124
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Tsuang et al. (2001) The Harvard twin study of substance abuse. Harvard Rev. Psychiatry 9:267-279
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Cooper, R.S. (2003) Gene-environments interactions and the etiology of common complex disease. Ann Inter Med 139:437-440
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Lower heart rate variability Slow recovery from exercise Elevated cortisol levels related to
accelerated cell aging Greater risk of metabolic syndrome Effects on hormonal regulation
(hypothalamic-pituitary-adrena axis) Increased risk for depression
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Although there are (temporary) exceptions, such as the immigrant paradox, having better income and education is protective against most diseases and mental illnesses in the U.S.
Paradox affects weathering over time and immigrants have similar disability and chronic disease levels as U.S. born
Reasons: more persistent life stress, fewer resources available for avoiding impact of personal problems and unhealthy behaviors
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SOCIOECONOMIC STATUS RACE/ETHNICITY SOCIAL NETWORKS/SOCIAL SUPPORT PSYCHOSOCIAL WORK ENVIRONMENT COMMUNITY ENVIRONMENT IOM (2006)
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Long range impacts of social determinants and low socioeconomic mobility
Organization of human services to support optimal human development
Role of research in promoting change The role of social determinants in changing
public policy
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Females: Alcohol Abuse/Dependence Rate by Parental Risk, Nativity, Time in Country, Age, and Language Preference
Only 3 subgroups show any effect of parental risk factors:• Female US born English all or most (high acculturation): 20% vs 2% (p < 0.001),• Female US born Spanish/English (low acculturation): 10% vs 2% (p = 0.04).• Female immigrant 13+ y Age 18–44 Spanish/English (high acculturation): 9% vs 2%
(suggestive but NS)
Females: Alcohol Abuse/Dependence Rate by Parental Risk, Nativity, Time in Country,
Age, and Language Preference
0
5
10
15
20
25
Female immigrant
<13y (all ages)Spanish
all the time
Female immigrant
<13y(all ages) Spanish/English
Female immigrant
13+y Age 45-59 Spanish
all the time
Female immigrant
13+y Age 45-59 Spanish/English
Female immigrant
13+y Age 18-44 Spanish
all the time
Female immigrant
13+y Age 18-44 Spanish/English
Female US born
(all ages)Spanish/English
Female US born
(all ages)English
all or most
%
One or more parental risk factors No parental risk factors
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Ph
enot
ype
Exposure
Mexico USA
GVP
GVA
GVP
Context Dependence: Gene-Environment Interaction Model
Adapted from Cooper, R.S. (2003). Annals of Internal Medicine, 139:437-440
GVA = Gene Variant AbsentGVP = Gene Variant Present
GVA
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Males: Alcohol Abuse/Dependence Rate by Parental Risk, Nativity, Time in Country, Age, and Language Preference
Males: Alcohol Abuse/Dependence Rate by Parental Risk, Nativity, Time in Country,
Age, and Language Preference
0
10
20
30
40
Male immigrant <13y
(all ages)Spanish
all the time
Male immigrant <13y
(all ages) Spanish/English
Male immigrant 13+y
Age 45-59 Spanish
all the time
Male immigrant 13+y
Age 45-59 Spanish/English
Male immigrant 13+y
Age 18-44 Spanish
all the time
Male immigrant 13+y
Age 18-44 Spanish/English
Male US born
(all ages)Spanish/English
Male US born
(all ages)English
all or most
%
One or more parental risk factors No parental risk factors
Only 2 subgroups have a significant effect of parental risk factors:
•Male immigrant <13y Spanish/English (high acculturation): 20% vs 5% (p = 0.01),
•Male US born Spanish/English (low acculturation): 33% vs 9% (p < 0.001).
Age significant for immigrant 13+ y (p = 0.01); NS for US born and immigrant <13y.
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1 NESARC. 2 from M. Medina-Mora et al., in press.
U.S.1
Mexico2 Immigrants U.S. born
Alcohol abuse 0.4 1.0 8.7
Alcohol dependence
0.5 1.7 11.0
Drug abuse 0.0 0.6 5.2
Drug dependence 0.1 0.3 3.2
Nicotine dependence
0.9 1.5 9.8
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1 NESARC. 2 from M. Medina-Mora et al., in press.
U.S.1
Mexico2 Immigrants U.S. born
Alcohol abuse 4.9 15.4 25.2
Alcohol dependence
8.8 9.6 19.4
Drug abuse 2.3 1.8 12.0
Drug dependence 0.7 0.5 4.5
Nicotine dependence
2.2 5.1 10.2
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Any alcohol abuse/dependence with or without drug dependence, and a co-occurring non-addictive DSM-IV disorder
Total for immigrant women 0.68%,men 5.25%
Total for U.S. born women 7.33%, men 16.22%
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Drugs: Costa Rica 15, Mex. 10, U.S. 29
Alcohol: Costa Rica 20, Mex. 19, U.S. 34
Any Sub A/D: Costa Rica 25,Mex. 23, U.S. 45
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Crabbe, JC (2002) Genetic contributions to addiction. Annu Rev Psychol 53:435-62
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Every system is perfectly designed to achieve
exactly the results it gets.
“In other words it sure didn’t get this way by accident”
Bill Vega
“The First Law of Improvement” from Donald
Berwick
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Access to care in a cost-control environment
Reconfiguring a fragmented health care system
Poor coordination of payers to providers for safety net populations
Low visibility and high stigma of mental health providers and treatments
Low availability of linguistically competent staff or translators
Low availability of co-ethnic specialists
Most mental health problems presented in primary care where behavioral health specialists are not available and providers are not disposed to offer treatment
Current levels of practicing mental health professionals: 29 Hispanics per 100,000 vs. 173 European Americans per 100,000
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The Chain of EffectThe Chain of Effectin Improving Cultural Competencein Improving Cultural Competence
Macro-system regulationsregulationsStandards of care, enforcement accountability
Research knowledgeknowledgeModel testing and develop-ment, efficacy and effective-ness trials, scaling up
Organizational Context
processes of processes of carecare
Policy development and implementation
Clinical SkillsClinical Skills
Design Concepts for practice standards, clinical culture, upskilling staff and continuous quality improvement
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THE REGULATORY COMMUNITY IMPOSING STANDARDS AND
ACCOUNTABILITY FOR SYSTEMS OF CARE (INCLUDING FEDS,
LICENSURE AND ACCREDITING BODIES)
THE RESEARCH COMMUNITY PROVIDING THEORY,
IMPLEMENTATION MODELS, AND EVIDENCE OF EFFECTIVENESS
THE INDIVIDUAL AS THE NEXUS OF CULTURALLY COMPETENT
(INDIVIDUALIZED) CARE MODELS
THE HEALTH CARE ORGANIZATION AS THE WEBWORK
CONTROLLING ACCESS, PROCESSES OF CARE AND PRACTICE
INNOVATIONS, AND OUTREARCH TO PATIENTS AND COMMUNITY
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Clarifying national aims for improvement
Changing the care, itself
Changing the organizations that deliver care
Changing the environment that affects organizational and professional behavior
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Spanish-speaking Latinos less likely to have physician visits, flu shots, or mammograms than English speaking Latinos or non-Latino whites. (Fiscella)
Children whose parents speak Spanish less likely to have usual source of care than English speaking Latinos or non-Latino whites. (Weinick)
Spanish speakers who could not communicate with their physicians less likely to be discharged from the ER with a follow-up appointment. (Sarver)
Fiscella K, Franks P, Doescher MP, Saver BG. Disparities in health care by race, ethnicity, and language among the insured. Med Care 2002;40:52-9.
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Spanish speakers less likely to be discharged from the ER with an understanding of their medications, special instructions, and plans for follow-up care (Crane)
Spanish-speaking Latinos more likely to report problems with communication than English-speaking Latinos (Commonwealth Fund 2002 Health Care Quality Survey)
Spanish speakers who needed but didn't receive an interpreter were at much higher risk for not understanding discharge medications. (Andrulis in toolkit/Appendix A)
Crane JA. Patient comprehension of doctor-patient communication on discharge from the emergency department. J Emerg Med 1997;15:1-7.
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Speaking a primary language other than English was an independent predictor of patient-reported drug complications. (Ghandi)
Spanish speaking patients less likely to receive standard of care (prompt surgery) in cholecystitis. (Diehl)
Ghandi TK, Burstin HR, Cook EF, et al. Drug complications in outpatients. JGIM 2000;15:149-154.
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Patients whose primary language was not English significantly less likely to want to return to same ER for future care (Carrasquillo)
Patients who needed but didn't receive an interpreter in the ER were less satisfied with the care they received, as well as less satisfied with their physician. (Baker)
Carrasquillo O, Orav EJ, Brennan TA, Burstin HR. Impact of language barriers on patient satisfaction in an emergency department. JGIM 1999; 14: 82-87.
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Pediatric patients with a language barrier had higher charges ($38) and longer stays (20 min) than those without language barriers. (Hampers 1999)
Pediatric patients who needed, but didn't receive, a professional interpreter had higher test costs and were the most likely to be admitted to the hospital (compared to patients who could speak directly with their doctors, and patients who had a trained interpreter). (Hampers 2002)
Hampers LC, Cha S, Gutglass DJ, Binns HJ, Krug SE. Language barriers and resources utilization in a pediatric emergency department. Peds 1999; 103(6): 1253-1256.
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Repeated studies have shown that African Americans
tend to receive significantly higher doses of
antipsychotics than Caucasians
On the other hand, Hispanics and Asians seem likely to
receive lower antipsychotic doses than Caucasians
African and Hispanic Americans are more likely to
receive depot antipsychotics than Caucasians
African and Hispanic Americans seem more likely to
receive typical antipsychotics than Caucasians
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