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© Hackman Consulting Group www.HackmanConsultingGroup.org Transforming Racial Disparities in Health Care by Addressing Provider Bias: A Framework for Addressing.

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Presentation on theme: "© Hackman Consulting Group www.HackmanConsultingGroup.org Transforming Racial Disparities in Health Care by Addressing Provider Bias: A Framework for Addressing."— Presentation transcript:

1 © Hackman Consulting Group www.HackmanConsultingGroup.org Transforming Racial Disparities in Health Care by Addressing Provider Bias: A Framework for Addressing Race, Racism and Whiteness Overcoming Racism-Cultivating Transformation November 14-15, 2014 Stephen C. Nelson, MD Children’s Hospitals and Clinics of Minnesota Bush Medical Fellow, 2008-2009 Hackman Consulting Group

2 © Hackman Consulting Group www.HackmanConsultingGroup.org Racial Identity o When did you first learn what your racial identity was in the U.S.? o How did it happen? o How did it impact you? o How did you respond?

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5 © Hackman Consulting Group www.HackmanConsultingGroup.org “ It is less useful to continue to characterize an insidious problem if these efforts do not result in the design and implementation of interventions that lead to meaningful change. ” Pediatr Blood Cancer 2013;60:349 – 350 HIGHLIGHT by Alexis A. Thompson, MD, MPH* Sickle Cell Disease and Racism: Real or False Barriers?

6 © Hackman Consulting Group www.HackmanConsultingGroup.org U.S. Death Rates-2009 o Black deaths 286,928 Crude death rate924 per 100K o Asian deaths 49,508 Crude death rate413 per 100K

7 © Hackman Consulting Group www.HackmanConsultingGroup.org U.S. Black Deaths o 128,248 excess deaths per year o 10,687 deaths per month o 2466deaths per week o 351deaths per day o 14deaths per hour o 1 death every 5 minutes

8 © Hackman Consulting Group www.HackmanConsultingGroup.org Why? o Genetics o SES, insurance, access, education o Racism, Unconscious bias, Stereotypes

9 © Hackman Consulting Group www.HackmanConsultingGroup.org Human Genome Project o 1990s o > 60 families’ genes analyzed o NO people of African descent o Howard University belatedly invited o Race has no genetic basis o Human subspecies do not exist o Most variation is within, not between “races” o www.understandingrace.org

10 © Hackman Consulting Group www.HackmanConsultingGroup.org o “racial disparities health” o 1981-present o 4925 citations!! o 150 per year o almost 3 articles per week

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14 © Hackman Consulting Group www.HackmanConsultingGroup.org White population

15 © Hackman Consulting Group www.HackmanConsultingGroup.org NHDR Results oRace is an independent factor

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17 © Hackman Consulting Group www.HackmanConsultingGroup.org BiologyBehaviorSocietyStructure DOWNSTREAM UPSTREAM Health Care and Medical Education

18 © Hackman Consulting Group www.HackmanConsultingGroup.org Advancing Health Equity in Minnesota: Report to the Legislature January 15,2014

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25 © Hackman Consulting Group www.HackmanConsultingGroup.org Advancing Health Equity in Minnesota: Report to the Legislature January 15, 2014

26 © Hackman Consulting Group www.HackmanConsultingGroup.org Advancing Health Equity in Minnesota: Report to the Legislature January 15, 2014

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28 © Hackman Consulting Group www.HackmanConsultingGroup.org *per 1000 births

29 © Hackman Consulting Group www.HackmanConsultingGroup.org CDC 2007-2009 o Life Expectancy in Minnesota White81.1 years Black75.4 years o Cancer deaths per 100,000 American men White217.8 Black281.5 o Cancer deaths per 100,000 Minnesota men White205.5 Black295.0

30 © Hackman Consulting Group www.HackmanConsultingGroup.org http://www.bcbsmnfoundation.org/

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35 © Hackman Consulting Group www.HackmanConsultingGroup.org Twin Cities Mortality-Wilder Study oRace is an independent factor

36 © Hackman Consulting Group www.HackmanConsultingGroup.org o Children with long bone fracture o ED 1-yr period o N=880 with pain scores o Time from injury to arrival in ED White8.3 hours Black10.7 hours p=0.014 Biracial11.9 hours p=0.004 Native American18.4 hours p=0.025 Volume 28, Number 11, November 2012

37 © Hackman Consulting Group www.HackmanConsultingGroup.org o 76,931 ED encounters o Mar 2, 2009- Mar 31, 2010 o Wait Times White32 minutes Black37 minutes Native American41 minutes Hispanic39 minutes P<0.001

38 © Hackman Consulting Group www.HackmanConsultingGroup.org o Children with long bone fracture o ED 1-yr period o N=878 o Opioid-containing prescription White67.4% Black47.1% RR 0.59 Hispanic47.9%RR 0.61 Native American58.3%RR 0.93 Biracial40.3%RR 0.45

39 © Hackman Consulting Group www.HackmanConsultingGroup.org o 76,931 ED encounters o Mar 2, 2009- Mar 31, 2010 o Odds Ratio of LWCET Black2.04 Native American3.59 Hispanic2.15 Biracial2.77 P<0.001

40 © Hackman Consulting Group www.HackmanConsultingGroup.org NACHRI October 2011 o Chart review long bone fractures o Jan 1 2008-Dec 31 2010 o 2206 patients 1386 M820F o Bone Radius/ulna1116 Humerus566 Ankle189 Tib/fib173 Femur162

41 © Hackman Consulting Group www.HackmanConsultingGroup.org NACHRI October 2011 o Mean time to getting pain med 50.3 min o Black64 minutes o White 45 minutes o IV narcotics White57.8% Black48.4% p <0.001

42 © Hackman Consulting Group www.HackmanConsultingGroup.org NACHRI October 2011 o Conclusions Racial and cultural differences need study to identify: Variable tolerance to pain Hesitation to reporting pain based on culture or poor health care literacy

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45 © Hackman Consulting Group www.HackmanConsultingGroup.org BiologyBehaviorSocietyStructure DOWNSTREAM UPSTREAM Health Care and Medical Education

46 © Hackman Consulting Group www.HackmanConsultingGroup.org Health Care Barriers o System insurance poverty geography transition to adult care research and support money o Patients lack of knowledge fear trust o Community advocacy public awareness o Providers bias attitudes/expectations

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48 © Hackman Consulting Group www.HackmanConsultingGroup.org USA Japan Per capita spending US$

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52 © Hackman Consulting Group www.HackmanConsultingGroup.org 37 th National Sickle Cell Disease Scientific Meeting Strouse et al Sunday April 13, 2014 o Funding per patient NIH 3.8-fold higher for CF Foundation350-fold higher for CF Combined11-fold greater for CF o NIH Career Development Awards same o New Drug Approval (2009-2013) CF5 SCD0 o Publications (2005-2010) 2:1CF:SCD

53 © Hackman Consulting Group www.HackmanConsultingGroup.org Health Care Barriers o System insurance poverty geography transition to adult care research and support money o Patients lack of knowledge fear trust o Community advocacy public awareness o Providers bias attitudes/expectations

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56 © Hackman Consulting Group www.HackmanConsultingGroup.org “When the Bough Breaks”

57 © Hackman Consulting Group www.HackmanConsultingGroup.org Health Care Barriers o System insurance poverty geography transition to adult care research and support money o Patients lack of knowledge fear trust o Community advocacy public awareness o Providers bias attitudes/expectations

58 © Hackman Consulting Group www.HackmanConsultingGroup.org FDA o FDA approved drugs o HIV-1981 37

59 © Hackman Consulting Group www.HackmanConsultingGroup.org FDA o FDA approved drugs o Sickle Cell disease – 1910 1

60 © Hackman Consulting Group www.HackmanConsultingGroup.org Why is this true? o Whites NHF ACT UP o Blacks SCDAA o System o Power o Money

61 © Hackman Consulting Group www.HackmanConsultingGroup.org Health Care Barriers o System insurance poverty geography transition to adult care research and support money o Patients lack of knowledge fear trust o Community advocacy public awareness o Providers bias ( racism ) stereotyping attitudes/expectations

62 © Hackman Consulting Group www.HackmanConsultingGroup.org THE EFFECT OF RACE AND SEX ON PHYSICIANS ’ RECOMMENDATIONS FOR CARDIAC CATHETERIZATION Race and sex of a patient independently influence how physicians manage chest pain. (N Engl J Med 1999;340:618-26.)

63 © Hackman Consulting Group www.HackmanConsultingGroup.org Provider Barriers to Hydroxyurea Use in Adults with Sickle Cell Disease: A Survey of the Sickle Cell Disease Adult Provider Network Sophie Lanzkron, MD; Carlton Haywood Jr., MA; Kathryn L. Hassell, MD; and Cynthia Rand, PhD JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 100, NO. 8, AUGUST 2008

64 © Hackman Consulting Group www.HackmanConsultingGroup.org Unpacking Racism and its Health Consequences April 2011 THE IMPACT OF RACISM ON CLINICIAN COGNITION, BEHAVIOR, AND CLINICAL DECISION MAKING Michelle van Ryn et al. Dept of Family Medicine and Community Health University of Minnesota

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66 © Hackman Consulting Group www.HackmanConsultingGroup.org Unconscious biases o Normal o Rooted in stereotyping cognitive process where we use social categories to acquire, process, and recall information about people o Helps us organize complex information o Heavy cognitive load rely on stereotyping to process information consciously reducing this is hard work

67 © Hackman Consulting Group www.HackmanConsultingGroup.org “Crisis” o http://www.youtube.com/watch?v=FuelQ DBOxXI http://www.youtube.com/watch?v=FuelQ DBOxXI o CRISIS: Experiences of people with sickle cell disease

68 © Hackman Consulting Group www.HackmanConsultingGroup.org

69 © Hackman Consulting Group www.HackmanConsultingGroup.org “ It is less useful to continue to characterize an insidious problem if these efforts do not result in the design and implementation of interventions that lead to meaningful change. ” Pediatr Blood Cancer 2013;60:349 – 350 HIGHLIGHT by Alexis A. Thompson, MD, MPH* Sickle Cell Disease and Racism: Real or False Barriers?

70 © Hackman Consulting Group www.HackmanConsultingGroup.org

71 © Hackman Consulting Group www.HackmanConsultingGroup.org “Unequal Treatment” o Institute of Medicine o March 2002 o Findings Racial disparities exist and are unacceptable These exist within broader social inequalities Multifactorial Bias, stereotyping and prejudice on the part of health care providers contribute to racial and ethnic disparities Small number of patients refuse therapy, this does not fully explain disparities

72 © Hackman Consulting Group www.HackmanConsultingGroup.org IOM Recommendations o Raise awareness of disparities o Legal, regulatory and policy changes o Health systems changes o Help patients navigate the system o Cross-cultural education for providers o Collect data on race, SES, language o Research sources of disparities and interventions

73 © Hackman Consulting Group www.HackmanConsultingGroup.org Provider Training o Diversity Training Awareness Appreciation o Cultural Competency Cross-cultural communication Information gathering Skills training

74 © Hackman Consulting Group www.HackmanConsultingGroup.org 74 Provider Training o Social Justice Oppression Power Societal resources Structural barriers Race/racism/whiteness

75 © Hackman Consulting Group www.HackmanConsultingGroup.org Provider Trainings o Address the definition of race/racism and history of the social construction of race o Differentiate among diversity, cultural competency, and social justice o Explore our current health care system (racial make-up of providers, how insurance became tied to employment, what we’re taught/not taught in school, evidence-based medicine, racial disparities) o Examine racism/whiteness in our society, including examples of racism/whiteness in medicine o Examine how race affects each of the Institute of Medicine's six measures of quality care, and provide trainees tools for understanding these effects o Introduce critical thinking tools for improving medical providers’ comfort and skills in caring for patients of color

76 © Hackman Consulting Group www.HackmanConsultingGroup.org Pilot Training o N=19, Family Medicine residents o 5 M, 14 F o 10 white, 7 Asian, 2 black o Mean age 31.9 years M= 32.8 yrs F= 31.6 yrs

77 © Hackman Consulting Group www.HackmanConsultingGroup.org Assessment o 1. My awareness level of issues of racism in the U.S. is: o 2. The impact of racism on health care delivery is: o 3. I am as effective at caring for white patients as I am at caring for patients of color. o 4. I feel well equipped to care for patients of color. o 5. The impact of racism on my ability to deliver quality care is:.

78 © Hackman Consulting Group www.HackmanConsultingGroup.org Results StatementPrePost P Awareness of racism ALL WHITE POC 3.40 3.89 3.45 4.50 0.036 0.422 0.009 Impact of racism on health care ALL WHITE POC 3.89 4.00 3.78 4.52 4.54 4.50 0.0004 0.0108 0.013 Effective caring for white patients as POC ALL WHITE POC 4.10 4.00 4.22 3.10 2.55 3.87 0.0018 0.0016 0.1785 Well-equipped to care for POC ALL WHITE POC 3.84 3.70 4.00 3.36 3.00 3.87 0.037 0.039 0.329 Impact of racism on delivering quality care ALL WHITE POC 2.58 2.70 2.44 3.58 3.82 3.25 0.0046 0.0055 0.1206 POC=person of color

79 © Hackman Consulting Group www.HackmanConsultingGroup.org Discussion o Awareness of racism and its impact on delivering quality care increased significantly in all participants. o Deconstructed white providers ’ previously held beliefs about race and racism. first step in working on our own racism and unconscious biases. o This was a small cohort. o Further study is warranted to define and refine the best training methods.

80 © Hackman Consulting Group www.HackmanConsultingGroup.org April 15, 1912

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82 © Hackman Consulting Group www.HackmanConsultingGroup.org April 15, 1912

83 © Hackman Consulting Group www.HackmanConsultingGroup.org January 15, 2009 1 st ClassCoach

84 © Hackman Consulting Group www.HackmanConsultingGroup.org “Of all forms of inequity, injustice in healthcare is the most shocking and inhumane.” Martin Luther King, Jr. National Convention of the Medical Committee for Human Rights, Chicago- 1966

85 © Hackman Consulting Group www.HackmanConsultingGroup.org “Not everything that is faced can be changed. But nothing can be changed until it is faced” James Arthur Baldwin - novelist, essayist, playwright, poet (August 2, 1924 – December 1, 1987)

86 © Hackman Consulting Group www.HackmanConsultingGroup.org


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