1. From Diabetes Disparities to Diabetes Health Equity George Rust, MD, MPH, FAAFP, FACPM Father of Dan & Christina, Husband of Cindy, Professor of Family Medicine Director, National Center for Primary Care National Center for Primary Care at Morehouse School of Medicine

2. Health Disparities “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” -- Martin Luther King, Jr.

3. Disparities in Prevalence Ma Y et al. All-Cause, Cardiovascular, and Cancer Mortality Rates in Postmenopausal White, Black, Hispanic, and Asian Women With and Without Diabetes in the United States: The Women's Health Initiative, 1993–2009 Am. J. Epidemiol. (2013) 178 (10): 1533-1541 online September 17, 2013

4. Disparities in Treatment Effectiveness

5. Primary Care Community Health Centers Impact on Uninsured ED Visits 31% Excess 62% Excess No CHC = 37% Excess ED Visits

6. Disparities in Hospitalizations Adult admissions for uncontrolled diabetes without complications per 100,000 population by race/ethnicity, 2001. http://archive.ahrq.gov/qual/nhdr04/fullreport/RQual.htmhttp://archive.ahrq.gov/qual/nhdr04/fullreport/RQual.htm Racial-ethnic Disparities and Rural-Urban Differences

7. Excess Cost Due to Racial Variation in Hospital Admissions by Disease (mid-range estimate) Excess Hospital Admissions (mid-range) Hospital Charges Attributable to Excess Hospital Admissions (mid-range) Payer Costs Attributable to Excess Hospital Admissions (mid-range) Asthma 2,044 $28,687,330 $13,339,608.45 Diabetes 3,955$92,172,057 $42,860,006.51 Heart Disease 5,021$187,289,234 $87,089,493.81 >Coronary Artery Disease 1,287$65,156,724 $30,297,876.66 >Congestive Heart Failure 5,868$162,561,372 $75,591,037.98 HIV 1,644$76,784,134 $35,704,622.31 $

8. Geographic Disparities

9. Disparities in Death Rates

10. Drivers of Health Disparities Health Potential Food, Water, Housing, & Health Behaviors Social Determinants Access to Care WorstMinorityAverageMajorityBest / Optimal

11. Adoption S-Curve Isolated or disenfranchised or non-majority cultural groups

12. Triangulating on Success to Improve America’s Health Research Discovery & Innovation Public Health & Health Promotion Primary Care Real-World Delivery

14. Diabetes Health Equity Equality in Risk Equality in Pre-Disposing Conditions Equality in Prevalence Equality in Treatment Equality in Self-Management Equality in Complication Rates Equality in Adverse Outcomes Equality in Survival

15. Is Equality the Same as Equity? Equity = Equality + Fairness

16. Does Equal Treatment Mean Treating Everyone the Same? Encouraging an hour a day of physical activity for children is different in a high-crime, resource-constrained urban neighborhood than it is in a wealthy upper-income neighborhood with lots of safe playgrounds.

17. Does Equal Treatment Mean Treating Everyone the Same? Providing linguistically-appropriate services for immigrants and linguistically-isolated families takes more conscious effort and resources than it does for English-language families.

18. Holding Ourselves Accountable to Achieve Equality in Outcomes Community Level Metrics Mortality Hospital Bed-Days Preventable Adverse Events (e.g., amputations) Practice-Level Data ED Visits Hospital Bed-Days Person-Level Feedback Missed refills Inadequate Care ED Visit yesterday!

19. 29 babies saved!!! Disparities are not Inevitable! Decline represents 29 infant deaths prevented (expected vs. actual)

20. Emergency Room Primary Care Mental Health Business & Community Leaders Hospitals Faith Communities Cohesive, Comprehensive, Integrated Local Health Systems

21. Community Health Promotion Health Outcomes Primary Care Health Home Tying it All Together to Achieve Optimal, Equitable Health Outcomes

22. Patient-Centered Primary Care Home Chronic Disease Care Management Integrated Behavioral Health Built on Community Strengths & Partnerships Consistently High Quality Care Optimal Outcomes

23. Humility in Working Together “We are all as angels, with only one wing; We can only fly when we embrace each other. -- Luciano de Crescenzo