1. Eliminating Health Disparities Michael A. Rodriguez, MD, MPH Associate Professor David Geffen School of Medicine at UCLA May 10, 2006

2. Moving Forward Advancements in biomedical sciences and medical practices

3. Public Interest Public Health Community

4. Health Disparities in perspective Identify risk factors Identify risk factors Quantify consequences Quantify consequences Discover and disseminate solutions Discover and disseminate solutions

5. Daily Reporting Basic Questions Who? Name, Age, Ethnicity, Gender Who? Name, Age, Ethnicity, Gender What? Type of condition, Outcome What? Type of condition, Outcome When? Date When? Date Where? Environment, House, Hospital Where? Environment, House, Hospital Why/How? What prompted the Incident Why/How? What prompted the Incident

6. Daily Reporting Additional Questions Perspective: What type of condition is this? How typical is this type of condition in this community? Perspective: What type of condition is this? How typical is this type of condition in this community? Employment & Education: Do the people have jobs? How much does the individual earn? What level of education? Employment & Education: Do the people have jobs? How much does the individual earn? What level of education? Environment: How much does the environment contribute to the condition? Environment: How much does the environment contribute to the condition? Health Costs: How much do these preventable ER visits and hospitalizations cost? Health Costs: How much do these preventable ER visits and hospitalizations cost? Consequences to Family: What happens to the families and homes of the individual? Consequences to Family: What happens to the families and homes of the individual? Solutions: What is being done to address this problem? Solutions: What is being done to address this problem?

7. Overview Background Background Contributing Factors Contributing Factors Efforts to Address Efforts to Address

8. Health Disparities Health disparities are differences in theHealth disparities are differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, 2002

9. Racial/Ethnic Disparities in Virtually all Health Domains Premature mortality including infant mortality Premature mortality including infant mortality Morbidity Morbidity –Chronic disease (cancer, diabetes) –Communicable disease Physiological risk factors Physiological risk factors –Hypertension –Obesity/overweight Functional limitations and disability Functional limitations and disability

10. Leading Health Disparities Cardiovascular Disease Cardiovascular Disease Cancer Cancer Diabetes Diabetes HIV/AIDS HIV/AIDS Asthma Asthma Mental Health Mental Health Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, 2002.

11. Diabetes Type 2 diabetes is more prevalent in Mexican Americans (13%) than in non- Latino Whites (8%) (Hertz et al.) Type 2 diabetes is more prevalent in Mexican Americans (13%) than in non- Latino Whites (8%) (Hertz et al.) Latinos in the US are almost twice as likely to die from diabetes as compared to non- Latino Whites Latinos in the US are almost twice as likely to die from diabetes as compared to non- Latino Whites (Multicultural Medicine and Health Disparities, 2005)

12. Mental Health Individuals with mental health illness have high co-morbidity and mortality rates Individuals with mental health illness have high co-morbidity and mortality rates Over 26% of Latinos in Los Angeles over age 60 reported major depression or dysphoria Over 26% of Latinos in Los Angeles over age 60 reported major depression or dysphoria (U.S. Department of Health and Human Services, 2001) (U.S. Department of Health and Human Services, 2001) Latinos are less likely than Non Latino Whites to seek treatment for mental health. (Cooper-Patrick, 1999) Latinos are less likely than Non Latino Whites to seek treatment for mental health. (Cooper-Patrick, 1999)

13. What causes these disparities in health? Social Determinants Access To Care Quality Of Care Health Disparities

14. What causes these disparities in health? Social Determinants Social Determinants

15. Factors leading to disparities: Social Determinants Low Levels of Education Low Levels of Education Low Socioeconomic Status Low Socioeconomic Status Behavior and Environment Behavior and Environment

16. Social Determinants: The Latino Case Example Education Education –Latino children have highest high school drop out rates Environment Environment –Latino children have greater exposure to pollutants, waste sites, pesticides, lead & mercury –3 of 5 largest landfills in Latino & AA communities (Kaiser Network) Employment Employment –Latinos are well represented in the workforce, but work in low wage and disproportionately higher risk jobs.

17. What causes these disparities in health? Social Determinants Social Determinants Access to Care Access to Care

18. Health Insurance Health insurance facilitates entry into the health care system Health insurance facilitates entry into the health care system The uninsured are more likely to die early & have poor health status because they are diagnosed at later disease states The uninsured are more likely to die early & have poor health status because they are diagnosed at later disease states Higher costs, poor outcomes, and greater disparities are observed among individuals without a usual source of care Higher costs, poor outcomes, and greater disparities are observed among individuals without a usual source of care

19. Access to Care: The Latino Case Example 40% of Latinos under 65 are uninsured (National Health Care Disparities Report, 2005) 40% of Latinos under 65 are uninsured (National Health Care Disparities Report, 2005) Latino children make up 29% of uninsured children (Flores et al., 2005) Latino children make up 29% of uninsured children (Flores et al., 2005) One quarter of the nations uninsured are Latino (11 of 44 million Americans) (Goldstein, 2000) One quarter of the nations uninsured are Latino (11 of 44 million Americans) (Goldstein, 2000) Reasons include lack of employer-based health insurance and low income Reasons include lack of employer-based health insurance and low income

20. What causes these disparities in health? Social Determinants Social Determinants Access to Care Access to Care Health Care Health Care

21. Racial/Ethnic Disparities in Health Care Within Medicare: Within Medicare: –Differential utilization based on race for: Mammography (Gornick et al.) Mammography (Gornick et al.) Amputations (Gornick et al.) Amputations (Gornick et al.) Influenza vaccination (Gornick et al.) Influenza vaccination (Gornick et al.) Lung Cancer Surgery (Bach et al.) Lung Cancer Surgery (Bach et al.) Renal Transplantation (Ayanian et al.) Renal Transplantation (Ayanian et al.) Cardiac catheterization & angioplasty (Harris et al, Ayanian et al.) Cardiac catheterization & angioplasty (Harris et al, Ayanian et al.) Coronary artery bypass graft (Peterson et al.) Coronary artery bypass graft (Peterson et al.) Treatment of chest pain (Johnson et al.) Treatment of chest pain (Johnson et al.) Referral to cardiology specialist care (Schulman et al.) Referral to cardiology specialist care (Schulman et al.) Pain management (Todd et al.) Pain management (Todd et al.)

22. Language Barriers Quality of health care requires effective communication between patient and physician Quality of health care requires effective communication between patient and physician Communication problems lead to lower patient adherence to medications and decreased participation in medical decision-making Communication problems lead to lower patient adherence to medications and decreased participation in medical decision-making

23. Language Barriers Spanish speakers are less likely to be discharged from the ER with an understanding of their medications, special instructions, and plans for follow- up care (Crane 1997) Spanish speakers are less likely to be discharged from the ER with an understanding of their medications, special instructions, and plans for follow- up care (Crane 1997) Spanish-speaking Latinos are less likely to have physician visits, flu shots, or mammograms as compared to English- speaking Latinos or non-Latino Whites (Fiscella 2002) Spanish-speaking Latinos are less likely to have physician visits, flu shots, or mammograms as compared to English- speaking Latinos or non-Latino Whites (Fiscella 2002)

24. Efforts to Address Disparities in Health

25. Steps Towards Translating Health Disparities Research Into Policy 1) Set The Agenda 2) Build The Case 3) Beware of Politics in Science 4) Develop Comprehensive Approaches 5) Recognize that Public Policies Are Complementary To Health

26. Set The Agenda Healthy People 2010- Clinton Administration Goal: Eliminate Health Disparities

27. Achieving Equity– The Healthy People Perspective –HP 2010 recognizes that communities, states, and national organizations will need to take a multidisciplinary approach to achieving health equity that involves improving health, education, housing, labor, justice, transportation, agriculture, and the environment. (HP2010 Vol. 1, p. 16) (HP2010 Vol. 1, p. 16) Set The Agenda

28. Build The Case Institute Of Medicine Report (2002): Unequal Treatment: Confronting Racial And Ethnic Disparities In Health Care (www.nap.edu) Physicians For Human Rights Report: The Right To Equal Treatment Numerous Health Research & Policy Publications – Health Affairs The Determinants Of Health (3/2003) American Journal Of Public Health, Eliminating Health Inequalities, October 2003 Milbank Quarterly A Journal for Population Health And Health Policy, Volume 1, 2004 Numerous Books on Health Disparities And Social Justice Health For All: Californias Strategic Approach To Eliminating Racial And Ethnic Health Disparities (11/2003)

29. Politics And Science in Federal Reports This first report clearly demonstrates that racial, ethnic and socioeconomic disparities are national problems that affect health care at all points in the process, at all sites of care, and for all medical conditions – in fact, disparities in the health care system are pervasive. - National Health Disparities Report, as submitted to the Department Of Health And Human Services (DHHS) by the Agency for Healthcare Research And Quality (AHRQ), July 2003

30. Politics And Science in Federal Reports This first report finds that, while most Americans receive exceptional quality of health care and have excellent access to needed services, some socioeconomic, racial, and ethnic differences exist. - National Healthcare Disparities Report, as released by the DHHS, December 2003

31. Differences Between the Two Reports Deletes most uses of the word disparity Eliminates the conclusion that healthcare disparities are national problems Removes findings on the social costs of disparities and replaces them with a discussion of success Omits key examples of healthcare disparities

32. Comprehensive and Integrated Approaches Does health disparities legislation address: –Social Determinants and Environment? – Health Care System? – Individual Factor?

33. A Commitment to Document Disparities Collect and report data on health conditions and health care access by ethnicity, SES and primary language Collect and report data on health conditions and health care access by ethnicity, SES and primary language Include measures of racial and ethnic disparities in performance measurements Include measures of racial and ethnic disparities in performance measurements Report racial and ethnic data by use of subpopulation groups where possible Report racial and ethnic data by use of subpopulation groups where possible

34. Recognition that Health and Other Social Policies are Complementary Invest in young children Provide services and opportunities for the neediest, including health care Strengthen support at the community level Improve the work environment Create a more equal economic environment Assess the effects of economic and social action on health

35. Resources CDC Media Relations-Hispanic Disparities Press Kit CDC Media Relations-Hispanic Disparities Press Kithttp://www.cdc.gov/od/oc/media/presskits/hhd.htm The Office of Minority Health The Office of Minority Health http://www.omhrc.gov/ The National Center for Minority Health The National Center for Minority Health http://ncmhd.nih.gov/

36. Summary There is a significant body of evidence that has identified disparities in health and health care for Latinos and other underserved populations. There is a significant body of evidence that has identified disparities in health and health care for Latinos and other underserved populations. To eliminate disparities, partnerships, research, advocacy and more comprehensive policy approaches will be required To eliminate disparities, partnerships, research, advocacy and more comprehensive policy approaches will be required