Health Equity

1
Health Equity

• Priyank Devta
• Deepa Patel
• Alicia Williams

2
Health Equity

• Health equity refers to the study of differences
  in the quality of health and health care across
  different populations.
• This may include differences in
• the presence of disease,
• health outcomes,
• or access to health care.

3
Health Equity

• Many different populations are affected by
  disparities, including
• racial and ethnic minorities,
• residents of rural areas,
• women,
• children,
• the elderly,
• and persons with disabilities.

4
Assessing Racial and Ethnic Disparities in Health
Care

• Alicia Williams
• 2012 PharmD Candidate
• Mercer University COPHS
• July 22, 2011

5
Overview

• Background
• The Commonwealth Fund 2001 Health Care Quality
  Survey
• 2010 National Healthcare Quality Disparities
  Report
• Conclusion

6
Background
7
Background

• Cultural and socioeconomic factors affect each
  persons health and their opportunities to
  receive the best possible health care.
• On a wide range of health care quality measures,
  minority Americans do not fare as well as whites.

8
Background

• In general, minorities tend to
• have worse access to health care
• receive lower quality care when they are able to
  access it
• have worse health outcomes than non-Hispanic
  whites.

9
Background

• A recent report estimated that between 2003 and
  2006, more than 200 billion could have been
  saved in direct medical care expenditures if
  racial and ethnic health disparities did not
  exist.
• The direct and indirect costs attributed to
  health disparities contribute to the growth of
  health care costs in national health care
  expenditures, which is one of the reasons
  Congress has undertaken health reform.

10
The Commonwealth Fund 2001 Health Care Quality
Survey
11
The Commonwealth Fund 2001 Health Care Quality
Survey

• Conducted from April 2001 to November 2001
• Conducted by the Princeton Survey Research
  Associates
• Collected current information on the care
  experiences of patients of various racial and
  ethnic backgrounds
• Focused on 5 core health care quality measures
• Based on telephone interviews with 6,722 adults
  age 18 and older
• 3,488 whites 1,153 Hispanics 1,037 African
  Americans and 669 Asian Americans

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Health Care Quality Measures

• Patient-Physician Communication
• Cultural Competence in Health Care Services
• Quality of Clinical Care for Minority Populations
• Access to Health Care
• Health Insurance Coverage

13
Patient-Physician Communication
14
Patient-Physician Communication
15
Patient-Physician Communication
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Cultural Competence in Health Care Services

• Defined as the incorporation of an awareness of
• health beliefs and behaviors,
• disease prevalence and incidence,
• and treatment outcomes
• for different patient populations.

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Cultural Competence in Health Care Services
18
Cultural Competence in Health Care Services
19
Cultural Competence in Health Care Services
20
Cultural Competence in Health Care Services

• Compared with whites, minority respondents
• feel less welcomed by the health care system,
• have more reservations about the benefits and
  value of health care,
• and are more likely to face significant language
  barriers.

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Quality of Clinical Care for Minority Populations

• The survey assessed
• preventive services and management of chronic
  diseases
• prevalence of medical errors
• sources of health information
• overall patient satisfaction

22
Quality of Clinical Care for Minority Populations
23
Quality of Clinical Care for Minority Populations
24
Access to Health Care

• Survey questions included asking U.S. adults
  about
• their usual source of care,
• whether they have a regular doctor or a choice of
  providers,
• and continuity in their care

25
Access to Health Care
26
Access to Health Care
27
Access to Health Care

• Minority adults are more likely to
• receive care in hospital- or health center-based
  facilities.
• Minority adults are less likely to
• have a regular doctor
• feel they have a choice in where they go for care
• have a long-term relationship with their doctor

28
Health Insurance Coverage

• Health insurance plays a critical role in
• mediating access to medical care
• interactions with the health care system
• ensuring quality of care
• The uninsured fare worse than the insured on
  every measure of satisfaction and quality used.
• Although people of color represent one-third of
  the U.S. population, they comprise more than half
  of the uninsured.

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Health Insurance Coverage
30
Health Insurance Coverage
31
2010 National Healthcare Quality Disparities
Report
32
2010 National Healthcare Quality Disparities
Report

• Produced by the Agency for Healthcare Research
  and Quality (AHRQ)
• Measures trends in effectiveness of care, patient
  safety, timeliness of care, patient centeredness,
  efficiency of care, and access to care in the
  general U.S. population
• The report is built on more than 250 measures
  categorized across these six dimensions.

33
2010 National Healthcare Quality Disparities
Report
34
2010 National Healthcare Quality Disparities
Report
35
2010 National Healthcare Quality Disparities
Report
36
2010 National Healthcare Quality Disparities
Report
37
Conclusion
Gaps in health care quality between whites and
people of color remain unchanged, and in some
cases are getting wider.
38
Disparities in healthcare Gender

• Deepa Patel
• Doctor of Pharmacy Candidate, 2012
• Mercer COPHS
• Presented on July 22, 2011

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Introduction

• Disparities in healthcare by gender can be
  somewhat linked to the greater need for care
  throughout the lifespan of a female patient when
  compared to males
• Females have a greater need for reproductive and
  preventative care during their younger yours
• Females also have a greater need for treatment
  from numerous chronic disease states at an older
  age
• Nearly 80 of women have a usual primary care
  provider, whereas 72 of males do
• Females are more likely to be unable to receive
  or receiveddelayed medical care, dental care, or
  prescription medications

40
Disparities In patient-physician communication by
gender

• Studies indicate that patients are more receptive
  to communicating when they are able to relate to
  the information being presented
• Female physicians have demonstrated a greater
  skill of gathering subjective information from
  patients

41
Quality of clinical care

• 2010 National Healthcare Quality and Disparities
  Report

42
Diabetes

• Both genders had decreases in hospitalizations
  for lower extremity amputation from 2005 to 2007
• Males, however, had twice as many admissions as
  women for diabetes

43
End stage renal disease (esrd)

• The number of female adult hemodialysis patients
  that were receiving adequate dialysis was higher
  than that of male adult hemodialysis patients
• Males are more likely to be registered on a
  kidney transplant waiting list

44
Heart Disease

• Leading cause of death
• Females had higher rates of inpatient heart
  attack mortality than men
• Rate of receipt of a fibrinolytic medication was
  higher in males than women
• Both male and female patients with heart failure
  were discharged with appropriate medications at
  a rate of 82

45
HIV

• HIV infection death rate for males was more than
  twice that of females
• (5.4 per 100,000 population versus 2.1)

46
Colorectal cancer

• 3rd most common cancer in adults
• Rate of advanced stage colorectal cancer in males
  are significantly higher than women
• The rate for both genders, however, is decreasing
  significantly

47
Respiratory diseases

• No differences in the treatment of hospitalized
  pneumonia patients
• Tuberculosis
• Both genders increased the percentage of patients
  who completed therapy
• Female patients were more likely to complete
  treatment when compared to males
• Females had lower rates of post operative
  respiratory failure, sepsis, and deaths following
  complications of care

48
Mental health

• Female patients are 11 more likely to receive
  treatment for a major depressive episode compared
  to male patients
• Males had suicide rates four times higher than
  females

49
Substance abuse

• Females are significantly less likely to complete
  substance abuse treatment, 41 compared to 47.1

50
Supportive palliative care

• Pressure ulcers
• Both genders had decreases in short and long term
  stay incidence of ulcers
• Females were less likely to have either type
• Female patients were more likely to receive
  potentially inappropriate medications

51
Favorable outcomes in disease states by gender

• Kidney transplant waiting list registration
• Inpatient myocardial infarctions
• Appropriate medication dispensed
• Completion of substance abuse treatment

• Diabetes
• Adequate dialysis in ESRD
• HIV
• Colorectal Cancer
• Tuberculosis
• Post operative respiratory failure
• Sepsis
• Deaths following complications of care
• Major Depressive Disorder
• Suicide Attempts
• Pressure Ulcers

• Male

• Female

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Disparities of accessibility

• Male patients are more likely to be uninsured
• Many associate the incidence of women having
  insurance coverage with increased ease of
  availability of programs such as Medicaid for
  children and prenatal care
• An argument can be formed that increased needs
  for healthcare in females makes having insurance
  a greater need than with male patients

53
healthcare reform

• March 2010 Two federal statutes colloquially
  referred to as Health care reform passed
• Patient Protection and Affordable Care Act
• Health Care and Education Reconciliation Act
• One of the main goals is to expand insurance
  coverage, particularly to low and moderate income
  and uninsured adults

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Massachusetts attempts universal healthcare

• In 2006 the state passed its health care
  insurance reform law
• Parallels goals with National Reform
• State regulated minimum healthcare insurance
  coverage
• Free health care for residents below established
  income levels even if patient doesnt qualify for
  Medicaid
• Reduce burden of EMTALA

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Results from the health reform in massachusetts

• Have Gender Gaps in Insurance Coverage and
  Access to Care Narrowed under Health Reform?
  Findings from Massachusetts.
• Cross sectional study based on surveys
• Observed differences pre health care reform
  (2006) and post reform (2009) in adults by gender
• Insurance coverage
• Access to health care
• Use of healthcare
• Affordability

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2006 findings ALL ADULTs
57
2009 findings ALL ADULTs
58
2006 Findings Differences in gender BY age group
59
2009 Findings Differences in gender BY age group
60
Conclusions

• Overall, younger and older women continue to use
  more care than men under healthcare reform
• Despite increases in insurance coverage, women
  were still more likely to report unmet needs for
  health care and problems affording care than men
• Especially true in younger adults

61
Applicability in national reform

• Coverage does not always translate to access to
  healthcare and affordability of care
• Particularly in patients with greater healthcare
  needs, such as women of all age groups
• Despite mandated healthcare coverage,
  affordability is a major concern
• Preventative care coverage standards vary greatly
  amongst states

62
Medical home

• Priyank Devta
• Pharm D candidate 2012

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Disparity and accessibility

• Disparity the condition or fact of being
  unequal, as in age, rank or degree
• Many factors lead to differences in health care,
  especially with respect to aggregate measure of
  use
• These include different underlying rates of
  illness due to genetic predisposition, local
  environmental conditions, or lifestyle choices
• There are differences in the care-seeking
  behavior of patients, which vary due to differing
  cultural beliefs, linguistic barriers, degree of
  trust of health care providers, or variations in
  the predisposition to seek timely care
• Availability of care is dependent upon such
  factors as the ability to pay for care, the
  location, management and delivery of health care
  services, clinical uncertainty, and health care
  practitioner beliefs

64
National Healthcare Disparities Report

• While disparities in health care potentially
  affect all Americans and individuals from any
  group, they are not uniformly distributed across
  populations
• 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
• Access to health care is prerequisite to
  obtaining quality care

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Examples

• Minorities are more likely to be diagnosed with
  late stage breast cancer and colorectal cancer
  compared with whites
• Patients of lower socioeconomic position are less
  likely to receive recommended diabetic services
  and more likely to be hospitalized for diabetes
  and its complications
• When hospitalized for acute MI, Hispanics are
  less likely to receive optimal care
• Many racial and ethnic minorities and persons of
  lower socioeconomic position are more likely to
  die from HIV
• Minorities also account for a disproportionate
  share of new AIDS cases
• The use of physical restraints in nursing homes
  is higher among Hispanics and Asian/Pacific
  Islanders compared with non-Hispanic whites
• Blacks and poorer populations have higher rates
  of avoidable hospital admissions (conditions that
  rarely require hospitalization in the presence of
  comprehensive primary care)

66
National Healthcare Disparities Report

• Health care disparities are costly
• Poorly managed care or missed diagnoses result in
  expensive and avoidable complications lead to
  higher cost in future
• Personal cost of disparities can lead to
  significant morbidity, disability, and lost
  productivity at individual level
• At social level, distal costs follow from
  proximal opportunities that were missed

67
Examples

• Without screening, cancers may not be detected
  until they grow large or metastasize to distant
  sites and cause symptoms
• Such lat stage cancers are usually associated
  with more limited treatment options and poorer
  survival
• Minorities and persons of lower socioeconomic
  status are less likely to receive cancer
  screening services and more likely to have late
  stage cancer when the disease is diagnosed
• Persons with diabetes of lower socioeconomic
  position are
• less likely to receive recommended diabetic
  services and more likely to be hospitalized for
  diabetes and its complications
• less likely to receive recommended immunizations
  for influenza and pneumococcal pneumonia
• More likely to suffer worse quality of care for
  pneumonia
• Differential rates of hospitalization and
  vaccination present opportunities for provider
  based and community based interventions to reduce
  disparities

68
National Healthcare Disparity Report

• Access to healthcare is an important prerequisite
  to obtaining quality care
• Patients may perceive barriers to delay seeking
  needed care, resulting in presentation of illness
  at a later, less treatable stage of illness
• Of the major measure of access, the lack of
  health insurance has significant consequences
• When healthcare needs are not met by primary
  health care system, rates of avoidable admissions
  may rise

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Examples

• Many racial and ethnic minorities and individuals
  of lower socioeconomic status are less likely to
  have a usual source of care
• Hispanics and people of lower socioeconomic
  status are more likely to report unmet health
  care needs
• While most of the population has health
  insurance, racial and ethnic minorities are less
  likely to report health insurance compared with
  whites
• Lower income persons are also less likely to
  report insurance compared with higher income
  persons
• Higher rates of avoidable admissions by blacks
  and lower socioeconomic position persons may be
  explained by lower receipt of routine care by
  these populations

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National Healthcare Disparities Report

• Opportunities to provide preventive care are
  frequently missed
• Our healthcare system emphasize care that occurs
  after an illness occurs, rather than preventive
  services that could potentially prevent the
  illness or reduce the burden of disease
• Significant disparities in the use of evidence
  based preventive services for certain populations
  smoking remains the single most preventable
  cause of mortality, rates of smoking cessation
  counseling during hospitalization are only 40
  29 in blacks

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Examples

• Blacks and people of lower socioeconomic status
  tend to have higher rates of death from cancer
  early treatment of cancers can lead to reductions
  in mortality
• Less likely to receive screening and treatment
  for cardiac risk factors
• Less likely to receive childhood immunizations
  and recommended immunizations for influenza and
  pneumococcal disease

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National Healthcare Disparities Report

• While blacks and poor patients are more likely to
  present with later stage cancers with higher
  death rates, black women have higher screening
  rates for cervical cancer and no evidence of
  later stage cervical cancer presentation.
  Significant investment in community based cancer
  screening and outreach programs for cervical
  cancer may be responsible for the lack of
  disparity
• Quality improvement efforts have resulted in
  demonstrable reductions in black-white
  differences in hemodialysis
• A greater perceived risk for significant
  cardiovascular disease among blacks may result in
  appropriately increased screening rates and
  treatment for risk factors

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Accessibility of Health Care

• 2 choices of healthcare available
• Government control of the medical system
  (socialized medicine as in Canada) which needs a
  lot of thought and consideration
• Private sector medical care system whose
  accountability remains more involved with its
  investors
• We have a split between private sector control
  (for those who can afford it) and public medical
  care system for those who can not (medicaid)
• Pharmaceutical companies claim that drug prices
  are higher because they need the money to
  continue researching new drugs for treatment
• Companies are businesses have accountability is
  to stockholders and less to general public
• Government enact laws to prevent people from
  getting medications from cheaper sources like
  Canada which they claim is for benefit of
  American population instead of performing quality
  checks on the meds

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Patient Centered Medical Home (PCMH)

• PCMH is an approach to providing comprehensive
  primary care for children, youth and adults
• PCMH is a health care setting that facilitates
  partnership between individual patients, and
  their personal physicians, and when appropriate,
  the patients family
• Principles to describe the characteristics of the
  PCMH have been developed by physicians

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Principles

• Personal physician
• Physician directed medical practice physician
  leads a team
• Whole person orientation personal physician is
  responsible for providing referrals
• Care is coordinated and/or integrated across all
  elements of health care system (subspecialty
  care, hospitals, home health agencies, nursing
  home) and the patients community

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Principles (cont.)

• Quality and safety compassionate, robust
  partnership between physicians, patients, and the
  patients family evidence based medicine,
  physicians accept accountability for continuous
  quality improvement, patients actively
  participate in decision making and feedback,
  information technology is used adequately,
  patients and family participate in quality
  improvement activities at the practice level
• Enhanced access open scheduling, expanded
  hours, new options for communication

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Principles (cont.)

• Payment should reflect the value of physician
  patient centered care management, should pay for
  coordination of care both within a given practice
  and between consultants, ancillary providers, and
  community resources, should support use of
  technology, allow for additional payments for
  achieving measurable and continuous quality
  improvements

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PCMH

• Table shows that most aspects of care and health
  outcomes, identification of a particular
  practitioner provides better services than mere
  identification of a particular place

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PCMH

• Primary care-oriented countries (Denmark,
  Finland, Netherlands, Spain, UK) achieve notable
  better outcome for health in early childhood low
  birth weight ratios, postneonatal mortality,
  infant mortality, and child mortality, including
  deaths from injury
• USA ranks near the bottom or at the bottom on all
  of these measures and is rated the lowest in
  primary care orientation of all the countries
• Advantages of primary care are most notable for
  health outcomes in childhood, although they are
  also marked for some health outcomes later in life

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Results

• Article reports the findings of the National
  Survey of Children with Special Health care Needs
  regarding parent perception of the extent to
  which children with special health care
  needs(CSHCN) have access to a medical home
• 5 criteria to qualify as medical home usual
  source of care, personal doctor or nurse,
  referrals for specialty care, coordinated care,
  family centered care
• prevalence of CSHCN in 2001 is 12.8 nationally
• Among CSHCN 52.6 had access to a medical home
• 90.5 of CSHCN had a usual source care
• Percentage of CSHCN who had usual source of care
  decreased as poverty level increased, 92.7 for
  nonpoor children to 87.6 for poor children
• 91.9 of non hispanic white children had a usual
  source of care, 85.2 of hispanics and 88 of AA

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Results

• 11 of CSHCN did not have a personal doctor
• This number increased as poverty increased
• 82.1 of poor children compared to 91.1 of non
  poor children had a personal doctor or a nurse
• 90.4 of whites had personal doctor or nurse
  compared to 86 AA and 86.8 of hispanics

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Results

• 78.1 reported having no difficulty getting
  needed referrals for specialty care
• 66.7 poor children had no difficulty compared to
  81.8 of non poor children
• 80.1 white had no difficulty compared to 68.9
  Hispanics, 76.2 AA, 74.6 of other races had no
  difficulty

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Results

• 11.7 of CSHCN reported the need for care
  coordination
• Care coordination was adequate for 39.8
• Care coordination was not provided when needed in
  18.1
• Communication between doctors and other programs
  was reported as very good or excellent by only
  37.1 of patients

84
Results

• 66.8 of parents reported that doctors provided
  all elements of family centered care
• 50.2 of poor children receiving family centered
  care, as opposed to 74.7 of non poor children

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Conclusion

• For the 90 of CSHCN who have a usual source of
  care, that source of care was most often a
  doctors office, a setting usually associated
  with the comprehensive care component of a
  medical home
• Poor and non white people were far less likely to
  use a doctors office as their usual source of
  care mainly due to lack of access as a result of
  insurance and other financial barriers
• Sociocultural factors and preferences may also
  play a role in determining where people of non
  white background receive their routine health care

88
References

• Collins K, Hughes D, Doty M, et al. Diverse
  communities, common concerns assessing health
  care quality for minority Americans. New York
  Commonwealth Fund 2002.
• AHRQ (Agency for Healthcare Research and
  Quality). 2010. National Healthcare Disparities
  Report. Rockville, MD AHRQ.
• Kaiser Family Foundation. September 2010. Health
  Reform and Communities of Color Implications for
  Racial and Ethnic Health Disparities. Menlo Park,
  CA KFF