Health Equity
Priyank DevtaDeepa PatelAlicia Williams
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.
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.
Assessing Racial and Ethnic Disparities in Health Care
Alicia Williams2012 PharmD CandidateMercer University COPHSJuly 22, 2011
Overview
Background The Commonwealth Fund 2001
Health Care Quality Survey 2010 National Healthcare Quality &
Disparities Report Conclusion
Background
Background
Cultural and socioeconomic factors affect each person’s 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.
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.
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.
The Commonwealth Fund 2001 Health Care Quality Survey
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
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
Patient-Physician Communication
Patient-Physician Communication
Patient-Physician Communication
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.
Cultural Competence in Health Care Services
Cultural Competence in Health Care Services
Cultural Competence in Health Care Services
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.
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
Quality of Clinical Care for Minority Populations
Quality of Clinical Care for Minority Populations
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
Access to Health Care
Access to Health Care
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
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.
Health Insurance Coverage
Health Insurance Coverage
2010 National Healthcare Quality & Disparities Report
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.
2010 National Healthcare Quality & Disparities Report
2010 National Healthcare Quality & Disparities Report
2010 National Healthcare Quality & Disparities Report
2010 National Healthcare Quality & Disparities Report
ConclusionGaps in health care quality between whites and people of color remain
unchanged, and in some cases are getting wider.
Deepa PatelDoctor of Pharmacy Candidate, 2012
Mercer COPHSPresented on July 22, 2011
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 malesFemales have a greater need for reproductive and
preventative care during their younger yoursFemales 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
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
2010 National Healthcare Quality and Disparities Report
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
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
Leading cause of death
Females had higher rates of inpatient heart attack mortality than menRate of receipt of a fibrinolytic medication
was higher in males than womenBoth male and female patients with heart
failure were discharged with appropriate medications at a rate of 82%
HIV infection death rate for males was more than twice that of females (5.4 per 100,000 population versus 2.1)
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
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
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
Females are significantly less likely to complete substance abuse treatment, 41% compared to 47.1%
Pressure ulcersBoth genders had decreases in short and
long term stay incidence of ulcersFemales were less likely to have either
type
Female patients were more likely to receive potentially inappropriate medications
Male Female
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 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
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
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 doesn’t qualify for Medicaid
Reduce burden of EMTALA
“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
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
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
Medical home
Priyank DevtaPharm D candidate 2012
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
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
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)
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
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
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
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
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
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
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
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
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 patient’s family
Principles to describe the characteristics of the PCMH have been developed by physicians
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 patient’s community
Principles (cont.)
Quality and safety – compassionate, robust partnership between physicians, patients, and the patient’s 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
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
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
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
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
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
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
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
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
Conclusion
For the 90% of CSHCN who have a usual source of care, that source of care was most often a doctor’s 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 doctor’s 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
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