Racial and Ethnic Health care Disparities

Vivien S. Fongue, OMS III

Des Peres HospitalOctober 2006

Racial and Ethnic Disparities

African Americans have the highest mortality rates from heart disease, cancer, cerebrovascular disease and HIV/AIDsAmerican Indians disproportionately die from diabetes, liver disease/cirrhosis and unintentional injuriesHispanic Americans are twice as likely to die from diabetes

Access?

Compared ethnic/racial minorities to whites

Less likely to have health insuranceFewer choices where to receive health careMore likely to receive care in an Emergency RoomLess likely to have a regular primary care provider

Resources?

Compared ethnic/racial minorities to whites

Disproportionately represented in lower socioeconomic groupsComplete less educationLive in poorer neighborhoods with• Violence• Pollution• Inferior infrastructure

Just Fix Access and Resources

Evidence Growing that at Equivalent Levels of Access Racial and Ethnic Minorities are LESS likely than Whites to

Receive Quality Health CareReceive EVEN routine Medical Procedures

Congress asked the Institute of Medicine to study this issue in 1999.

Institute of Medicine Report

Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (2002)

Assess extent of disparity unrelated to accessEvaluate potential sources

• Bias, discrimination and stereotyping• Individual, institutional and health system

Provide recommendations to eliminate disparities

Definitions

Quality of Care“quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (IOM, Measuring Quality Health Care, 1990)

Definitions

Race and Ethnicity2001 OMB definitions• American Native, Asian, African

American, Pacific Islander, White, Hispanic, Not-Hispanic

• Race as a social construct• Self definition

Why Should We Care?

Public Trust in Health ProfessionalsSocial Triaging – Am I next?

The Health of One is the Health of AllInfectious Diseases

Economic ConsiderationsLater Diagnosis Leads to Complications

Legacy of Racial Discrimination

IOM Literature Review Ethnic/Racial Disparities

600 citationsPublished 1992-2002Peer-reviewed JournalsExamined Variation in Medical CareMet Principles of Scientific ResearchAdequate Control for Access

Racial/Ethnic DisparitiesCardiovascular Care

Compared to White patients:Lesser rates of thrombolytics, beta blockers and aspirin.Lesser rates of catheterizationLesser rates of revascularizationLesser rates of PTCA

Teaching hospitals like Private hospitalsWorsened Mortality

Racial/Ethnic DisparitiesCancer

Breast Cancer – African American Women less likely to get progesterone receptors, less like to be offered reconstructionProstate Cancer – African American Men less likely to get prostatectomyAfrican Americans less likely to get post treatment surveillanceAnalgesia- African Americans less

Racial/Ethnic DisparitiesCerebrovascular Diesease

African Americans half as likely as Whites to get imaging studies after TIAWhites more likely to get endarterectomy African Americans less likely to receive anti-coagulant therapyAfrican Americans less likely to see a Neurologist

Racial/Ethnic DisparitiesRenal Transplantation

African Americans less likely to be offered peritoneal dialysisAfrican Americans less likely to be placed on the transplant listAfrican Americans less likely to receive transplant

Racial/Ethnic DisparitiesHIV/AIDs

African Americans less likely to receive antiretroviral therapyAfrican Americans less likely to receive prophylaxis for Pneumocystis cariniiAfrican Americans less likely to receive protease inhibitors

Racial/Ethnic Disparities

African Americans greater morbidity/mortality from ASTHMAAfrican Americans, Hispanics and Native Americans experience 50-100% higher morbidity/mortality from DIABETESMental Health Services less

Racial/Ethnic DisparitiesAnalgesia

Hispanic patients treated in ER for long bone fractures twice as likely as whites to be dismissed with NO ANALGESIAAnother study of African American patients 63% more likely to be dismissed with NO ANALGESIAMinority Cancer patients more likely to receive INADEQUATE pain management

Responsibility

IndividualWe may be unaware of our own biases and prejudicesEducation

InstitutionalSpeak up in our own institutions

SystemSpeak up politically

Rural Healthcare Disparities

1999-2000 National Health Interview Surveys Included

34.6 million Adults were surveyed84.4% white, 8.0% black, 4.9% Hispanic and 2.7% other racial backgrounds

Rural Health Care Disparities

5 million of these rural adults self reported decreased ability to carry out daily activities. Rural residents were educationally and financially worse off than their urban counterparts, minorities more so than whites.

Rural Health Care Disparities

Urban whites had a 73.2% chance of having employer sponsored health insurance. Rural whites had a 63.7% chance, Rural blacks a 46.8% chance, Rural Hispanics a 52.4% and Rural ‘other’ a 51.9%. Minorities were more likely to have government health insurance coverage.

Rural Health Care Disparities

Rural minorities were less likely to have a regular source of care and reported fewer health care visits. Rural residents were less likely than urban residents to have seen a dentist in the past year Rural residents were more likely to have visited an emergency room.

Rural Health Care Disparities

Infant mortality rates are 26% higher in rural than suburban America. The death rate for persons aged one to twenty four is 31% higher than even urban rates. The death rate for persons 25-64 years was 32% higher than suburban ratesThe death rate for those over 65 was 7% higher.

Rural Health Care Disparities

Rural residents smoke moreRural residents exercise less Rural residents are more likely to be obese than the general population Health is defined by physical vitality and productivity.

Short term solutions to stay at work can mean long term complications

Rural Health Care DisparitiesRural patients with MYOCARDIAL INFARCTION had higher mortality rates even when the admissions were controlled for comorbidities. Several of the missed opportunities for intervention consisted of oral or intravenous medications and did not require high technology services. Patients transferred who were more likely to be white, male and younger were more likely to get recommended treatments.

Rural Health Care Disparities

CERVICAL CANCER deaths are higher in rural areas The use of regular Pap smears for early detection of cervical cancer is lower. It is also discouraging to note a report indicating that physicians practicing in rural areas are less likely to recommend Pap smears.

Rural Health Care Disparities

Rural women with BREAST CANCER were not as likely to have an adequate determination of estrogen receptor statusThese women were also less likely to receive radiation therapy as part of treatment. Finally, breast conservation surgery in place of more extensive mastectomy was not offered as often

Rural Health Care Disparities

Data suggest that physicians treating HIV/AIDs in rural settings have fewer total patients with the disease and thus less experience Rural patients were less likely to receive courses of highly active antiretroviral therapy (HAART). Rural patients were also less likely to receive preventive antibiotics for Pneumocystis carinii pneumonia,.

Improving Rural Health Care

As part of the series Crossing the Quality Chasm: A New Health System for the 21st Century, the Institute of Medicine released Quality Through Collaboration: The Future of Rural Health in November of 2004.[1] This Committee made five recommendations to improve healthcare for rural Americans.

Improving Rural Health Care

IOM recommendations1. Improve payment for services.2. Recruit more healthcare personnel to work in Rural areas.3. Shift emphasis to population health.4. Create Quality Improvement networks5. Increase information and digital communication.

Global Health Care Disparities

Article 25, Universal Declaration of Human Rights:

Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the vent of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond control

Global Health Care Disparities

Life expectancies:

Developed countries – 78 years

East Asia – 69 years

Sub-saharan Africa – 47 years

Global Health Care Disparities

Malaria kills 3,000,000 people a year.Most of the victims are CHILDREN.90% are in Africa.Malaria is treatable.The treatment is cheap.Prevention is elementary.

Simple Steps

Primary education for all children.Nutrition programs.Antimalarial bed nets.Safe drinking water.

The UN Millenium Project

What would it cost?

Fair contribution from developed countries.For the United States

70 cents of every 100 dollars of our GNP.

United States current contribution15 cents of every 100 dollars of our GNP.

Responsibility

IndividualWe may be unaware of our own biases and prejudicesEducation

InstitutionalSpeak up in our own institutions

SystemSpeak up politically

Health Care Disparities

Let no one be discouraged by the belief there is nothing one man or one woman can do against the enormous array of the world’s ills – against misery and ignorance, injustice and violence…few will have the greatness to bend history itself; but each of us can work to change a small portion of events, and in the total of all those acts will be written the history of this generation…..

Health Care Disparities

It is in the numberless diverse acts of courage and belief that human history is shaped. Each time a man stands up for an ideal, or acts to improve the lot of others, or strikes out against injustice,

Health Care Disparities

He sends a tiny ripple of hope, and crossing each other from a million different centers of energy and daring, those ripples build a current which can sweep down the mightiest walls of oppression and resistance.”

Robert F. Kennedy

ReferencesIOM Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (2002)IOM, Measuring Quality Health Care, (1990)OMB Definitions of Race, 20011999-2000 National Health Interview Surveys IncludedIOM Quality Through Collaboration: The Future of Rural Health in November of (2004)Article 25, Universal Declaration of Human RightsThe End of Poverty, Jeffrey Sachs,