beal keynote-nih health literacy - boston university

Hedge Funds

2/28/04

Addressing Low Health Literacy to Achieve Racial and Ethnic Health Equity

Health Literacy Conference

October 2009

Anne Beal, MD, MPHPresidentAetna Foundation, Inc.

2

Health LiteracyConference

Minorities Are More Likely to Have Diabetes

9.48

14.813.6

6.65.3

11.2 10.5

2.9 2.83.9 3.5

02468

101214161820

Total White Black Mexican

% With Diabetes Diagnosed Undiagnosed

Age Adjusted Percent of Population With Diabetes, 1999-2002

Source: Centers for Disease Control and Prevention, National Center for Health Statistics National Health and Nutrition Examination Survey. Health, United States, 2005

3


Minorities Have More Complications Resulting from Diabetes

1

1.41.3

1.7

0.3

00.20.40.60.8

11.21.41.61.8

2

White Black Hispanic AIAN API

Source: Young et al. Effects of Ethnicity and Nephropathy on Lower-extremity Amputation Risk Among Diabetic Veterans. Diabetes Care, 2003; 26:495-501

Relative Risk of Amputation Resulting from Diabetes, 1998

*

* Whites Are Referent Group

4


Minorities Have Higher Death Rates Due to Diabetes

22.2

49.5

35.6

43.2

17.4

0

10

20

30

40

50

60

White Black Hispanic AIAN API

Age Adjusted Death Rate per 100,000

Source: Centers for Disease Control and Prevention, National Vital Statistics System Health, United States, 2005

5


Co-Morbid Conditions

Access To Care/Coverage

Quality of Healthcare

Patient Adherence

Genetic PredispositionCommunity Factors

Environmental Factors

Cultural Factors

Economic Factors

Physiologic Response to Meds

Ease of Lifestyle Changes

What Causes Health Disparities?

Patient Literacy

6


Genetic Predisposition


Economic Factors

Cultural Factors

Community Factors




Patient Adherence



--------Disparities--------


Patient Literacy

7


Disparities in Healthcare and Quality of Care

• Measures of healthcare disparities are essentially quality measures.

• Disparities in health is not a marginal or special interest issue.

• There is a larger quality movement; use their tools, language and techniques.

• Calls upon quality movement to address quality for vulnerable patients.

8


http://www.nap.edu/

IOM Framework for Health Care Quality

9


IOM Healthcare Quality Domains*

1. Access to care2. Timeliness ingetting care3. Timeliness within and across episodes of care

1. Experience of care2. Effective partnership

1. Preventive care 2. Acute, chronic, and end-of-life3. Appropriate procedures

1. Diagnosis2. Treatmenta. Medicationb. Follow-up

3. Health careenvironment

TimelinessPatient Centeredness

EffectivenessSafety

*Source: Margarita P. Hurtado, Elaine K. Swift, and Janet M. Corrigan, Eds. “Envisioning the National Health Care Quality Report”, National Academy Press, Washington DC, 2001


10


IOM Healthcare Quality Domains*

1. Access to care2. Timeliness ingetting care3. Timeliness within and across episodes of care

1. Experience of care2. Effective partnership

1. Preventive care 2. Acute, chronic, and end-of-life3. Appropriate procedures

1. Diagnosis2. Treatmenta. Medicationb. Follow-up

3. Health careenvironment

TimelinessPatient Centeredness

EffectivenessSafety

*Source: Margarita P. Hurtado, Elaine K. Swift, and Janet M. Corrigan, Eds. “Envisioning the National Health Care Quality Report”, National Academy Press, Washington DC, 2001


11


Problem: Medical Errors– Communication is Often

Root Cause

Solution: Improve Communication– Limited English Proficiency

– Low Health Literacy

Safety and Quality for Vulnerable Populations

12


Who Is at Risk for Low Health Literacy?

13


89

56

30

80

45

17

57

30

11

88

67

50

0

20

40

60

80

100

High school graduateor more

Some college or more Bachelor's degree ormore

White, non-Hispanic Black Hispanic Asian

Note: “Some college” includes respondents who had completed some college but had not completed a degree and those who had completed an associate’s degree.

Source: Racial and Ethnic Disparities in US Health Care: A Chartbook. The Commonwealth Fund

United States Census Bureau. Current Population Survey, Annual Social and Economic Supplement. 2003.

Percentage of population age 25 and olderby education level achieved, 2003

Blacks and Hispanics Have Lower Levels of Educational Attainment

14


49,94054,698

33,255 34,397 33,144

59,324

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

Total White, non-Hispanic

Black Hispanic AI/AN Asian

AI/AN = American Indian/Alaska Native.

Source: Racial and Ethnic Disparities in US Health Care: A Chartbook. The Commonwealth Fund

United States Census Bureau. Census 2000.

Median family income in U.S. dollars, 1999

Median Family Income Is Higher for Whites and Asians Than for Other Groups

15


Do Minority Patients Experience Poorer Communication?

16


Percent of adults (ages 18+) reporting health providers “sometimes” or “never” listen carefully, explain things clearly, respect what they say, and spend enough time with them

* Insurance for people ages 18–64. ** Urban refers to metropolitan area >1 million inhabitants; Rural refers to noncore area <10,000 inhabitants.Data: Medical Expenditure Panel Survey (AHRQ 2007b).

19

16

14

119

10

0 5 10 15 20

Uninsured*

Private insurance*

<100% of poverty

400+% of poverty

Asian

Hispanic

Black

White

Total

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

Doctor-Patient Communication by Race/Ethnicity, Family Income, and Insurance, 2004

17


3531

36

48*54*

0

25

50

75

Total White African

American

Hispanic Asian

American

Percent of adults ages 18–64 with any chronic condition who were not given a plan from a doctor or nurse to manage condition at home

* Compared with whites, differences remain statistically significant after adjusting for income or insurance.Source: Commonwealth Fund 2006 Health Care Quality Survey.

About Half or More of Hispanics and Asian Americans with Chronic Conditions Were Not

Given Plans to Manage Their Condition at Home

18


29 31

15 10 23 39

56 5950

2327

37*

0

25

50

75

100

Total White African American Hispanic

Does not check BP

Checks BP, not controlled

Checks BP, controlled

Source: Commonwealth Fund 2006 Health Care Quality Survey.

Percent of adults 18–64with high blood pressure

* Compared with whites, differences remain statistically significant after adjusting for income and insurance.

Opportunities for Improving Hypertension Management Exist Across All Groups, Especially Hispanics

19


57%51%

37%47%

16%

0%

35%

70%

Total U.S. HispanicEnglish

Speaking

HispanicSpanish

Speaking

AsianAmericanEnglish

Speaking

AsianAmerican Non-

Englishspeaking

* English is not primary language spoken at home.

Source: The Commonwealth Fund 2001 Health Care Quality Survey.

Percent of adults reporting it’s very easy to understand information from doctor’s office

Non-English* Speakers Have More Difficulty Understanding Instructions from Doctor’s Office

20


Can Addressing Low Health Literacy Reduce Disparities?

21


2.12 (1.93-2.32)Low Literacy

1.80 (0.51-5.85)2.40 (1.14-5.08)Black

Model w/ Literacy

AOR (95% CI)

Model w/o Literacy

AOR (95% CI)

Source: CY Osborn, MK Paasche-Orlow, TC Davis et al. Health Literacy: An Overlooked Factor in Understanding HIV Health Disparities. Am J Prev Med 2007;33(5):374–378

Multivariate Regression Analysis for Non-Adherence to HIV Medication Regimen

22


• Choosing Aggressive End-of Life Therapies

• Stage of Diagnosis for Prostate Cancer

Similar Findings for Other Conditions

23


160 157

238

127

98

0

50

100

150

200

250


Black Hispanic Asian orPacific

Islander

29 26

64

2218

11

0

20

40

60

80


Black Hispanic AI/AN* Asian/PacificIslander

AI/AN = American Indian/Alaska Native.Note: Data are age adjusted.Source: National Center for Health Statistics. Health, United States, 2006: With Chartbook on Trends in the Health of Americans. 2006.

New cases per 100,000 male population, 2003 Deaths per 100,000 male population, 2000–2003

Incidence Mortality

Black Men Are 50% More Likely to Have Prostate Cancer and Over 200% More Likely to Die From It

24


Genetic Predisposition


Economic Factors

Cultural Factors

Community Factors




Patient Adherence



--------Disparities--------


Patient Literacy

beal keynote-nih health literacy - boston university

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