eliminating health disparities in an urban area virginia a. caine, m.d., director marion county...
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ELIMINATING HEALTH DISPARITIES IN AN URBAN
AREA
VIRGINIA A. CAINE, M.D., DIRECTORMARION COUNTY HEALTH DEPARTMENT
INDIANAPOLIS, INDIANAMay 1, 2002
“Racial and ethnic disparities in health care are unacceptable in a country that values equality and equal opportunity for all. And that is why we must act now with a comprehensive initiative that focuses on health care and prevention for racial and ethnic minorities.”
President Bill ClintonFebruary 21, 1998
President’s Initiative to Eliminate Racial and Ethnic Disparities in
HealthTarget conditions
• Infant mortality
• Cancer screening and management
• Cardiovascular disease
• Diabetes
• HIV infection/AIDS
• Immunizations
Healthy People 2010
Two Overarching Goals:
• Increase Quality and Years of Healthy Life
• Eliminate Health Disparities
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.
What Are Health Disparities?
Why The Interest In Disparities?
• The changing demography of the American population
• The persistence of disparities in the health status of racial and ethnic minorities
Percent Distribution of U.S. Population by Race and Ethnicity, 2000
African American/Black12.2%
Asian/Pacific Islander3.8%
Hispanic/Latino11.9%
American Indian/Alaska Native0.7%
White, not Hispanic/Latino71.4%
Source: U.S. Census Bureau, 2000
Percent of the Population by Race and Hispanic Origin, 2000 and 2050
71.8%
52.8%
11.4%
24.5%
12.2%13.6%
AmericanIndian/Alaska Native
Asian/Pacific Islander
Black/African American
Hispanic/Latino
White, not Hispanic/Latino
2000 2050
8.2%3.9%
Source: U.S. Bureau of the Census 2000
Minority people are the majority in three states
• California (50.1%)
• Hawaii (71%)
• New Mexico (53%)
• District of Columbia (71%)
Emerging Majorities
Minority people are now at least 30% of the population in ten states:
• Texas (45%)
• Mississippi (38%)
• Maryland (36%)
• New York (35%)
• Georgia (34%)
• Arizona (32%)
• Florida (32%)
• New Jersey (32%)
• South Carolina (32%)
• Nevada (30%)
Emerging Majorities
Percent of the Population by Race and Hispanic Origin, Indiana
1990White, not Hispanic: 90.1%
Black/African American: 7.8%
Asian/Pacific Islander: 0.2%
Hispanic/Latino: 1.7%
American Indian/Alaska
Native: 0.3%
2000White, not Hispanic: 86.5%
Black/African American: 8.3%
Asian/Pacific Islander: 1.0%
Hispanic/Latino: 3.6%
American Indian/Alaska
Native: 0.7%
Life Expectancy at Birth, 1900-1998
20
30
40
50
60
70
80
1980
YearsWhite
Black
0
SOURCE: CDC/NCHS, National Vital Statistics Systems, 1900-98
19981900 1950
47.6
33.0
71.3
77.3
Infant Mortality Rates, 1980-1998
0
5
10
15
20
25
1980 1985 1990 1995 1998
White
Black
Deaths <1 year/1000 live births
10.9
6.0
22.2
14.3
SOURCE: CDC/NCHS, National Vital Statistics System, 1980-1998
Infant mortality rates by race and Hispanic origin of mother
5.3
14.3
6.3
6.3
0 4 8 12 16
Total Hispanic
Non-Hispanic white
Non-HispanicblackAsian/Pacific Islander
Deaths <1 year per 1000 live birthsSOURCE: CDC/NCHS, National Vital
Statistics System, 1995
Infant mortality rates by Hispanic origin of mother
5.3
5.3
8.9
6.0
6.3
0 2 4 6 8 10
Total HispanicMexican
Puerto Rican
Cuban
Central/South
American
Deaths <1 year per 1000 live births
SOURCE: CDC/NCHS, National Vital Statistics Systems, 1995
Infant mortality rates by Asian/PacificIslander subgroup
5.6
6.6
5.3
3.8
5.3
0 1 2 3 4 5 6 7
Asian/Pacific Islander
Chinese
Japanese
Hawaiian
Filipino
Deaths <1 year per 1000 live birthsSOURCE: CDC/NCHS, National Vital Statistics Systems, 1995
Coronary heart disease death rates
78.1
81.2
63.1
151.3
111.4
72.7
74.5
56.7
102.1
140.4
0 50 100 150 200
1990
1996
Per 100,000 populationNOTE: Death rates are age-adjusted to 1940 standard million age distribution. A/PI is Asian American or Pacific Islander; AI/AN is American Indian or Alaska Native. SOURCE: CDC/NCHS, National Vital Statistics System, 1990 and 1996
White
Black
A/PI
AI/AN
Hispanic
Racial and Ethnic Disparities: Morbidity and Mortality
• African American men have a 40 percent higher heart disease rate than White men
• Women of Vietnamese origin in the United States suffer from cervical cancer at nearly five times the rate than White women
• Native Americans have a diabetes rate that is nearly three times the rate of Whites. The Hispanic rate is nearly double that of Whites
• African American women are 28% more likely to die from breast cancer, although the incidence is greater in White women
Racial and Ethnic Disparities: Morbidity and Mortality
How Do We Explain Racial And Ethnic
Disparities In Health?
Several Causal Factors
• Socioeconomic status (SES)
• Health risk behaviors
• Psycho-social factors
• Acculturation
• Biologic/Genetic factors
• Health care
Socioeconomic Status
•Education
•Occupation
•Income
•Environment
•Culture
14.8
10.0
6.5
13.9
11.6
5.0
10.4
4.1
0
5
10
15
NHW=Non-Hispanic White NHB=Non-Hispanic Black
<12 12 13-15 16+
Infant Mortality Rates in the United States
Deaths/1000 Live births
SOURCE: CDC/NCHS/NVSS
Education in years
Health Risk Behaviors
31.9
1.7
16.3
27.9
1.2
21.2
39.1
1.8
23.4
0 10 20 30 40 50
>1 oz. alcoholper day
Current smokers
Regular exercise
or sports
SOURCE: CDC/NCHS, National Health Interview Survey, 1990
White
BlackHispanic
FemaleHealth Risk Behaviors
percentage engaging in activity
Health Risk BehaviorsMale
38.4
8.8
30.9
42.2
8.2
32.5
44.1
10.1
28.0
0 10 20 30 40 50
Current smokers
>1 oz. alcoholper dayRegular
exercise or sports
White
BlackHispanic
percentage engaging in activity
SOURCE: CDC/NCHS, National Health Interview Survey, 1990
Age-adjusted Prevalence of Obesity (BMI 30.0)
25.4
30.0
14.8
43.2
37.4
22.4
0 10 20 30 40 50
Non-Hispanic
Blacks
Non-Hispanic
Whites
Mexican Americans
SOURCE: CDC/NCHS, Second National Health and Nutrition Examination Survey, 1976-80 Third National Health and Nutrition Examination Survey, 1988-94
Percent
Female
NHANES III
NHANES II
>
Age-Adjusted Prevalence of Obesity (BMI 30.0)
Male
23.1
21.3
20.0
15.4
15.0
12.0
0 5 10 15 20 25
Non-Hispanic
WhitesNon-
Hispanic Blacks
Mexican Americans
SOURCE: CDC/NCHS, Second National Health and Nutrition Examination Survey, 1976-80 Third National Health and Nutrition Examination Survey, 1988-94
NHANES II NHANES
III
Percent
>
Psychosocial Factors
Psychosocial Factors
• Large complex literature relating factors such as stress and discrimination with racial/ethnic differences in hypertension
Acculturation
Acculturation
Some health behaviors “worsen” with acculturation
Biological and Genetic Factors
Health Care
Percentage Uninsured Under Age 18United States
21.0 20.0
30.0
05
10
1520253035
404550
White Black Hispanic
Per
cen
t o
f P
op
ula
tio
n
Source: CPS, USCB
Health Care Coverage of Persons Under 65 (Age-adjusted)
18.05
19
15
35
15.0
25.0
5.0
65.4
55
80
25.055
0 20 40 60 80
NH White
All Hispanic
NH Black
SOURCE: CDC/NCHS, National Health Interview Survey, 1996
PrivateMedicaid/Public Assistance
Not covered
Percent
Asian/PI
Health CareExtensive evidence of racial and/or ethnicDifferences in utilization of health care
• Diagnostic tests and procedures• Therapeutic procedures• Intensity of care• Pain control• Transplants• Preventive services
Possible Explanations for the Racial and Ethnic Differences in Utilization
• Socioeconomic status
• Language
• Insurance status
• Severity of illness
• Patient health behaviors
• Provider bias
IOM Report Findings
Racial and ethnic disparities in healthcare exist and, because they are associated with worse outcomes in many cases, are unacceptable.
Factors contributing to racial and
ethnic disparities in healthcare:• Health systems• Healthcare providers• Patients and utilization managers• Bias, stereotyping, prejudices• Clinical uncertainty on the health of
care providers
IOM ReportFindings
IOM ReportRecommendations
• Increase awareness of racial and ethnic disparities among the general public, key stakeholders, and healthcare providers
• Legal, regulatory, and policy interventions
• Health systems interventions
Factors Influencing Optimal Medical Care
• Effective patient-physician communication• Overcoming cultural and linguistic barriers• Access to affordable health insurance• Alternatives to hospital emergency rooms• Improvement in continuity of care• Improving information for patients• Participate in the latest quality
improvement innovations
Of all the forms of inequality, injustice in health is the most shocking and the most inhumane.
-- Dr. Martin Luther King, Jr.