From Diabetes Disparities to Diabetes

Health Equity

George Rust, MD, MPH, FAAFP, FACPM Father of Dan & Christina, Husband of Cindy,

Professor of Family MedicineDirector, National Center for Primary Care

National Center for Primary Care at Morehouse School of Medicine

Health Disparities

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

-- Martin Luther King, Jr.

Disparities in Prevalence

Ma Y et al. All-Cause, Cardiovascular, and Cancer Mortality Rates in Postmenopausal White, Black, Hispanic, and Asian Women With and Without Diabetes in the United States: The Women's Health Initiative, 1993–2009 Am. J. Epidemiol. (2013) 178 (10): 1533-1541 online September 17, 2013

Disparities in Treatment Effectiveness

Primary Care Community Health Centers Impact on Uninsured ED Visits

0

200

400

600

800

1000

1200

1400

1600

1800

Rate per 100,000

uninsured

Rates of ED Visits Among the Uninsured

in Counties with and without a CHC

CHC

No CHC

31% Excess

62% Excess

No CHC = 37% Excess ED Visits

Disparities in Hospitalizations

Adult admissions for uncontrolled diabetes without complications per 100,000 population by race/ethnicity, 2001. http://archive.ahrq.gov/qual/nhdr04/fullreport/RQual.htm

Racial-ethnic Disparities and

Rural-Urban Differences

Excess Cost Due to Racial Variation in Hospital Admissions by Disease

(mid-range estimate)

Excess Hospital Admissions(mid-range)

Hospital Charges Attributable to Excess Hospital Admissions (mid-range)

Payer Costs Attributable to Excess Hospital Admissions (mid-range)

Asthma 2,044 $28,687,330 $13,339,608.45

Diabetes 3,955 $92,172,057 $42,860,006.51

Heart Disease 5,021 $187,289,234 $87,089,493.81 >Coronary

Artery Disease 1,287 $65,156,724 $30,297,876.66

>Congestive Heart Failure 5,868 $162,561,372 $75,591,037.98

HIV 1,644 $76,784,134 $35,704,622.31

$

Geographic Disparities

Disparities in Death Rates

Drivers of Health Disparities

Health Potential

Health Potential

Food, Water, Housing, & Health Behaviors

Social

Determ

inants

Access to Care

Adoption S-Curve

Isolated or disenfranchised or non-majority cultural groups

Triangulating on Success to Improve America’s Health

Diabetes Health Equity

• Equality in Risk • Equality in Pre-Disposing Conditions• Equality in Prevalence • Equality in Treatment• Equality in Self-Management• Equality in Complication Rates• Equality in Adverse Outcomes• Equality in Survival

Is Equality the Same as Equity?

Equity = Equality

+ Fairness

Does Equal Treatment Mean Treating Everyone the Same?

Encouraging an hour a day of physical activity for children is different in a high-crime, resource-constrained urban neighborhood than it is in a wealthy upper-income neighborhood with lots of safe playgrounds.

Does Equal Treatment Mean Treating Everyone the Same?

• Providing linguistically-appropriate services for immigrants and linguistically-isolated families takes more conscious effort and resources than it does for English-language families.

Holding Ourselves Accountable to Achieve Equality in Outcomes

• Community Level Metrics • Mortality• Hospital Bed-Days• Preventable Adverse Events (e.g., amputations)

• Practice-Level Data• ED Visits• Hospital Bed-Days

• Person-Level Feedback• Missed refills• Inadequate Care• ED Visit yesterday!

29 babies saved!!!29 babies saved!!!

Disparities are not Inevitable!Disparities are not Inevitable!

Decline represents 29 infant deaths prevented (expected vs. actual)

Emergency Emergency RoomRoom

Primary Primary CareCare

Mental Mental Health Health

Business & Business & Community Community

Leaders Leaders

HospitalsHospitals Faith Faith CommunitiesCommunities

Cohesive, Comprehensive, Integrated Local Health Systems

Tying it All Together to Achieve Optimal, Equitable Health Outcomes

• Patient-Centered Primary Care Home

• Chronic Disease Care Management

• Integrated Behavioral Health

• Built on Community Strengths & Partnerships

• Consistently High Quality Care

• Optimal Outcomes

Humility in Working Together

“We are all as angels, with only one wing;

We can only fly when we embrace each other.

-- Luciano de Crescenzo