1. Health Disparities From knowledge to action

2. Overview of Disparities Ethnicity Socioeconomic Status Geographic location

3. Overview of Disparities Minority Americans report widespread patient-physician communication differences Minority Americans report widespread patient-physician communication differences Minority Americans are more likely to feel treated with disrespect when obtaining health care Minority Americans are more likely to feel treated with disrespect when obtaining health care Though the gap is closing disparities persist in satisfaction with primary and secondary care Though the gap is closing disparities persist in satisfaction with primary and secondary care

4. Overview of Disparities From : Unequal Treatment; Confronting Racial and Ethnic Disparities in Health care – IOM 2003

5. Overview of Disparities Minority Americans have worse health status and more chronic conditions Minority Americans have worse health status and more chronic conditions Minority Americans have lower rates of insurances coverage and less access to care Minority Americans have lower rates of insurances coverage and less access to care

6. Overview of Disparities Disparities are found across a range of clinical settings, including public and private hospitals, teaching and non-teaching hospitals, etc. Disparities are found across a range of clinical settings, including public and private hospitals, teaching and non-teaching hospitals, etc. Disparities in care are associated with higher mortality among minorities (e.g., Bach et al., 1999; Peterson et al., 1997; Bennett et al., 1995) Disparities in care are associated with higher mortality among minorities (e.g., Bach et al., 1999; Peterson et al., 1997; Bennett et al., 1995)

7. Overview of Disparities Disparities consistently found across a wide range of disease areas and clinical services Disparities consistently found across a wide range of disease areas and clinical services Disparities are found even when clinical factors, such as stage of disease presentation, co-morbidities, age, and severity of disease are taken into account Disparities are found even when clinical factors, such as stage of disease presentation, co-morbidities, age, and severity of disease are taken into account

8. Potential sources of healthcare disparities Health systems-level factors – financing, structure of care; cultural and linguistic barriers. Health systems-level factors – financing, structure of care; cultural and linguistic barriers. Patient-level factors – including patient preferences, refusal of treatment, poor adherence, biological differences. Patient-level factors – including patient preferences, refusal of treatment, poor adherence, biological differences. Disparities arising from the clinical encounter. Disparities arising from the clinical encounter.

9. Causes of Death (2000) USA Rank White White African American Hispanic 1CardiovascularCardiovascularCardiovascular 2CancerCancerCancer 3CerebrovascularCerebrovascular Unintentional Injury 4COPD Cerebrovascular 5 Unintentional injury DiabetesDiabetes 6PneumoniaHomicide Chronic liver disease 7DiabetesHIV/AIDSHomicide

10. Mortality Rates* (All causes) 2000 AllWhite African American Asian American Hispanic US870.4849.81126.6516.5670.1 Southern US 884.7838.71138.4435.3603.5 Georgia965.7915.31148.6530.8441.6 From National Center for Health Statistics * - rates reported per 100,000 individuals

11. Cardiovascular/Cerebrovascular Leading cause of death in African American men (33.5%) and women (40.6%) Leading cause of death in African American men (33.5%) and women (40.6%) More than twice as likely to die from hypertensive heart disease More than twice as likely to die from hypertensive heart disease Prevalence of high blood pressure one of the highest in the world ( worse in the southeastern US) Prevalence of high blood pressure one of the highest in the world ( worse in the southeastern US) 45% have blood cholesterol levels of > 200 mg/dl 45% have blood cholesterol levels of > 200 mg/dl 36%of African Americans have hypertension African Americans at greater risk than whites for death from both Two to three times greater risk to have an ischemic stroke Higher death rates from stroke Americans

12. Diabetes 2.7 million or 11.4% of all African Americans more than twenty years old have DM. 2.7 million or 11.4% of all African Americans more than twenty years old have DM. African Americans and Hispanics are twice as likely to have DM than non-Hispanic whites. African Americans and Hispanics are twice as likely to have DM than non-Hispanic whites. There is twice the risk of developing heart disease and stroke. There is twice the risk of developing heart disease and stroke. 2 to 4 times the risk of dying from heart disease. 2 to 4 times the risk of dying from heart disease. One in every four African American women over 55 years has DM. One in every four African American women over 55 years has DM.

13. HIV/AIDS Problem of EPIDEMIC proportion. Problem of EPIDEMIC proportion. African Americans accounted for half of the new cases in 2001. African Americans accounted for half of the new cases in 2001. More than 168,000 African Americans died of AIDS in 2001. Leading cause of death in African American men aged 35-44. More than 168,000 African Americans died of AIDS in 2001. Leading cause of death in African American men aged 35-44. Approximately 78% of HIV infected women are minorities. Approximately 78% of HIV infected women are minorities. African-American and Hispanic children accounted for more than 80% of pediatric AIDS cases in 2000. African-American and Hispanic children accounted for more than 80% of pediatric AIDS cases in 2000.

14. Aids Infection by Gender and Race Females Males 64% 17% 43% 35% 20%

15. Cancer Death Rates, by Race and Ethnicity, 1996-2000 *Per 100,000, age-adjusted to the 2000 US standard population. † Hispanic is not mutually exclusive from whites, African Americans, Asian/Pacific Islanders, and American Indians. Source: Surveillance, Epidemiology, and End Results Program, 1975-2000, Division of Cancer Control and Population Sciences, National Cancer Institute, 2003.

16. All sites 356.2 249.5 1.4 All sites 356.2 249.5 1.4 Larynx 5.7 2.4 2.4 Larynx 5.7 2.4 2.4 Prostate 73.0 30.2 2.4 Prostate 73.0 30.2 2.4 Stomach 14.0 6.1 2.3 Stomach 14.0 6.1 2.3 Myeloma 9.2 4.5 2.0 Myeloma 9.2 4.5 2.0 Oral cavity and pharynx 7.9 4.0 2.0 Oral cavity and pharynx 7.9 4.0 2.0 Esophagus 12.2 7.3 1.7 Esophagus 12.2 7.3 1.7 Liver 9.3 6.0 1.6 Liver 9.3 6.0 1.6 Lung & bronchus 107.0 78.1 1.4 Lung & bronchus 107.0 78.1 1.4 Pancreas 16.4 12.0 1.4 Pancreas 16.4 12.0 1.4 Small intestine 0.7 0.5 1.4 Small intestine 0.7 0.5 1.4 Colon & rectum 34.6 25.3 1.4 Colon & rectum 34.6 25.3 1.4 Cancer Sites in Which African-American Death Rates Exceed White Death Rates for Men, US, 1996-2000 *Per 100,000, age-adjusted to the 2000 US standard population. Source: Surveillance, Epidemiology, and End Results Program, 1975-2000, Division of Cancer Control and Population Sciences, National Cancer Institute, 2003. Site African American White Ratio of African American/White

17. Cancer Survival*(%) by Site and Race,1992-1999 Cancer Survival*(%) by Site and Race,1992-1999 *5-year relative survival rates based on cancer patients diagnosed from 1992 to 1999 and followed through 2000. Source: Surveillance, Epidemiology, and End Results Program, 1975-2000, Division of Cancer Control and Population Sciences, National Cancer Institute, 2003. All Sites645311 Breast (female)887414 Colon & rectum635310 Esophagus15 9 6 Leukemia4839 9 Non-Hodgkin lymphoma574710 Oral cavity603624 Prostate9993 6 Urinary bladder836419 Uterine cervix736112 Uterine corpus866026 Site White% Difference African American

18. Causes of Death in African Americans (2000) - Georgia

19. Health Status in Georgia

20. Disparities in Georgia Outcomes in Georgia Outcomes in Georgia Infant mortality rates in African Americans is more than twice that in Whites. Infant mortality rates in African Americans is more than twice that in Whites. Prostate Cancer death rates are > 50% higher in African Americans. Prostate Cancer death rates are > 50% higher in African Americans. African Americans are more than twice as likely to die from Hypertensive Heart Disease. African Americans are more than twice as likely to die from Hypertensive Heart Disease. Hispanics are twice as likely to die from Diabetes than whites. Hispanics are twice as likely to die from Diabetes than whites. From: Georgia Division of Public Health; Vital Statistics 2001

21. Disparities in Georgia Coverage in Georgia Coverage in Georgia More likely to use emergency room as main source of medical care. More likely to use emergency room as main source of medical care. 4 to 5 times less likely to have had BP check in last 2yrs. 4 to 5 times less likely to have had BP check in last 2yrs. 3 to 4 times less likely to have had a mammogram in last 2yrs. 3 to 4 times less likely to have had a mammogram in last 2yrs. Children 2 times less likely to have seen a doctor in last 2 years. Children 2 times less likely to have seen a doctor in last 2 years.

22. Uninsured by Ethnicity (2002) - GA. 11%6.8% 20.3%13.8% From : Georgia Healthcare Coverage Project ( Custer & Ketsche 2003)

23. Uninsured by Ethnicity (2002) - USA 18.2% 10.7% 20.2% 32.4%

24. Uninsured by race and income From : Georgia Healthcare Coverage Project ( Custer & Ketsche 2003)

25. I.O.M Report “In unassailable terms, the report found that even when their insurance and income are the same as those of whites, minorities often receive fewer tests and less sophisticated treatment for a panoply of ailments, including heart disease, cancer, diabetes and HIV/AIDS. By stripping away the pretense that the differences can be explained by minorities' lack of access to timely care, the report should spur doctors and patients to question why racial disparities are tolerated in medicine.” USA Today, March 22 “Racial Bias in Health Care”

26. I.O.M. Recommendations Policy & Regulatory Policy & Regulatory Avoid fragmentation of health plans along socioeconomic lines. Avoid fragmentation of health plans along socioeconomic lines. Strengthen the stability of patient-provider relationships in publicly funded health plans. Strengthen the stability of patient-provider relationships in publicly funded health plans. Increase the proportion of under-represented US racial and ethnic minorities among health professionals. Increase the proportion of under-represented US racial and ethnic minorities among health professionals. From : Unequal Treatment; Confronting Racial and Ethnic Disparities in Health care – IOM 2003

27. I.O.M. Recommendations Policy & Regulatory Policy & Regulatory Apply the same managed care protections to publicly funded HMO enrollees that apply to private HMO enrollees. Apply the same managed care protections to publicly funded HMO enrollees that apply to private HMO enrollees. Provide greater resources for the DHHS Office for Civil Rights to enforce civil rights laws. Provide greater resources for the DHHS Office for Civil Rights to enforce civil rights laws. From : Unequal treatment; Confronting Racial and Ethnic Disparities in Health care – IOM 2003

28. I.O.M. Recommendations Health Systems Health Systems Promote the consistency and equity of care through use of evidence based guidelines. Promote the consistency and equity of care through use of evidence based guidelines. Structure payment systems to ensure adequate supply of services to minority patients and limit provider incentives that promote disparities. Structure payment systems to ensure adequate supply of services to minority patients and limit provider incentives that promote disparities. Enhance patient-provider communications and trust by providing financial incentives for practices that decrease barriers and encourage evidence based practices. Enhance patient-provider communications and trust by providing financial incentives for practices that decrease barriers and encourage evidence based practices. From : Unequal treatment; Confronting Racial and Ethnic Disparities in Health care – IOM 2003

29. I.O.M. Recommendations Health System Health System Support the use of interpretation services where community need exists. Support the use of interpretation services where community need exists. Support the use of community health workers Support the use of community health workers Implement multi-disciplinary treatment and preventive care teams. Implement multi-disciplinary treatment and preventive care teams. From : Unequal treatment; Confronting Racial and Ethnic Disparities in Health care – IOM 2003

30. I.O.M. Recommendations Education Education Implement patient education programs to increase patient’s knowledge of how to best access care and participate in treatment decisions. Implement patient education programs to increase patient’s knowledge of how to best access care and participate in treatment decisions. Integrate cross cultural education into the training of all current and future health professionals. Integrate cross cultural education into the training of all current and future health professionals. From : Unequal treatment; Confronting Racial and Ethnic Disparities in Health care – IOM 2003

31. Federal Action DHHS Initiative to Eliminate Racial and Ethnic Disparities in Health DHHS Initiative to Eliminate Racial and Ethnic Disparities in Health NIH Strategic Research Plan to Reduce and Ultimately Eliminate Health Disparities NIH Strategic Research Plan to Reduce and Ultimately Eliminate Health Disparities NLM Strategic Plan to Reduce Racial and Ethnic Disparities NLM Strategic Plan to Reduce Racial and Ethnic Disparities Healthy People 2010 Healthy People 2010 100% access, Zero Disparities - BPHC 100% access, Zero Disparities - BPHC

32. Community Action Hispanic Health Care Outreach Hispanic Health Care Outreach North West Georgia Healthcare Partnership Vision North West Georgia Healthcare Partnership Vision “Promotora” – Community health worker “Promotora” – Community health worker Improved access Improved access Focus on Men's Health Focus on Men's Health Network of South-central counties Network of South-central counties Screening ( PSA, Cholesterol and BP) Screening ( PSA, Cholesterol and BP) Early detection Early detection

33. Knowledge is Key Action is Power