Transcript Racial and Ethnic Disparities in Women’s Health

Achieving Equity in
Women’s Health
New York Hospital Queens
4/26/10
Raymond L. Cox, MD, MBA
Educational Objectives
At the end of this presentation the learner will
be able to:
Determine how healthcare system inequities
impact health inequity
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Discern how physician and patient bias
influences clinical decision-making
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Give at least 3 solutions for reducing disparities
in Women’s Health
Health Equity
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Improving average health of countries
Abolishing avoidable inequalities in health
within countries
- WHO
Equity is the absence of socially unjust or
unfair practices in access to services,
quality of services, and health and mental
outcomes
If the infant mortality rate in
Iceland were applied to the
whole world, only two
babies would die in every
1000 births; there would be
6.6 million fewer infant
deaths annually - WHO
“ If black VLBW infants had been
born in the same proportions in the
same hospitals in New York City as
white VLBW infants, then
black/white disparity in VLBW
neonatal mortality rates would be
reduced by 34.5%” –
Howell et al- Pediatrics 3/08
65% of African-Americans and
58% of Hispanics (compared to
22%of whites) were afraid of
being treated unfairly when
accessing health care services
Kaiser Family Foundation
“Our leadership understands that
we cannot improve quality without
improving equity, and we have
engaged in a process of building
the systems and interventions
necessary to make this a reality”
Peter Slavin, MD
President
Massachussetts General Hospital
Equity is achieved by providing care
that does not vary in quality by
personal characteristics such as
ethnicity, gender, geographic
location, and socioeconomic status
The Disparities Solutions Center at
Mass. General Hospital
Social Determinants of Health
National Women’s Law Center
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“Making the Grade on Women’s Health: A
National and State-by-State Report Card”10/07
US fails to meet 12 of 27 benchmarks
designated by Healthy People 2010
No state received a satisfactory grade
18% of women aged 18-64 are uninsuredno improvement since 2004
“Affordability Gap”
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Women more likely to have lower incomes
Less likely to have employer-based
coverage
Use more health services
Have higher out-of-pocket costs
More likely to avoid needed health
services
Health Care System
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Health care is not a right of citizenship
Ultimate goal of health care system –
maximize profits
Lack of access to uninsured and
underinsured.
Geographic access - less in poorer areas
Gender inequality- uninsured women have
more difficulty getting health care than
uninsured men Lambrew 2001. In 2004, >14% of
women were uninsured
Census Bureau 2005
“I think the three major
arguments for addressing
disparities are the quality
argument, the caring argument,
and the financial argument”
William Fulkerson, MD
CEO, Duke University Hospital
Disparities impact quality
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Minorities more likely to be re-admitted,
especially for chronic conditions such as
CHF
Increased risk of hospitalization for
ambulatory care sensitive chronic
conditions such as asthma, diabetes
Joint Commission, National Quality Forum
have developed quality measures on
disparities, cultural competence
Disparities impact safety
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Patients with LEP, health literacy issues,
as well as minorities are more likely to
suffer adverse events, with greater clinical
consequences
LEP-Longer ER wait time
Delay in definitive breast cancer surgery
Disparities impact cost
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Health care providers tend to order more
expensive tests for conditions that could
have been diagnosed through basic
history-taking
LEP patients have longer hospital stays
Pay-for-performance, “Never-events”
Community benefit
Disparities impact risk
management
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Communication problems due to language
barriers, cultural differences and low
health literacy are the most frequent
cause of serious adverse events
Multiple liability exposures such as patient
misunderstanding of medical condition,
treatment plan, discharge instructions
Improper preparation for tests, procedures
Poor or inadequate informed consent
Claims vs. Events
Claims
Events
16%
16% of claims based on
preventable adverse events
The Core Paradox
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How could well-meaning and highlyeducated professionals, working in their
usual circumstances with diverse
populations of patients, create a pattern of
care that appears to be discriminatory?
“Addressing cultural and linguistic
barriers is about saving lives. Any
progressive leader can understand
that communicating effectively with
patients is essential to making
healthcare delivery safer. The issue
of disparities needs to be embedded
in safety policies and procedures”
Pete Delgado, CEO, LA County
Teamwork Requires Non-Negotiable
Mutual Respect
- R. Gardner, MD
Cultural Competence
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Knowledge, skills and attitude required to
provide quality clinical care to patients
from different cultural, ethnic and racial
backgrounds
Delivery of healthcare services is tailored
to meet patient’s social, cultural and
linguistic needs
Activities have included:
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Development of a strategic plan to address
disparities,
Standardized collection of patient’s race and
ethnicity,
Stratification of quality measures by race and
ethnicity,
Development of quality measurement tools to
monitor for disparities,
Development and expansion of interpreter
services
Disparities Solution Structure,
Process
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Disparities committee
Needs assessment
Collect patient race/ethnicity data
Create a “disparities dashboard”
Evaluate pilot studies
Embed successful practices into standard
programs of care
Potential Resource Needs
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Culturally-competent disease management
models
Bilingual health coaches
Patient navigators
Community outreach programs
Several hospitals have
distinguished themselves as leaders
in efforts to improve quality, address
disparities and achieve equity
Overview of Birth Outcomes in New York State
Table 1- States with the Lowest African-American Infant Mortality Rates,
by percent and number of African-American (A-A) Births
States
1. Oregon
2. Minnesota
3. Washington
4. Massachusetts
5. Rhode Island
6. Kentucky
7. Iowa
8. Arizona
9. California
10. New York
A-A IMR
(2003-05)
8.58
8.86
8.96
10.02
10.80
10.92
10.97
11.22
11.40
11.77
Percent
A-A Births (2007)
2.3%
8.9
16.9
4.2
9.3
8.4
9.1
4.4
3.8
5.6
Number
A-A Births (2007)
1,145
6,615
42,738
3,812
7,262
1,045
5,418
1,804
6,700
31,777
source: Mathews TJ and Mac Dorman, MF, Infant Mortality statistics from the 2003-2005 period linked
Regulating Cultural Competence
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The Joint Commission
National Quality Forum
State licensure- NJ, Calif., Md., Ohio?, NY?
Successful Change Strategy
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Create Burning Platform
Engage Leadership
Borrow Shamelessly
Establish Non-Negotiable Mutual Respect
Practice Relentless Persistence
Create Ongoing Opportunity for Discussion
Constantly Measure and Adjust
Summary
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Equity is a key component of quality; addressing
disparities will help achieve this goal
Failure to address equity and disparities has
significant implications for quality, safety, cost,
risk management, and soon may affect
accreditation
There are hospitals and healthcare leaders
around the country engaged in this work
There are a basic set of activities that can help
physician leaders initiate an agenda for action to
achieve equity