Annual Report on Healthcare Quality and Disparities

In July, the Agency for Healthcare Research and Quality (AHRQ) posted the 2016 National Healthcare Quality and Disparities Report on its website. Mandated by Congress, this annual report “provides a comprehensive overview of the quality of healthcare received by the general US population and disparities in care experienced by different racial and socioeconomic groups.”  Based on over 250 quality measures, the report covers a wide range of healthcare services and settings. The key findings from the report were:

Access: While most access measures (65%) tracked in this report did not demonstrate significant improvement (2000-2014), uninsurance rates (measured as uninsured at the time of interview) decreased from 2010 to 2016.

Quality: Quality of health care improved overall from 2000 through 2014-2015 but the pace of improvement varied by priority area:

  • Person-Centered Care: About 80% of person-centered care measures improved overall.
  • Patient Safety: Almost two-thirds of patient safety measures improved overall.
  • Healthy Living: About 60% of healthy living measures improved overall.
  • Effective Treatment: More than half of effective treatment measures improved overall.
  • Care Coordination: About half of care coordination measures improved overall.
  • Care Affordability: About 70% of care affordability measures did not change overall.  

Disparities: Overall, some disparities were getting smaller from 2000 through 2014-2015, but disparities persist, especially for poor and uninsured populations in all priority areas:

  • While 20% of measures show disparities getting smaller for Blacks and Hispanics, most disparities have not changed significantly for any racial and ethnic groups.
  • More than half of measures show that poor and low-income households have worse care than high-income households; for middle-income households, more than 40% of measures show worse care than high-income households.
  • Nearly two-thirds of measures show that uninsured people had worse care than privately insured people.

See the table of contents and description of the report.

Download the full report.

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Talking about Health Equity

Recently, the Health Policy Research Consortium create a YouTube Series, Conversations on Health Equity,  exploring health equity with leading experts. Available videos include

 

Useful Resource: Behavioral Health Equity

The Office of Behavioral Health Equity of the Substance Abuse and Mental Health Services Administration (SAMHSA) provides resources to address disparities related to mental health and/or substance use disorders in various populations. Available resources include: Data, Reports and Issue Briefs; SAMHSA Programs and Initiatives; SAMHSA Behavioral Health and In-Language Resources; and  Federal Initiatives and Resources. Items are organized by minority group:

Visit the Office of Behavioral Health Equity website to learn more.

Racial Differences in Outcomes Demand Greater Vigilance

The following excerpt comes from the July 17, 2017, article by Ada Stewart on the Leader Voices Blog: A Forum for AAFP Leaders and Members.


My father didn’t have a documented history of heart disease. He was never diagnosed as having hypertension, diabetes or other conditions that would have alerted us to the fact that he was at risk. So it was a shock — and one of the events that led me to the field of medicine — when he died of a massive heart attack at age 59.  

Unfortunately, his story isn’t unique.

It’s well documented that blacks are more likely than whites to suffer from an array of health conditions, including asthma, diabetes, hypertension and lung cancer. However, a study published this month in Circulation makes it clear just how different the outcomes are for black men compared with those for their white peers. Black men ages 45-64 (like my father) are twice as likely to die from a first heart attack.

My father lacked health insurance, so he rarely sought care and missed opportunities for discussions about risk factors and prevention, blood pressure and cholesterol screenings, as well as potentially life-saving treatment that may have resulted from such visits.

It’s a familiar story. One of the study’s authors said in an interview that “racial and institutional discrimination” and a lack of access to care are major factors in the wide difference in outcomes. In fact, researchers found that black patients actually have a lower risk for nonfatal cardiac events, but that lack of access to care means that too many black patients aren’t properly diagnosed with a heart condition until it’s too late.

Researchers said blacks have a higher burden of unfavorable social determinants of health,  and access to care is only one such factor. Others include limited access to nutritious food, social stressors, poor neighborhood safety and lack of recreational facilities.

Education and health literacy also are social determinants of health, and researchers said lack of patient awareness is a potential issue that should be considered regarding this issue. Although most patients likely would recognize that severe chest pain is a symptom of a heart attack, they might be less likely to recognize milder symptoms that could be cause to seek care.

So what can family physicians do? We can make sure our at-risk patients who do seek our care understand the symptoms of a heart attack and know when they need to seek treatment. We also can talk to them about exercise, nutrition, tobacco cessation and other prevention efforts, as well as the importance of follow-up when they are being treated for conditions such as hypertension and diabetes.

Read the full article.

The Health Care System Is Leaving The Southern Black Belt Behind

The following excerpt comes from an article by Anna Maria Barry-Jester on FiveThrityEight.

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Sitting outside of a Starbucks on the corner of a strip mall in Tuscaloosa late last year, Dr. Remona Peterson described her hometown of Thomaston, Alabama, population 400. “Everybody loves our grocery store. That’s, like, our pride,” she said with a laugh. She was in Tuscaloosa, Alabama’s fifth-largest city, finishing her medical residency when Dave’s Market opened in an old Thomaston high school gym last year. Peterson said it became the only place to buy groceries for miles in any direction, and it was one of the few changes to the town she can remember from the last three decades.

Peterson wants to be a part of positive change in the region, which is why she’s back after a circuitous journey through medical school. She was valedictorian of her 29-person high school class and graduated summa cum laude from Tuskegee University, where she earned a full scholarship and the university’s distinguished scholars award. She went on to medical school and got the residency in Tuscaloosa. It was her first choice; she felt that the University of Alabama would best prepare her for her long-term goal: to add her name to the short list of African-American doctors working in the Alabama Black Belt who were also born and raised there.

The Black Belt refers to a stretch of land in the U.S. South whose fertile soil drew white colonists and plantation owners centuries ago. After hundreds of thousands of people were forced there as slaves, the region became the center of rural, black America. Today, the name describes predominantly rural counties where a large share of the population is African-American. The area is one of the most persistently poor in the country, and residents have some of the most limited economic prospects. Life expectancies are among the shortest in the U.S., and poor health outcomes are common. This article is part of a series examining these disparities.

The disparities partly stem from a lack of access to care — but access is a complicated notion. Early in the Republican efforts to repeal and replace the Affordable Care Act, the GOP homed in on the idea, saying the party wanted to guarantee “access to health care” for everyone. But the ongoing national policy conversation has hinged on insurance coverage, the main issue tackled by both the Affordable Care Act and the current GOP efforts. Yes, measuring who’s insured illuminates one way by which people have access to the health care system, but it’s only part of the picture. The term “access to health care” has a standardized federal definition that’s much broader: “the timely use of personal health services to achieve the best health outcomes.” And there’s a list of metrics to measure it. Researchers consider structural barriers, such as distance to a hospital or how many health professionals work in an area, to be important. As are metrics that gauge whether a patient can find a health care provider that she trusts and can communicate with well enough to get the services she needs.

Southern states have health outcomes that are among the worst in the U.S. overall, and they have some of the largest in-state health disparities, according to County Health Rankings, an annual report from the Robert Wood Johnson Foundation and the University of Wisconsin. Transportation options are limited, and health care worker shortages are routine. In Alabama, Black Belt counties have fewer primary care physicians, dentists and mental health providers per resident than other counties. They also tend to have the highest rates of uninsured people. Poverty rates, which are associated with limited access to care, are also high.

Read the full article.

Health Insurance Coverage, Doctor-Patient Relationship, and Health Care Utilization

A recent study published in Preventive Medicine Reports explored the effect of health insurance coverage and doctor-patient relationships on the likelihood that an individual would receive diagnostic tests for diabetes and cardiovascular disease. Using data collected from 230 participants in the Labor Market Health Care Survey (LMHCS), the study examined three questions:

  • How does health insurance affect the likelihood of having a regular health care provider?
  • How does health insurance coverage affect the likelihood of receiving tests for cardiovascular disease?
  • To what extent does having a regular health care health care provider mediate the effect of health insurance coverage on receiving the diagnostic tests?

The research team, led by Dr. Kenneth Hudson, the LMHCS was a multi-wave longitudinal study of adults 18 and older living in nine high-poverty census tracts in a county of approximately 400,000 residents. For the study, high poverty census tracts were defined as those where 50% of the households have incomes below the poverty threshold. Interview participants were selected through a two-stage random sample. To be included in the study, an individual had to be over 18 years of age. While data collection began in 2006, about 90% of the data in this study were collected since 2013. The research team interviewed participants every 2 to 3 years when they could be located. During interviews, participants provide information on their household composition, employment history, health status, health care utilization and income. Of the 230 participants in the study, about half were under the age of 40.

Analysis of the data included 3 dependent variables:

  • Whether or not participants have health insurance from any source
  • Whether or not the participant has a regular health care provider and knows their doctor’s name
  • Whether or not participants receive diagnostic tests for blood pressure, cholesterol levels and blood sugar levels.

In terms of health insurance coverage, only 12% of participants reported having coverage through an employer, 7% purchased coverage from the private market, and 5% had coverage through a family member. About ⅓ of participants had coverage through Medicare or Medicaid. The final ⅓ did not have any type of insurance coverage.

In relation to health care utilization, 45% of participants reported not having a regular provider. 17% reported having a regular health care provider but did not know their doctor’s name. The remaining 38% had a regular provider and could report the doctor’s name. Around half of the participants reported having cholesterol, blood sugar and blood pressure tests in the last 2 years.

Through the analysis, Dr. Hudson and his team found that participants with health insurance coverage were more likely to have had recent tests for diabetes and cardiovascular disease than those without coverage. However, they also found that having a regular health care provider mediates the effects of insurance coverage, especially when the participant could report the name of their doctor.

Read the full study.

Attitudes for Designing Population Health Interventions

In this video from AJMC.com,  Dr. Moon S. Chen, Jr., professor of hematology and oncology at UC Davis Comprehensive Cancer Center and principal investigator of The National Center for Reducing Asian American Cancer Health Disparities, responds to the question , “What are some important considerations in designing health interventions for minority populations?” As a part of his answer, Dr. Chen discusses the attitude of humility and the need to work with the community instead of on the community.

How med student loan burdens can deepen health disparities

The following article by Caleb Zimmerschied originally appeared on AMA Wire on April 27, 2017.


The high loan burden associated with medical school can discourage students from underrepresented minority groups or lower-income families from pursuing a career as a physician. This creates a ripple effect of widening health care disparities that disproportionately affect the accessibility of primary care physicians in underserved areas.

Adjusted for inflation, the average medical student graduated in 2014 with a loan burden 3.5 times greater than a medical student in 1978. By 2014, the average loan burden was over $170,000.

Higher interest rates and unsubsidized loans for graduate students mean that they pay off more per dollar owed than undergraduate students. The Association of American Medical Colleges (AAMC) estimates that, accounting for interest under the Pay As You Earn repayment program, a student with $180,000 in loan burdens could pay almost $380,000 in total repayment. During a three-year residency, the AAMC estimates that total repayment to reach nearly $450,000. This amount increases further if a student pursues a specialty care field.

Those kinds of figures may be enough to intimidate any bright student considering a career in medicine. But students in ethnic and racial minority groups that are underrepresented in medicine, and those from lower-income families, can be particularly daunted by the prospect of six-figure loan burdens. According to the most recent AAMC report, 18.2 percent of black high-school sophomores said they aspired to apply to medical school, but only 6.7 percent actually applied. For Hispanic high-school sophomores, 24.4 percent said they wanted to go to medical school but only 6.8 percent applied.

According to 2014 AAMC data, while 13 percent of the U.S. population was black, they only made up 4.1 percent of the physician workforce. Hispanics accounted for 18 percent of Americans, but only 4.4 percent of the physician workforce. This in turn likely contributes to the lack of physicians making direct efforts to serve these communities. According to research published in JAMA, despite making up less than 30 percent of the physician workforce in 2013, physicians from underserved groups are significantly more likely to see nonwhite patients, and “nonwhite physicians cared for 53.5 percent of minority and 70.4 percent of non-English-speaking patients.”

Additionally, the cost of medical school likely deters applicants from lower-income rural communities as well. This could contribute to the fact that while 20 percent of Americans live in rural areas, only 10 percent of physicians practice where people in rural communities can access them. With a shortage of about 4,000 primary care physicians, 77 percent of rural U.S. counties are designated as health professional shortage areas.

Read full article

Segregated Living Linked To Higher Blood Pressure Among Blacks

The following article by Carmen Heredia Rodriguez originally appeared on Kaiser Health News.


For African-Americans, the isolation of living in a racially segregated neighborhood may lead to an important health issue: higher blood pressure.

A study published Monday in JAMA Internal Medicine suggested blacks living in such areas experienced higher blood pressure than those living in more diverse communities. Moving to integrated areas was associated with a decrease in blood pressure, and those who permanently stayed in localities with low segregation saw their pressure fall on average nearly 6 points.

Kiarri Kershaw, assistant professor of preventive medicine at Northwestern University in Chicago and lead author of the study, said the findings reinforce the close relationship between social policy and community health outcomes.

“It lends credence to the notion that we should bring public health practitioners and health policy officials to the table to make these decisions,” she said. Researchers used data from a long-term study that has followed 2,280 African-Americans over the course of 25 years, checking in every three to seven years to track blood pressure.

Heart disease is the leading cause of death in the United States, and African-Americans are disproportionately affected by the condition. According to the American Heart Association, 46 percent of non-Hispanic black men and nearly 48 percent of non-Hispanic black women live with a form of heart disease, while about 36 percent of non-Hispanic white men and 32 percent of non-Hispanic white women do.

Georges Benjamin, executive director of the American Public Health Association, said the burden to address such disparities falls on society at large.

“It doesn’t just hurt African-Americans or people of color. This hurts everybody,” he said. “Because everyone pays not just in terms of humanity, but in terms of dollars.”

Doctors generally record two numbers for blood pressure: the diastolic pressure — the blood’s force inside the veins when the heart is at rest — and the systolic pressure, which gauges the blood’s force when the heart beats. Blood pressure is measured in millimeters of mercury, or mmHg (using mercury’s chemical element symbol), with systolic pressure reported first, such as 115 mmHg over 75 mmHg.

Researchers found residential segregation was associated with changes in systolic blood pressure, which is tied to adverse cardiovascular events, such as a heart attack. The findings did not show any changes in diastolic blood pressure.

The scientists also collected data on a variety of other social indicators including level of education, poverty and marriage status. They ranked the level of segregation in participants’ neighborhoods as “low,” “medium” and “high” based on the number of African-Americans in the larger area.

When compared to African-Americans living in highly segregated locations, participants living in medium-segregation neighborhoods recorded blood pressure that was on average 1.33 mmHg lower. Those residing in low-segregation areas were an average 1.19 mmHg lower.

Blood pressure for black residents who permanently moved into medium segregation locations decreased on average 3.94 mmHg. African-Americans who stayed in low-segregation locales saw an average decrease of 5.71 mmHg.

Read the full article.

The Insidiousness of Unconscious Bias in Schools

From the article by Seth Gershnson and Thomas S. Dee at Brookings:

Humans frequently make automatic decisions at a subconscious level. The human brain’s capacity for reflexive decisionmaking is what Nobel Laureate Daniel Khaneman calls “System 1” (as opposed to the more analytical, thoughtful, deliberate decision making of “System 2”) in the best-selling “Thinking, Fast and Slow.” This evolutionary adaptation was, and is, sometimes necessary for survival. However, these automatic responses occur via the rapid processing of new information through existing patterns of thought. Thus, because our automatic responses are shaped by our lived experiences and the broader social contexts in which we live and work, a pervasive byproduct of reflexive decisionmaking is unconscious bias (UB), which is also referred to as implicit bias or implicit social cognition.

Specifically, UB is the phenomenon in which stereotypes, positive or negative, influence decisions and behaviors without the individual consciously acting on the stereotype or being aware that he or she is doing so. Moreover, UB can occur even when individuals know or believe the stereotype to be false.

The insidiousness of UB is that it can create self-fulfilling prophecies that create and perpetuate inequities between in- and out-groups, even when the initial stereotype was incorrect (and there was no pre-existing difference between in- and out-group members). This post outlines some promising interventions we identify in a recent report, commissioned by Google’s Computer Science Education Research Division, that can short-circuit the recursive processes and self-fulfilling prophecies triggered by UB.

In this report, we argue that the consequences of UB may be particularly salient in the hierarchical environments of schools. Specifically, UB likely perpetuates socio-economic, gender, and racial gaps in educational outcomes such as academic performance, engagement with school, course and major choice, and persistence in higher education, particularly among historically disadvantaged and underrepresented groups such as low-income and racial-minority students. These gaps in educational outcomes then manifest in corresponding workplace disparities in pay, promotions, and employment.

Indeed, there is ample evidence of UB in educational settings, both in experimental labs and “in the field” with real individuals who were unaware of their participation in an experiment. For example, Moss-Racusin and colleagues conducted a lab experiment in which science faculty at research universities reviewed fictitious applications for a hypothetical lab assistant position and systematically rated male “applicants” higher than otherwise-identical female “applicants.” In a similar field experiment, Milkman and colleagues emailed meeting requests from fictitious prospective doctoral students to professors and found that white male “students” received more, and faster, responses than female and non-white students, particularly in higher-paying STEM careers like computer science and engineering. A recent field experiment conducted by one of us and colleagues found that the instructors of online courses were nearly twice as likely to respond to discussion-forum comments placed by students who were randomly assigned white-male names. Consistent with a UB interpretation, the pro-male bias was observed among both male and female faculty in these studies. The K-12 context is also ripe with suggestive, quasi-experimental evidence of pervasive UB in the form of systematic grading biases and student-teacher racial match effects.

Additionally, individuals from stereotyped out-groups themselves react negatively to seemingly innocuous environmental factors, such as the demographic composition of a classroom, the race or sex of an instructor or proctor, and even the design and decoration of the classroom. One example of this is the phenomenon of stereotype threat, whereby the mere threat of being stereotyped by a white (male) instructor, even when no outright bias is expressed, may distract black (female) students, ultimately leading to poor performance on exams and even disengagement from school.

Read the full article.