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VERY INTERESTING: Kaiser's October Update on Health Disparities
Kaiser Family Foundation

November, 2011

The update also summarizes recent journal articles and other research developments in the field and features a data slide from a relevant Kaiser Family Foundation publication.

DISPARITIES IN THE NEWS

1. Obesity Rates for Local Kids Raise Concern

2. Tackling Infant Mortality Rates among Blacks

3. Young Gay Men Lead in New HIV Infections

4. Disabled Men at Higher Risk of Sexual Abuse Than Non-Disabled Men

5. Adult Obesity Named Lake County’s Top Health Concern

6. LGBT Patients Search for Healing

7. Healthy People: Nation’s Health Improved, But Disparities Persist

8. More Americans Face Longer Trips To ER

9. Mercer County Survey: Children’s Health Affected by Race And Riches

10. Rural Oklahoma Health-Care Needs Underserved, Areas Lack Specialists

11. Minority Populations Often Face Increased Risk of Breast Cancer


DISPARITIES IN RESEARCH

12. Racial Differences in Survival After Surgical Treatment for Melanoma

13. Disparities in Reconstruction Rates After Mastectomy for Ductal Carcinoma in Situ (DCIS): Patterns of Care and Factors Association with the Use of Breast Reconstruction for DCIS Compared with Invasive Cancer

14. Eliminating Health and Health Care Disparities among The Growing Population of People With Disabilities

15. Awareness of Racial and Ethnic Health Disparities Has Improved Only Modestly Over a Decade

16. Disparities in Diabetes Self-Management and Quality of Care in Rural Versus Urban Veterans

17. Language Barriers, Location of Care, and Delays in Follow-up of Abnormal Mammograms

18. Impact of Hysterectomy and Bilateral Oophorectomy Prevalence on Rates of Cervical, Uterine, and Ovarian Cancer among American Indian and Alaska Native Women, 1999 – 2004

19. Indian Health Service Innovations Have Helped Reduce Health Disparities Affecting American Indian and Alaska Native People

20. Where Health Disparities Begin: The Role of Social and Economic Determinants—and Why Current Policies May Make Matters Worse

21. Low-quality, High-cost Hospitals, Mainly in South, Care for Sharply Higher Shares of Elderly Black, Hispanic, and Medicaid Patients

22. A Mental Health Needs Assessment of Urban American Indian Youth and Families

23. Higher Risk of Death in Rural Blacks and Whites than Urbanites is Related to Lower Incomes, Education, and Health Coverage


DISPARITIES DATA SPOTLIGHT

Perceptions of HIV/AIDS among DC’s Black Residents, by Ward


DISPARITIES IN THE NEWS

1. Obesity Rates for Local Kids Raise Concern

An article published in the WCF Courier discussed a study by the Black Hawk County Health Department, which found more children in Waterloo, Iowa are overweight or obese than their neighbors in Cedar Falls, Iowa.

Nationally, 31.7 percent of students between kindergarten and 12th grade are overweight or obese.  In Cedar Falls, Iowa, the overweight and obesity rate hovers around the national average at 32 percent, but in Waterloo, Iowa, the proportion is much higher with 45 percent of students being classified as overweight or obese. Bruce Meisinger, director of public health for the county, said “That’s the eye popper right there in terms of the disparity between the two communities.” The overweight and obesity rate among students in Waterloo has increased over 10 percent in the last decade. As a result, the county health department has set up grants to fund student health and wellness interventions that will address these health issues. Shannon Ingamells, school nurse program manager, commented that more children are now being seen by nurses with Type 2 diabetes. “A lot of that is related to obesity, really, and we’re seeing that at younger and younger ages, too, so that’s definitely concerning,” she said.

The article pointed out that the Highland Elementary School zone has the highest concentration of students who are overweight, ranging from 46 to 57 percent. Mesinger noted that having the data by school site will help researchers to identify other factors that may be contributing to the increasing obesity rates, such as economic status (Hinz, 10/16).

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2. Tackling Infant Mortality Rates among Blacks

A recent article published in The New York Times discussed infant mortality disparities between black and white women and the role Healthy Start has supporting some of Pittsburgh’s most vulnerable women.

According to the article, the infant mortality rate for the United States continues to be one of the worst among the developed countries, and the situation is significantly worse for blacks in the United States.   Nationally, the infant mortality rate is 6.7 deaths per 1,000 live births, ranking 46th in the world.  For blacks however, the rate is nearly double at 13.3 deaths per 1,000, a rate that is worse than that of Sri Lanka.  Within the U.S., there is significant variation both across and within racial and ethnic populations.  While the infant mortality rate for blacks nationally is 13.3, in Pittsburgh the rate for blacks is 20.7 deaths per 1,000 live births, and that rate is five times as large as the rate for whites in Pittsburgh.  This disparity persists despite the fact that Pittsburgh has an unemployment rate that is significantly lower than the national average. “As a city you want to be known for your football and baseball teams, but you don’t want to be known as a place where babies die,” said Cheryl Squire Flint, who leads the Pittsburgh branch of Healthy Start.  Healthy Start is a federally funded national nonprofit group. The group’s $2.35 million budget has not increased since 1997, making it difficult for them to address the problem.  Although obesity, smoking, and other behavioral lifestyles increase the likelihood of infant mortality, Dr. Bruce W. Dixon, Allegheny County’s health commissioner for the last 19 years, said the primary cause for the growing disparity is the inequity in access to health care. “It’s not medical care, it’s social issues,” he said. Dr. Garth Graham, deputy assistant secretary for minority health in the Office of Minority Health at the Department of Health and Human Services, noted that “the disparity remains despite our best efforts.”

According to the article, black residents of Allegheny County said the disparity was not perceived as a problem because as one resident puts it, Wilford Payne, “It wasn’t affecting whites, so no one really cared because they didn’t know about it.” Carmen Anderson, senior officer with the Heinz Endowments of Pittsburgh, said “We are in day-to-day crisis mode. Sometimes those who scream the loudest get the attention. And there’s no screaming” (Williams, 10/14).

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3. Young Gay Men Lead in New HIV Infections

A recent article published in the Atlanta Journal Constitution discussed the disproportionate impact of new HIV infection rates on young gay men, particularly young gay black men.

More so than any other population in the United States, gay and bisexual men are most affected by HIV.  Young men, especially young gay black men bear more of the burden.  Tim Ward, a young black man who is HIV positive, found out his status when he was 18 years old. Since then, he has worked to inform other teens about the disease, the risks of having unprotected sex, and the ways to prevent themselves from contracting the virus. Tracy Elliot, executive director of AID Atlanta, said the disproportionate rate of HIV infections among blacks is largely due to poverty and unemployment. “It follows that black gay men are more impoverished than white gay men so the disparity isn’t that surprising if you look at the why,” he said.  Jacob Burgess, another young man who is HIV positive thinks his “generation and younger forget that HIV is a real and growing infection in our community.”  Both of these young men are Georgia residents, where there were 1,366 new HIV diagnoses in 2009.

Among the Georgia residents who were diagnosed in 2009, 49 percent were gay men—black men accounted for 74 percent, whites 21 percent, and Hispanics 5 percent.  Mr. Elliot said the current numbers demonstrate the need for the agency to host, and continue to host, its annual AIDS Walk Atlanta and 5K Run (Staples, 10/13).

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4. Disabled Men At Higher Risk of Sexual Abuse Than Non-Disabled Men

A recent article published in The Los Angeles Times discussed the results of a study from the American Journal of Preventive Medicine, that found that men and women with disabilities are much more likely to be the victim of sexual abuse compared to their non-disabled counterparts.

The article noted that few studies have focused on sexual abuse and men with disabilities. The study surveyed more than 25,000 men and women, and found 13.9 percent of disabled men reported experiencing sexual violence at some point during their lifetime as compared to 3.7 percent of non-disabled men. The percentage of disabled men who reported sexual abuse was slightly higher than the percentage for non-disabled women (12.4 percent).

The study also found that the victims weren’t just abused by intimate partners, but also by acquaintances, family members, dates and strangers. Monika Mitra, lead author at the University of Massachusetts Medical School, said, “This is particularly relevant for people with disabilities whom earlier studies have suggested are especially likely to experience abuse from caregivers and personal care and other attendants, in addition to intimate partners” (Stein, 10/11).

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5. Adult Obesity Named Lake County’s Top Health Concern

A recent article published in The News Herald discussed the results of a local community health survey, which found adult obesity to be local residents’ top concern.

According to the article, 2,568 county residents were interviewed residents and asked to identify the community’s needs, concerns, and to help identify ways in which public health officials can address those needs. Fifty-three percent of respondents identified obesity as the number one issue, followed by drug addiction (44.4 percent) and childhood obesity (42.2 percent).  Ron Graham, the county’s Deputy Health Commissioner, said the data sparked governmental officials to initiate policies, such as the Healthy Lifestyle Initiative and Community Health Improvement Plan, that will address the issues identified in the survey and improve the health among community residents.

Although these initiatives are taking place in this community, Graham said “We are seeing many of the trends as a nation, and minorities often experience significant health disparities when compared to their Caucasian counterparts” (Hutchison, 10/10). 

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6. LGBT Patients Search for Healing

A recent article published in The Boston Globe discussed some of the health challenges faced by LGBT patients and the efforts of health care providers in the Boston area to offer more culturally competent care to them.

According to the article, a number of patients who identify themselves as lesbian, gay, bisexual, or transgender have enormous difficulties finding care that addresses their needs and does not alienate them because of their sexual orientation.  The article notes there are major gaps in medical care and patient sensitivity that are not being addressed by either medical research or medical school education. According to the article, only .21 percent of publications relating to humans in the PubMed database include LGBT-related keywords. Furthermore, one study found that a third of medical schools offer no instruction on LGBT-related content during student’s clinical years. According to Dr. Scott Leibowitz, a psychiatrist at Children’s Hospital Boston, “You can’t learn this stuff through books or a written exam. The only way to foment sexual-and gender-competent care would be to have treatment programs that exist that bring in the patients.”

Medical facilities like Fenway Health are trying to do just that, by establishing programs and an atmosphere that help bring more LGBT patients through the door.  For example, many of the doctors cited in the article say the first step to making a member of the LGBT community feel comfortable begin with the questions a doctor asks. “How do you like to be called,” or “Have you noticed any attraction to boys or girls or both,” are examples of some questions used by Dr. Carole Allen of Harvard Vanguard Medical Associates, to help put her patients at ease. Other efforts include visual cues in the lobby for support groups for HIV-positive people and requests for LGBT study participants.  The efforts appear to be paying off.  Jessica, a patient at Fenway, noted that it is vastly different walking into Fenway as compared with other health settings, and this helps to make her feel comfortable receiving care there (Rudick, 10/10).  

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7. Healthy People: Nation’s Health Improved, But Disparities Persist

A recent article published in The Connecticut Mirror reported on a webinar during which Dr. Howard Koh, the Assistant Secretary of Health, discussed a review of Healthy People 2010 which found that despite significant progress in many areas, racial and ethnic disparities remain.

Beginning in 1980, and continuing every ten years since, the government releases national public health objectives aimed at “increasing the quality and years of healthy life, and eliminating health disparities across race and ethnicity, sex, education, income, geographic location, disability status and sexual orientation.  According to Dr. Howard Koh, Healthy People is “A roadmap and a compass for the country.” Healthy People 2010 achieved some of its outlined goals, such as decreases in smoking rates, cancer deaths, and fatal cases of coronary heart disease.  However, obesity rates and disparities in health among racial and ethnic minorities have either increased or remained unchanged this past decade according to the article.  For example, in 2000 the disparity in life expectancy at birth for blacks and whites was 5.5 years, indicating on average, the number of years a black child born in 2000 would die before a white child born at the same time.  In 2007, the difference was 4.9 years.  
At the state level, similar findings as well as some contradictions exist, and some states are trying to put policies in place that will achieve similar goals as Healthy People 2010.  Connecticut has a higher median age, higher degree of educational attainment than the country on average, and a higher proportion of white residents. Yet it also has one of the highest income disparity and widest achievement gap among high school students, and blacks in Connecticut experience a clear disparity in infant mortality rates compared to whites. Dr. Jewel Mullen, Connecticut Public Health Commissioner, noted the findings have helped to identify challenges for the next 10 years (Becker, 10/06).

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8. More Americans Face Longer Trips to ER

A recent article published in US News & World Report reported that millions of Americans now live farther from trauma centers than they did ten years ago, and that many vulnerable populations including the poor, rural residents and the uninsured are disproportionately among them.

According to researchers at the University of California, San Francisco, one in four Americans now have to travel farther to reach the nearest trauma center than they did ten years ago.  For nearly 16 million individuals, an additional 30 minutes has been added to their trip.  This is largely attributed to the fact that more trauma centers have closed.  The article noted that areas with more poor, black, uninsured and rural residents were farther from trauma centers than areas with fewer residents from these populations.  Dr. Renee Y. Hsia, an assistant professor of emergency medicine at the University of California San Francisco, said “This study will help us better understand how trauma center closures are affecting people.”

The article noted that between 1990 and 2005, 30 percent of the 1,125 trauma centers in the United States closed.  According to the researchers, this is largely due to the increasing costs in medical care and patients not being able to pay their bills (Health Day, 10/05). 

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9. Mercer County Survey: Children’s Health Affected by Race And Riches

A recent article published in The Trenton Times discussed the findings of a survey of child health in Mercer County, New Jersey, which found that most children in Mercer County have health coverage and that children’s health varies by race and ethnicity.

The survey, which was the first-of-its-kind, asked a little more than 1,000 people a variety of questions about the health and well-being of children in Mercer County.  The results showed that the majority of children in the “County are in excellent, very good, or good health, [and] have health insurance,” but there are some challenges.  Nearly 20 percent of children have a chronic condition and 27 percent visited an emergency room in the past year.  The study also found variations by race and ethnicity.  A higher percentage of Hispanic children are in fair or poor health as compared to black and white children, and a greater share of black and Latino children live below 150 percent of the federal poverty line.

According to the article, this survey provides an outline of how health providers may want to address the challenges children face. “The findings can be used by health providers, social service agencies and policy makers to identify children’s needs, develop new programs and provide a baseline for monitoring progress,” said Dr. Kendall Sprott, the organization’s board chair (Cusido, 10/04).

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10. Rural Oklahoma Health-Care Needs Underserved, Areas Lack Specialists

A recent article published in the Tulsa World discussed the shortage of health professionals in Oklahoma and some of the challenges rural residents face when accessing health care.

According to a 2011 report from the American Medical Association, Oklahoma ranked 44th in the nation with regards to access to primary care physicians.  Access to specialty care is also a challenge, as specialists in Oklahoma tend to locate in metropolitan areas.  The article noted that the northwest quadrant of the state is practically devoid of cardiologists, and 55 of the 77 counties lack an oncologist.  For individuals living in one of the 68 rural counties, these access challenges can mean delaying care, forgoing preventive services, and having a lower quality of life.  Residents in the rural counties experience the lowest life expectancy rates in the state. Furthermore, these areas tend to have the highest minority populations in the state.  According to Dr. Richard Helton, the loan physician in Coal County, “You’re out here on your own, and you have to make do.”  

Recruiting doctors to work in rural areas can be challenging.  James Hess, chief operating officer with the Oklahoma State University Center for Health Sciences, cites differences in lifestyle and Medicaid and Medicare reimbursements as two of the reasons.  He said, “The only way to get people to go to rural Oklahoma is to recruit them from rural Oklahoma,” and he thinks loan forgiveness programs or loan repayment programs for physicians who choose to practice in rural areas could help attract more doctors (Muchmore, 10/02).

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11. Minority Populations Often Face Increased Risk of Breast Cancer

A recent article published in the Chicago Tribune discussed the unique breast cancer challenges faced by lesbian women and women of different racial and ethnic backgrounds in the United States.

Women of every race, color and creed are susceptible to breast cancer, but the specific risks tend to vary across populations.  Lovell Jones, director of the Center for Research on Minority Health at the MD Anderson Cancer Center in Houston, said “We tend to (group) everything in terms that ‘one size fits all’ as opposed to looking at the disease as it impacts different populations.” According to the article, white women have the highest incidence rate of breast cancer.  However, black women have the highest rate of pre-menopausal breast cancer diagnosis and at every age, are more likely to die from breast cancer.  Although Asian and Pacific Islander women have the lowest incidence rates of any racial or ethnic population, the data indicate that women of Japanese descent have identical incidence rates as white women, and Filipina women have the lowest five year survival rate of all racial and ethnic populations in the United States.  Latina women are more likely than white women to be diagnosed at an early age with worse tumors.  In addition to racial and ethnic disparities, the article points out that several studies have found that lesbian women have a greater odds of being diagnosed with a form of breast cancer in their lifetime than heterosexual women.

Elizabeth Thompson, president of Susan G. Komen for the Cure, said women should know their family history, calculate their risk, and map out a screening schedule with their doctor to have better self-awareness of their breast health (Elejalde-Ruiz, 9/22). 

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DISPARITIES IN RESEARCH

12. Racial Differences in Survival After Surgical Treatment for Melanoma

A recent study that was published in Annals of Surgical Oncology found significant disparities in melanoma cancer treatment and survival rates between blacks and whites.

While the incidence of melanoma is much higher for whites than it is for minorities, cutaneous melanoma ranks as the third most common skin cancer in racial and ethnic minorities, and differences in the type, diagnosis and treatment of it have been previously observed.  The researchers undertook the study to better understand racial and ethnic disparities in overall and melanoma-specific survival.  They did a retrospective study of more than 151,000 patients with a first primary cutaneous melanoma and for whom race data were available using information from the Surveillance, Epidemiology, and End Results Program (SEER) that was gathered between January 1, 1973 and December 31, 2004. The variables for types of tumors included histologic subtype, SEER historic stage A, primary anatomic site, satellite nodules/tumors, skin ulceration and lymph node extension.  The results of the study showed significant disparities between black and white melanoma patients.  Black patients were more likely to be diagnosed with regional and distant disease, more likely to have certain types including acral lentiginous melanoma, tumor ulcerations and satellite nodules, and less likely to be surgically treated, and when surgically treated more likely to undergo amputation.  Blacks continued to experience worse outcomes when the study examined survival rates after surgery and the type of surgery.  For example, the 10-year overall survival rate for melanoma-specific cancer was lower for blacks compared to whites and other races.  Neither overall nor melanoma-specific mortality differences by race were observed for individuals who did not have surgery.

The authors noted that their study is one of the first to use population-based data to find survival differences for black patients with melanoma.  They suggested that early detection continues to be important, particularly when dealing with more aggressive forms of cancer, which may be more common among blacks, and they indicated that prospective studies that can uncover the genetic and/or biologic characteristics of melanoma tumors in black patients are needed in order to improve their survival rates.     

(Collins KK, Fields RC, Baptiste D, et al. Racial differences in survival after surgical treatment for melanoma. Annals of Surgical Oncology. 2011 Oct; 18(10): 2925-2936).

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13. Disparities in Reconstruction Rates after Mastectomy for Ductal Carcinoma in Situ (DCIS): Patterns of Care and Factors Association with the Use of Breast Reconstruction for DCIS Compared with Invasive Cancer

A recent study published in Annals of Surgical Oncology examined reconstruction rates after mastectomy and found that patients with ductal carcinoma in situ (DCIS) were more likely to undergo reconstruction than patients with invasive breast cancer, and that a patient’s age, race, type of insurance, and the type of hospital from which they received their care influenced whether they had reconstruction.

Slightly more than one in four women diagnosed with DCIS opt for a mastectomy.  Prior research has found an increase in the quality of life and in patient satisfaction among patients who had reconstruction following their mastectomy.  The researchers sought to determine whether patients with DCIS are more likely to undergo reconstruction compared to patients with invasive breast cancer, and to determine what factors are associated with reconstruction. The study included 2,428 DCIS patients and 15,794 invasive carcinoma patients who had a mastectomy and/or reconstruction between 2003 and 2007, as identified by data from the California Office of Statewide Health Planning and Development (OSHPD). The researchers compared outcomes by age, race and ethnicity, type of insurance, and type of hospital in which they received care. The findings indicated that white women, younger women, women with either private coverage or Medicare, and women who were treated at a teaching hospital had the highest odds of undergoing immediate reconstruction following a mastectomy. The researchers also discovered that the odds of Hispanic and of Asian women receiving immediate reconstruction were one-fifth  the odds of white women.  The researchers noted that some of their findings conflicted with prior research. Where previous studies found black women were less likely to undergo reconstruction, this study found no significant difference.  The authors hypothesized that the finding might be unique to DCIS, but noted that further research is needed to be certain.  

The researchers concluded that stage of breast cancer is not a limiting factor when it comes to reconstruction surgery after a mastectomy for women with DCIS, although it may be for women with invasive cancers.  They also noted that other factors such as age, Medicaid recipient, Hispanic or Asian descent, and receiving care at a non-teaching hospital are all possible factors that contribute to the disparities in reconstruction surgery.

(Kruper L, Xu X, Henderson K, et al. Disparities in reconstruction rates after mastectomy for ductal carcinoma in situ (DCIS): patterns of care and factors association with the use of breast reconstruction for DCIS compared with invasive cancer. Annals of Surgical Oncology. 2011 Oct; 8(11): 3210-3219).

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14. Eliminating Health and Health Care Disparities among the Growing Population of People With Disabilities

A recent article published in Health Affairs discussed the disparities in health and health care faced by people with disabilities in the United States.

The author noted that 20 years after the Americans with Disabilities Act was enacted, people with disabilities still face significant challenges with the physical environment and stigmatizing social attitudes.  In the health care system, these challenges are compounded by among other things, a lack of accessible equipment and facilities, few health care professionals capable of addressing the needs of people with disabilities, and a lack of communication modalities.  There is no single definition of disability, but many people agree that it should be a combination of both the physical and social models, and that people living with disabilities are a diverse group with unique and sometimes complex health needs.  According to data from the 2001-05 National Health Interview Survey, whereas 3.4 percent with people without disabilities reported their health as fair or poor, rates were significantly higher for people with difficulty seeing or hearing (30.6 percent), people with movement difficulties (37.9 percent), people with emotional difficulties (51.8 percent), and people with cognitive difficulties (63.8 percent). In addition to worse health, the author noted that people with disabilities tend to be less likely to receive preventive services including mammograms and Pap tests.   

The author recommended that because the number of people living with disabilities in the United States is growing and because of the increased cost burden to the health care system associated with this growth, disparities among people with disabilities in the United States should be a top priority for the nation.

(Iezzoni LI. Eliminating health and health care disparities among the growing population of people with disabilities. Health Affairs. 2011 Oct; 30(10): 1947-1954).

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15. Awareness of Racial and Ethnic Health Disparities Has Improved Only Modestly Over a Decade

A recent study published in Health Affairs discussed the results of a survey of public awareness of disparities, and found there was a slight increase in awareness between 1999 and 2010, and that awareness of disparities varied substantially by race and ethnicity.

In 1999, a poll conducted by the Kaiser Family Foundation examined public awareness of racial and ethnic disparities in health care.  At that time, the majority of adults in the United States were unaware that blacks and Hispanics had worse health outcomes on a number of health indicators relative to non-Hispanic whites, including infant mortality and uninsured rates.  Since then, numerous efforts have been undertaken aimed at increasing the public’s awareness and interest in racial and ethnic health disparities.  The authors sought to determine whether public awareness of disparities has changed since the 1999 poll, and whether racial and ethnic differences in awareness persist.  Using a stratified random sample, the researchers conducted telephone interviews of 3,159 individuals, including 1,329 whites, 855 blacks, 591 Hispanics, and 179 Asians or Native Hawaiians and other Pacific Islanders. They used a questionnaire that included some of the questions from the 1999 survey, and classified respondents as “aware” of health disparities if they said there was a disparity for at least six of the twenty-four survey items. The findings showed a change in the public’s awareness from 1999-2010 for many indicators.  The largest change was an eight percentage increase in the public’s awareness of disparities between Hispanics and whites.  However, perceived disparity between blacks and whites changed moderately over time. The study revealed a significant difference in awareness based on educational level. Fifty-five percent of individuals with at least a high school degree or higher were aware of health disparities as compared with thirty-six percent of those without a high school degree. For some indicators, there was no change in awareness of disparities between whites and blacks.  The results also showed that most of the public believed outcomes for Asians and Native Hawaiians and other Pacific Islanders were similar to those of whites.   

The authors noted that much more work needs to be done in order to elevate the public profile of racial and ethnic health and health care disparities, a goal which aligns with the Affordable Care Act and the federal Action Plan to Reduce Racial and Ethnic Health Disparities.  They concluded that increasing the awareness of health disparities is a necessary first step toward their elimination.

(Benz JK, Espinosa O, Welsh V, et al. Awareness of racial and ethnic health disparities has improved only modestly over a decade. Health Affairs. 2011 Oct; 30(10): 1860-1867).

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16. Disparities in Diabetes Self-Management and Quality of Care in Rural Versus Urban Veterans

A recent study published in the Journal of Diabetes and Its Complications examined diabetes self-management behaviors among and quality of diabetes care received by veterans, and found veterans living in rural areas had higher levels of self-management care as compared to urban veterans, despite having significant disparities in other areas.

Prior research has shown that rural residents are more likely than their urban counterparts to have diabetes, and to experience worse health care access and quality, which ultimately lead to worse diabetes outcomes.  The authors of this study sought to better understand differences between rural and urban veterans in diabetes self-management care and indicators in quality of care. The study included data from the 2007 Behavioral Risk Factor Surveillance System (BRFSS), and examined four diabetes self-management behaviors and seven indicators of quality of diabetes care for 3,693 rural veterans and 6,779 urban veterans who were ever told by a doctor that they have diabetes.  The results indicated that rural veterans were less educated, poorer, in worse health, had lower rates of health insurance coverage, and received less diabetes education than urban veterans.  Despite these demographic disparities, in many instances rural and urban veterans did not differ in their management of diabetes or in the quality of care they received, but there were several places where differences were observed.  Rural veterans were more likely to check their feet, and more likely to receive a pneumonia vaccine, but they were less likely to have had a dilated eye exam in the last 12 months.  After adjusting for sociodemographic characteristics, rural veterans had a greater odds of checking their feet, but a lower odds of testing their blood sugar at least once a day. 

The researchers noted that this study contributes to the larger discussion of improving quality care for veterans living different geographic regions, and suggested that the findings indicate rural veterans have better self-management behaviors than urban veterans.

(Lynch CP, Strom JL, and Egede LE. Disparities in diabetes self-management and quality of care in rural versus urban veterans. Journal of Diabetes and Its Complications. 2011 Oct;  doi:10.1016/j.jdiacomp.2011.08.003).

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17. Language Barriers, Location of Care, and Delays in Follow-up of Abnormal Mammograms

A recent study published in Medical Care investigated the link between limited English proficiency and mammogram follow-up, and found that non-English speaking women experience longer delays in follow-up care after an abnormal mammogram than English speaking women.

Prior research has indicated that women of color face several obstacles in obtaining timely follow-up care after an abnormal mammogram.  However, few studies have examined whether limited English proficiency contributes to this disparity.  The study used data from the San Francisco Mammography Registry (SFMR) collected between the years of 1997-2008 from three facilities in the San Francisco area.  Women were designated by a registration clerk, as either English speaking or non-English speaking.  The three facilities differed in the number of years for which data were available, the predominant languages spoken by their patients, the language services provided, and the predominant type of health coverage the patients had.  Of the 13,014 women included in the study, 4,027 were classified as non-English speaking.  In all three facilities, non-English speaking patients had longer follow-up times than English speaking patients. Sixty-seven percent of English speaking patients had a timely 30-day follow-up compared to 50 percent of non-English speaking patients.  Facility B had the lowest proportion of non-English speaking patients and the fastest follow-up times for all patients.  Additionally, follow-up times for Russian patients at Facility B were similar to those of English speaking patients, but were longer for Spanish and Chinese speaking patients.  Although the other two facilities had longer follow-up times, there was no difference between the patients by language, and at Facility C, where there were the most non-English speaking patients, follow-up time were actually shorter for non-English speakers than they were for English speakers.  After adjusting for education, the results remained the same at Facilities A and C, but the odds of delay increased for non-English speaking patients at Facility B.   

The authors suggested more research is needed to better understand how patient navigation systems affect different populations and that alternative solutions need to be developed to help reduce delays at mammography facilities.  They also recommended that researchers focus on facilities with lower follow-up times to see what can best practices can be translated to other places.

(Karliner KS, Ma L, Hofmann M, et al. Language barriers, location of care, and delays in follow-up of abnormal mammograms. Medical Care. 2011 Oct; doi: 10.1097/MLR.0b013e31822dcf2d).

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18. Impact of Hysterectomy and Bilateral Oophorectomy Prevalence on Rates of Cervical, Uterine, and Ovarian Cancer among American Indian and Alaska Native Women, 1999-2004

A recent study published in Cancer Causes and Control found that American Indian and Alaska Native women have a higher prevalence of hysterectomy than white women, and have higher prevalence rates for cervical cancer, uterine cancer and ovarian cancer.

This study examined the prevalence of cervical, uterine, and ovarian cancer and the prevalence of hysterectomy and oophorectomy among American Indian and Alaska Native women by geographic region.  According to the researchers, no prior research has focused specifically on the prevalence of hysterectomy among American Indian and Alaska Native women at a regional level. The researchers linked records of invasive cervical, uterine and ovarian cancer from the National Program of Cancer Registries (NPCR) and the Surveillance, Epidemiology, and End Results (SEER) Program with information from the Indian Health Service’s (IHS) patient registration database.  The data were analyzed together and by IHS regions.  The study found that regardless of race, women in the Southern Plains region had the highest hysterectomy rate, whereas women in Alaska had the lowest rates.  In all but two regions, American Indian/Alaska Native women had a higher hysterectomy prevalence than white women.  Non-Hispanic white women had a higher rate of hysterectomy with bilateral oophorectomy than American Indian and Alaska Native women.  When examining cancer prevalence, the study found that American Indian and Alaska Native women had higher rates of cervical cancer than white women in all regions, but lower rates of both uterine and ovarian cancer.

The authors recommended using a correction for hysterectomy and oophorectomy status when assessing cancer disparities, and suggested that additional questions be included in national surveys, like the Behavioral Risk Factor Surveillance System, in order to better assess the prevalence of hysterectomy and oophorectomy and their subsequent health implications.

(Wong CA, Jim MA, King J, et al. Impact of hysterectomy and bilateral oophorectomy prevalence on rates of cervical, uterine, and ovarian cancer among American Indian and Alaska Native women, 1999-2004. Cancer Causes and Control. 2011 Oct; DOI: 10.1007/s10552-011-9844-2).

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19. Indian Health Service Innovations Have Helped Reduce Health Disparities Affecting American Indian and Alaska Native People

A recent article published in Health Affairs discussed efforts by the Indian Health Service (IHS) to develop innovative programs aimed at improving the health of American Indian and Alaska Native people, such as the Special Diabetes Program, the Improving Patient Care Initiative, and the use of health information technology.

American Indian and Alaska Native people are disproportionately affected by many health and social challenges including diabetes, obesity, injury, cancer, and cardiovascular disease. They are also less likely to have an income above the federal poverty level, less likely to be employed, and less likely to graduate from college than the overall US population.  In an effort to address many of these issues, IHS has implemented programs and services targeted towards some of the specific health needs of American Indians and Alaska Native communities, some of which have helped improve health and reduce disparities.  The Injury and Prevention Program is largely responsible for the decrease in the unintentional injury rate from 223.2 per 100,000 people in 1972-74 to 94.8 per 100,000 in 2002-04.  The Special Diabetes Program for Indians is a grant program that was established to support local activities aimed at improving diabetes care and at reducing health disparities. Grantees provide a variety of educational programs that are culturally appropriate and in many cases incorporate traditional methods and foods.  IHS has also implemented the Improving Patient Care initiative, modeled after the Chronic Care Model.  The goal of the Improving Patient Care initiative is “to provide more patient-centered, community-focused care, which results in tangible improvement in patient experiences, preventive services, chronic care outcomes and the use of health services.”  The authors also noted that IHS is using health information technology to do help manage patients with complex chronic conditions, to create culturally relevant patient education materials, and to create patient registries.

The authors concluded that despite recent improvements, more work needs to be done to continue improving the health of American Indians and Alaska Natives. They also stressed the need to “build on recent funding increases to achieve parity.”

(Sequist TD, Cullen T, and Acton KL. Indian health service innovations have helped reduce health disparities affecting American Indian and Alaska Native People. Health Affairs. 2011 Oct; 30(10): 1965-1973). 

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20. Where Health Disparities Begin: The Role of Social and Economic Determinants—and Why Current Policies May Make Matters Worse

A recent article published in Health Affairs discussed the impact social determinants of health and the policies affecting them have on health disparities, and how it is unlikely to have a significant reduction in disparities without addressing the source of the disparities.

Prior research has consistently shown that health disparities are not simply the result of differential access to care or differences in the quality of medical care a patient receives.  They are also the result of many social factors that affect the environment in which people live, work and play.  According to the authors, these social and economic conditions compound an individual’s health significantly, even creating a generational cycle.  Income and education are the two factors that most influence an individual’s health.  The authors note that the general public is largely unaware of the role social determinants have on health, but some policymakers are.  They argue that all policymakers should consider the health implications of their decisions, regardless of what the policy’s main focus may be, a recommendation advocated for by numerous groups, including the World Health Organization’s Commission on the Social Determinants of Health.  The authors suggest that advocates for programs focused on education or jobs might receive more support if they point out the health benefits of their programs.

The authors said now is a critical moment for the health equity movement because fiscal and political pressures could lead to cuts in programs that affect the social determinants which will have health consequences, and because “health disparities will persist until attention turns to the root causes outside the clinic.”

(Woolf SH, and Braveman P. Where health disparities begin: the role of social and economic determinants—and why current policies may make matters worse. Health Affairs. 2011 Oct; 30(10): 1852-1859).

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21. Low-Quality, High-Cost Hospitals, Mainly in South, Care for Sharply Higher Shares of Elderly Black, Hispanic, and Medicaid Patients

A recent study published in Health Affairs examined high-quality and low-quality hospitals to determine how they differ and whether vulnerable populations are more likely to receive care at one type over the other, and found differences in the size, profit-status,  geographic location, and health outcomes between the best and worst hospitals, and found higher proportions of older black and Hispanic and of Medicaid beneficiaries among the patients treated at the worst hospitals.

The Affordable Care Act of 2010 allows the Centers for Medicare and Medicaid Services (CMS) to make higher payments to hospitals that achieve better quality performance and to cut payments to hospitals that do not improve.  While conflicting evidence exists as to whether higher-quality hospitals have higher costs, there is more certainty that minority populations are more likely to receive care at low-performing hospitals.  The authors undertook this study to determine whether structural and health outcomes differ by hospital types, and to determine whether there are differences in the patient mix treated at each hospital type.  The researchers used data from the Medicare Hospital Compare program to calculate summary scores for each condition as well as an overall quality score which they used to classify hospitals as “high” and “low” performing.  Next, they used the Medicare Impact File, the American Hospital Association survey, Medicare data, and the Area Resource File to calculate risk-adjusted cost for each hospital.  The hospitals were then grouped into four categories for analyses: high quality, low cost, or “best” (n = 122); high quality, high costs (n = 139); low quality, low cost (n = 132); and low quality, high cost, or “worst” (n = 178).  The results showed that the best hospitals were more likely to be in the Northeast, whereas the worst hospitals were more likely to be located in the South. The best hospitals were also more likely than the worst hospitals to be nonprofit, to have a higher proportion of Medicare patients, and to discharge fewer elderly black and Hispanic patients.  Moreover, the patients discharged from the best hospitals were more likely to rate them higher and more likely to recommend them than patients who received care at the worst hospitals. 

The researchers indicated that the findings of their study have implication for the national value based purchasing program and disparities, and concluded that as the country delves further into improving hospital quality through value-based purchasing, efforts must be undertaken to “help hospitals improve quality and efficiency simultaneously” and to insure that “we do not inadvertently worsen disparities in care.”  

(Jha AK, Orav EJ, and Epstein AM. Low-quality, high-cost hospitals, mainly in South, care for sharply higher shares of elderly black, Hispanic, and Medicaid patients. Health Affairs. 2011 Oct; 30(10): 1904-1911).

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22. A Mental Health Needs Assessment of Urban American Indian Youth and Families

A recent study published in American Journal of Community Psychology used community-based participatory research (CBPR) and qualitative methods to understand the needs of American Indian and Alaska Native youth in the Chicago area from the perspectives of both American Indian and Alaska Native adults and American Indian and Alaska Native youth.  A myriad of needs emerged, as did some differences between what the youth said their needs are and what adults said the needs of the youth are.

Prior research has demonstrated that American Indian and Alaska Native youth face significant challenges, including high poverty rates, high rates of depression, suicide, substance abuse and other mental health issues, and high rates of exposure to violence.  Although the problems American Indian and Alaska Native youth face on the whole are well documented, the hurdles specific to urban American Indian and Alaska Native youth are not.  In order to better understand the needs of American Indian and Alaska Native youth in Chicago, which is home to one of the largest urban American Indian and Alaska Native populations in the country, the researchers undertook a study and combined CBPR and qualitative methods.  They adapted the Community Story Framework, a culturally-informed qualitative methodology that was developed for American Indian communities, to create a structured focus group guide that explored three topics: 1) the mental health and positive development needs of urban American Indian and Alaska Native youth; 2) the available support systems, mental health services, and service utilization; and 3) potential cultural and historical parameters that might drive the development of innovative services approaches to meet community needs. The researchers used the guide at each of the sixteen two-hour focus groups, which included a total of 107 participants.  These focus groups were audio recorded and analytically coded using AtlasTi software.  Numerous themes emerged from the focus groups, and they were grouped into eight categories.  Some common themes included: the division within the community; concerns about violence, alcohol and drug use; financial instability; living a healthy lifestyle; and achieving spiritual strength and practice.  With regards to service needs, common themes included: better funding for programs; improving the infrastructure; poor communication; lack of trust; and stigma.  Some of the themes that were unique to the youth related to developing coping skills, dealing with peer pressure, accountability from adults, receiving positive reinforcement, having positive role models, and  having to deal with shame or embarrassment when accessing services.  The authors classified the themes that emerged into four overarching categories: 1) need to address the historical trauma and internalized oppression in these communities, 2) the importance of extensive community mobilization efforts to address community politics, factions of the community, and organizational alliances, 3) the need to honor locally-meaningful conceptualizations of mental health and wellness, and 4) the need for community-based and culturally-relevant clinical services and programs, and discussed how a system of care (SOC) could address the needs of the community.

The researchers suggest that these findings can help benefit local communities by reinforcing the importance of broader system changes to SOC and its ability to meet the needs of diverse communities.

(West EA, Williams E, Suzukovich E, et al. A mental health needs assessment of urban American Indian youth and families. American Journal of Community Psychology. 2011 Oct: DOI 10.1007/s10464-011-9474-6).

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23. Higher Risk of Death in Rural Blacks and Whites than Urbanites is Related to Lower Incomes, Education, and Health Coverage

A recent study published in Health Affairs found that blacks and whites who live in rural areas were at a higher risk of premature death than those who live in urban areas.

Prior studies have provided evidence of racial and ethnic and geographic disparities in mortality rates, but the authors note that few studies have examined the relationship between race and ethnicity, geography, and mortality.  The researchers used data from the 2010 National Health Interview Survey Linked Mortality File to determine whether mortality rates or premature mortality rates differed by race and geography among individuals between the ages of 45 and 64 years. The researchers only included non-Hispanic whites, non-Hispanic blacks, and Hispanics, and excluded individuals who were obese or smoked. The final sample included 228,890 individuals. The analysis revealed that rural whites and blacks had a significantly higher risk of dying by 2006 and of dying before the age of 65 than whites living in urban areas.  Rural blacks also had a higher risk of premature death than urban blacks.  Urban blacks had a higher odds of death by 2006 and a higher odds of premature death than urban whites.  Urban Hispanics had a reduced risk of death by 2006 compared to urban whites, and both urban and rural Hispanics had a reduced risk of premature death compared to urban whites.  The study also found differences in mortality risk by demographic characteristics.  Being female was associated with a reduced risk of death by 2006.  Conversely, being female was associated with a higher risk of premature mortality, as was being uninsured or publicly insured, being hospitalized in the past year, and being less educated.

The authors recommend including rural minority populations in routine public health monitoring, improving access to care for rural minority populations, and working over time to improve geographic disparities in income, education and health. They conclude that sustained efforts to monitor access to care among rural population are critical, and that “targeted efforts that recognize unique local cultures and address specific educational and economic disadvantages are key to achieving change.”

(Probst JC, Bellinger JD, Walsemann KM, et al. Higher risk of death in rural blacks and whites than urbanites is related to lower incomes, education, and health coverage. Health Affairs. 2011 Oct; 30(10): 1872-1889).



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