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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. 1. IOM: More Data Needed On Health Status of Children
9. AHRQ Reports Declines in Diabetes Care 13. Lung Cancer Deaths Fall for Women 14. Washington Area Counties Reflect Health Disparities DISPARITIES IN RESEARCH 16. Health Literacy and Outcomes Among Patients with Heart Failure 17. Persistent Racial Disparities in Survival After Heart Transplantation 18. Socioeconomic Disparities for Hearing-Impaired Children in the United States 21. Migration from Mexico to the United States and Subsequent Risk for Depressive and Anxiety Disorders DISPARITIES DATA SPOTLIGHT DISPARITIES IN THE NEWS 1. IOM: More Data Needed On Health Status of Children The recommendations of the IOM Committee on Pediatric Health and Health Care Quality Measures were the topic of a recent article in FierceHealthcare. In response to a Congressional request in the Children’s Health Insurance Reauthorization of 2009, the Institute of Medicine (IOM) and the National Research Council evaluated current practices in the measurement of child and adolescent health and quality of care. The committee concluded that efforts “to identify, monitor, and address persistent health and healthcare quality disparities among children and adolescents” is hindered by a lack of standardization in many key areas of measurement, including race and ethnicity, socioeconomic status, primary language spoken at home and parental English proficiency. The committee recommended five steps to stimulate research in this area, and recommended that one of the key plans for reducing disparities in measuring child and adolescent health and healthcare quality include a “life-course approach,” that would examine the way in which certain events at each stage of development affect future health and healthcare quality. The committee said the increasing diversity among the child and adolescent population is one of reasons for which measurement is particularly important. More information on the report is available at http://www.iom.edu/Reports/2011/Child-and-Adolescent-Health-and-Health-Care-Quality/Report-Brief.aspx (Simmons, 4/26). 2. Study Challenges Data for Multiracial Patients A recent article from Politico Pro discussed the findings of a study from the journal Demography, which found that one of the national surveys used to measure disparities does not adequately account for multiracial individuals. The new health law included new requirements for the reporting of health disparities, but according to Jenifer Bratter and Bridget Gorman of Rice University, the Behavioral Risk Factor Surveillance System, one of the major national health surveys does not appropriately account for people of two or more races because it asks these individuals to choose which race “best describes” their background. According to Drs. Bratter and Gorman, “placing multiracial groups into a single ‘best race’ category likely obscures the pattern of health disparities for selected group because some multiracial adults…tend to identify with single-race groups whose health experiences they do not share.” The article noted that mixed-race American Indians and mixed-race Asians have health outcomes that are very similar to single-race American Indians and Asians respectively, yet individuals who identify as white and black tend to have health outcomes that more closely align with single-race whites. When the researchers analyzed data comparing the “best race” selections, they found that almost two-thirds more multiracial whites report fair or poor health than single-race whites. While it was a relatively small portion of the population who self-identified as more than one race in the 2010 Census, Dr. Bratter said that “the concern is that if the government is not accounting for the increased complexity in ancestry given the population that is multiracial, we could confuse some trends” (Feder 4/22). 3. Lack of Success Terminates Study in Africa of AIDS Prevention in Women According to the results of a study discussed in a recent article published by The New York Times , the pre-exposure prophylaxis study using the drug Truvada, which earlier proved effective when used by gay men, was stopped because it was found to be no more effective than the placebo in women. The clinical drug study, known as FEM-PReP, took place in South Africa, Kenya, and Tanzania and evaluated its effectiveness in preventing HIV infection in women. Approximately 1,900 women participated in the trial which consisted on taking the antiretroviral pill daily before its conclusion. Twenty-eight women became infected in both the placebo and Truvada group study, according to Family Health International (FHI), the nonprofit group that was conducting the study. The data suggested that the pill showed no efficacy, which is a very different outcome than the 90 percent protection rate Truvada showed among gay men. The results from that study were published last November. “It’s surprising, disappointing and frustrating,” said Mitchell Warren, executive director of AVAC, an advocacy group for AIDS prevention in New York. According to Dr. Robert M. Grant, a California AIDS researcher who led the study of Truvada in gay men, vaginal gels are more effective in delivering the antiretroviral drug into the vaginal walls. One question that remains unanswered is whether the women taking Truvada were as compliant as the men. The researchers collected blood samples to measure compliance, but have yet to evaluate the data. Two other “pre-exposure prophylaxis” studies in women are still under way in Africa with results expected over the next two years (McNeil Jr. 4/18). 4. Social Environment Linked to Gay Teen Suicide Risk Hatzenbuehler concluded that changes in school policies can reduce attempted suicides among LGB youth, such as allowing gay-straight alliances, implementing anti-discrimination policies, and implementing anti-bulling policies (Pittman 4/18). 5. Hospital Care at Life’s End: A Disparity An article from The New York Times discussed the findings from a report recently released that found patients in New York with chronic diseases get more aggressive care at the end of their life than patients in any other part of the country. Using federal data from 2007, researchers at Dartmouth College found that nationally 28 percent of chronic patients were treated at a hospital when they died. However, rates were significantly higher in four regions that encompass and surround New York City. Among the 4 regions, the number of chronically ill patients treated in a hospital ranged from 46 percent in the Manhattan hospital region to 39 percent in the New Brunswick, N.J. region. Dr. Elliott S. Fisher, one of the study’s co-authors, suggested that some of the observed differences may be the result of financial incentives providers receive for keeping patients in the hospital, but Dr. Gary Kalkut denied that financial incentives were a factor at Montefiore Medical Center in the Bronx, where he is the chief medical officer. Dr. David C. Goodman, a professor of pediatrics and health policy at Dartmouth Medical School said, “end-of-life care in the U.S. is changing fairly rapidly,” and patients “are spending less time in the hospital and receiving more hospice care over all,” something the researchers found to be true in both New York and the rest of the country (Hartocollis 4/11). 6. Federal Report Recommends Steps to Address Health Disparities The Associated Press recently wrote about a new report from the U.S. Department of Health and Human Services recommending specific action steps to reduce racial and ethnic health disparities. At all ages, people of color have worse health and receive worse health care than whites. To address these issues, the government released a plan that covers a broad spectrum of activities, aimed at reducing these disparities. In recent years, there has been a growing acknowledgement that disparities are the result of a myriad of factors. Some of those factors include geography, culture, local businesses, the availability of healthy foods, and the safety and accessibility of the community in which a person lives. As Dr. Howard Koh, assistant secretary of Health and Human Services put it, the disparities in our society are “a product of where people live, labor, learn, play and pray.” Some of the specific items included in the plan are: working with states to improve the receipt of preventive dental care among poor children; developing reimbursement incentives to improve the quality care for minority populations; and creating an online national registry of certified interpreters that doctors and hospitals can use for patients who do not speak English. Although the current economic situation suggests states may not able to contribute much financially to the implementation of the plan, the Department of Health and Human Services plans to pay for plan with money already available 7. U.S. Teen Birth Rate Hits Record Low A recent article from Health Day discussed the findings of a CDC report which noted that while the teen birth rate in the United States has reached a record low, the rate remains substantially higher than other developed countries, and evidence of racial and ethnic disparities persists. The CDC report is based on 2009 data on those aged 15-19 which found that teen births have dropped 37 percent in the last two decades. While the teen birth rate has hit a record low, racial and ethnic disparities persist. Black and Hispanic teens are more than twice as likely as white teens to have a baby. Disparities were also found among teens who reported being sexually active. About 46 percent of teens surveyed said they’ve had sexual intercourse and about 14 percent of girls and 10 percent of boys reported never having used contraception. Among girls, a greater share of African Americans (58%) reported having sex than Hispanics (45%) and whites (45%). Similarly, a larger proportion of African American boys (72%) reported having sex compared to Hispanics (53%) and whites (40%). According to Ursula Bauer, director of CDC’s National Center for Chronic Disease Prevention and Health Promotion, “while we are making significant progress in bringing down the teen birth rate, we have much more work to do in order to bring those rates in line with other developed countries.” Dr. Wanda Barfield, director of the National Center for Chronic Disease Prevention and Health Promotion’s division of reproductive health, noted that “only 50 percent of high school students are getting comprehensive sexual education including abstinence and contraception.” Teen pregnancy and births cost taxpayers about $3 billion each year, $6 billion in lost taxes, and almost $3 billion in other public costs. Despite the reported high rates of sexual activity among teens, Barfield noted that “we are seeing an increase in contraception and a decrease in the number of high school students who report being sexually.” Bill Albert, chief program officer at the National Campaign to Prevent Teen and Unplanned Pregnancy said that parents need to get more involved in order for the country to continue reducing teen pregnancy rates (Reinberg 4/05). 8. Disparities: Illness More Prevalent Among Older Gay Adults A recent article from The New York Times reported on the higher prevalence rate of mental illness among older gay adults compared to their heterosexual counterparts. Researchers at the University of California, Los Angeles used data from three years of the California Health Interview Survey to compare the health of older gay adults to their heterosexual peers. Older gay and bisexual men reported higher rates of many health problems, including high blood pressure, diabetes and physical disability than heterosexual men. Relative to older heterosexual women, older lesbian and bisexual women experienced similar rates of some conditions such as diabetes and hypertension, and higher rates of other conditions including physical disabilities and psychological distress. The researchers also studied the living situation of older adults. They found that one in four lesbian and bisexual women live alone, compared to one in five heterosexual women, and about half of older gay and bisexual men live alone compared with 13% of older heterosexual men. “The gay culture tends to be youth-driven, and the aging community network doesn’t usually think about gay and lesbian elders,” said Steven P. Wallace, associate director of the U.C.L.A. Center for Health Policy Research and lead author of the brief (Rabin 4/01). 9. AHRQ Reports Declines in Diabetes Care An article from HealthLeaders Media discussed the results of the latest disparities report from the Agency for Healthcare Research and Quality, which found that not only are there socioeconomic and racial and ethnic disparities in diabetes care, but in some cases, there were declines in care received. It is recommended that diabetic patients have an annual eye and foot examine, and have their blood sugar levels tested annually, yet the latest National Healthcare Disparities Report found that among low income adults ages 40 and older, only 23% had all three tests in 2007, down from 39% in 2002. Similar findings were evident when the data were examined by race and ethnicity. Among blacks, 32% of adults age 40 and over received all three tests in 2007 compared to 43% in 2002. For Hispanics, the proportion decreased from 34% to 27%. There was also a decline among whites, but the change was not as great, falling from 43% to 39%. The report also noted differences in the receipt of recommended screenings geography and educational attainment (Clark 4/1). 10. U.S. Panel Suggests Research into Causes and Prevalence of Health Issues Facing Gays A recent article on The New York Times reported on the need to increase federally-funded research on the health of lesbian, gay, bisexual, and transgender people to “identify gaps in research on the health of gay Americans.” Responding to a request from federal officials, the Institute of Medicine convened a panel to identify gaps in research on the health of gay Americans. The report noted many challenges, including a lack of training about sexuality on the part of medical schools and an unwillingness to disclose one’s sexual orientation for fear of discrimination and prejudice. The reported also discussed the current body of knowledge about the health of gay Americans, noting that gay youths and adults were more likely to be depressed and have suicidal thoughts, that Lesbians and bisexual women may be at higher risk for breast cancer than heterosexual women, and that long-term use of hormone therapy by transgender people may increase their risk for cancer. According to Dr. Robert O. Graham, the chairman of the panel that did the study and professor of family medicine at the University of Cincinnati, “the available evidence on the health of lesbian, gay, bisexual and transgender people is sparse…researchers need to do much more than simply filling gaps.” Among some of the recommendations put forth by the committee included in the report is a recommendation for more a systematic collection of demographic data on gay, lesbian and transgender people on the part of the federal government, and a recommendation that the National Institutes of Health put forth an ambitious research agenda and encourage it grantees to include sexual and gender minorities in studies when possible. The committee also recommended that the federal government support the development of standardized measures of sexual orientation and gender identity (Pear 3/31). 11. The Perils of Assimilation Hispanics comprise the largest minority group in the U.S. However, they continue to experience worse health outcomes than non-Hispanic whites, and according to the National Journal , assimilation is partially to blame for some of the observed disaprities. Hispanics experience higher rates of obesity, diabetes, and asthma than the national average. Health experts note that the “Immigrant Effect,” the idea that as a population integrates into U.S. society, it encounters more health problems, is a major contributing factor to the low health outcomes of Hispanics. Hispanics are replacing traditional diets with high-fat and high-calorie diets, while simutaneously adopting sedentary life styles. The affects of assimilation have also influenced the health of Latino children. “We know we have a generation of Latino youth that’s at risk,” said Jennifer Ng’andu, deputy director of health policy at the National Council of La Raza, in response to the fact that half of Latino children born in 2000 are on track to develop diabetes without some sort of lifestyle change. Poor access to health care and low utilization rates also contribute to health disparities, as Hispanics are more likely to be uninsured. Because Hispanics tend to work low-paying jobs that do not offer private health coverage, 32% are uninsured and approximately 13 million Hispanics rely on public government programs like Medicaid and the Children’s Health Insurance Program (CHIP). Undocumented immigrants are not eligible for public coverage, and those who are here legally must wait five years before being eligible for benefits. Hispanics continue to be the fastest growing group in the country and caring for this population will be a challenge for many providers. According to Marshall Chin, a professor of medicine at the University of Chicago and director of the Robert Wood Johnson Foundation’s research on health care disparities, “There’s going to be a strain upon the safety net, which is already pushed to its max because of underfunding” (DoBias 3/31). 12. Health Procedures’ Costs Vary Widely Across State (Texas) A recent article from the The New York Times reported on the differences between Medicaid reimbursement rates for hospitals in Texas. Medicaid is a state-federal health care program for indigent children, the disabled, and the very poor. Medicaid pays hospitals for about 60 percent of its costs in the state of Texas, and reimbursement rates vary significantly, with hospitals that have complex costs receiving the largest average reimbursement rates. For example, the cost for a coronary bypass surgery can differ by $5,000 between Laredo Medical Center and Harlingen Medical Center, though both hospitals are along the Texas-Mexico border. Similarly, a Caesarean section can cost $4,300 at Texas health Presbyterian Hospital Dallas, twice the cost at Texas Health Presbyterian Plano, though both hospitals are part of the same system. In an effort to fill the budget shortfall, state health officials are considering changing to a single reimbursement rate for all hospitals. Currently, Medicaid uses a formula which attaches a relative value to each procedure and multiplies it by a hospital-specific rate called a Standard Dollar Amount (S.D.A.) to estimate Medicaid reimbursement rate. State health officials note that such a formula creates large disparities in reimbursement and underscore the need to have a single base rate for all hospitals, with allowances for expensive-to-operate facilities. Susan Turley, the chief financial officer at Doctors Hospital at Renaissance in Edinburg, notes that modifying the formula that dictates Medicaid reimbursement rates “would level the playing field for hospitals forced to run a lean, efficient operation.” Eighty percent of patients in Doctors Hospital at Renaissance in Edinburg are covered by Medicaid or Medicare. Joel Allison, president and chief executive of the Baylor Health Care System, disagrees. He thinks the rate should remain “hospital-specific, to give recognition to those hospitals offering a greater scope and level of service.” (Ramshaw 3/26). 13. Lung Cancer Deaths Fall for Women An article from The Washington Post reported on the findings of a recent journal article which noted that nearly ten years after the trend could be seen for men, the death rate for lung cancer among women has started to decrease, and the diagnosis and death rates of the leading cancers continues to fall. The report, published in the Journal of the National Cancer Institute examined incidents and deaths from cancer between 2003 and 2007. The results were mixed. On the plus side, overall cancer deaths continue to fall, and the rates at which new cancers are diagnosed also fell. Of note, was that for the first time, lung cancer deaths in women began to show a statistically significant decline, and that the gap between blacks and whites in cancer mortality narrowed, although blacks continue to experience a significantly higher mortality rate. According to some experts, the decline is the result of a myriad of factors such as a decrease in smoking rates, improved rates of early detection, and better treatment. In conjunction with these gains, the report noted that the incidence rates and mortality rates for some cancers, including melanoma, liver, pancreas, and uterine cancer, continue to rise. Also of concern is that as Joseph DiFranza, a professor of family medicine and community health at the University of Massachusetts Medical School points out, the decline in smoking rates for adults and adolescents have stalled. At the same time, states are cutting back on tobacco-control programs as they try to address their budget shortfalls. Professor DiFranza believes that as a result, “we can expect that declines in lung cancer death rates that we celebrate today will also stall sometime in the future.” For now, experts disagree on the path forward. Some say the country needs a fundamental shift in its strategy to focus more on preventing cancers, while others believe we should continue with current efforts because there is a paucity of knowledge as to how to prevent many cancers (Stein 3/31). 14. Washington Area Counties Reflect Health Disparities According to an article published by The Washington Post, the findings from a series of reports that rank U.S. counties and cities on health showed that the District of Columbia fared worse on several indicators than its neighboring counterparts. The rankings, which are available at www.countyhealthrankings.org, compiled data on longevity, health, and some of the social factors that influence health outcomes such as high school graduation rates, teen birth rates, poverty and uninsured rates. For the first time, the rankings included data from the District of Columbia. Several counties surrounding the District of Columbia: Fairfax, Arlington, Loudoun, Howard, Montgomery and Frederick received the highest marks in their state for overall health. Prince George’s County ranked 17th among the 23 counties in Maryland and Baltimore City. Although the District of Columbia fared worse than its neighbors on several measures, there were some for which the District scored better, including the ratio of primary-care providers per population and the number of uninsured adults, and while Fairfax County had the highest overall health rating in Virginia, it again ranked last in air quality. The rankings are similar to the findings of other studies released by the University of Wisconsin and the Robert Wood Johnson Foundation, and as expected, there was little change from the previous year. Patrick Remington, a professor at the University of Wisconsin, and directors of the county health rankings program, said the reason for doing the rankings is to help policymakers and community groups in a broad array of areas think about health because effective solutions will require doing more than telling people to “get your flu shot and quit smoking” (Sun 3/30). DISPARITIES IN RESEARCH 15. Regional, Geographic, and Racial/Ethnic Variation in Glycemic Control in a National Sample of Veterans with Diabetes Researchers from the Centers for Disease Control and Prevention (CDC) recently published an article in the journal Diabetes Care in which they found racial and ethnic and small geographic disparities in hemoglobin A1c (HbA1c) levels and control. Diabetes is the seventh leading cause of death in the United States, and while racial and ethnic disparities have been well documented, few studies have examined the impact geographic variation has on diabetes outcomes. Using data collected over a 5-year period from a retrospective cohort study that included more than 690,000 veterans with type 2 diabetes, who had a diabetes prescription for insulin or an oral hypoglycemic agent, researchers sought to examine racial and ethnic variations in HbA1c levels and HbA1c control by geography. The researchers analyzed data geographically based on the five Veteran’s Integrated Service Networks (VSNs): Northeast, Med-Atlantic, South, Midwest, and West. Data were also examined by location of residence, which was classified as either urban or rural/highly rural. Unadjusted analyses found Hispanics and non-Hispanic blacks to have higher HbA1c levels than non-Hispanic whites. After controlling for demographic characteristics, including urbanicity and geographic region, racial and ethnic disparities persisted, although their magnitude decreased. Instead of having an HbA1c level that was 45% higher than whites, non-Hispanic blacks had a rate was 27% higher, and the rate for Hispanics went from being 38% higher to 32% higher. Non-Hispanic blacks and Hispanics also had a higher odds of having uncontrolled diabetes relative to white veterans. The researchers also found modest geographic variations in HbA1c levels and HbA1c control, such that HbA1c levels among veterans in South were the lowest, while HbA1c levels for veterans in the Mid-Atlantic were among the highest. Veterans in the Mid-Atlantic also had the highest odds of having uncontrolled diabetes. Few studies have looked at geographic variation in diabetes outcomes, and despite equitable access to services through the VA, racial and ethnic disparities persist. The authors suggest that “understanding geographic differences in HbA1c levels and control may have important policy implication if the findings are replicated in non-VA samples and we are able to identify factors with each setting that contribute to differences.” (Egede LE, Gebregziabher M, Hunt KJ, et al. “Regional, geographic, and racial/ethnic variation in glycemic control in a national sample of veterans with diabetes.” Diabetes Care. 2011 Apr; 34(4): 938-43). 16. Health Literacy and Outcomes Among Patients with Heart Failure A recent study from the Journal of the American Medical Association examined data from outpatients with heart failure in an integrated managed care organization, and found that low health literacy was associated with a greater mortality rate, but not with a higher hospitalization rate. It is estimated that nearly 1 in 3 Medicare beneficiaries have low health literacy. The Institute of Medicine defines health literacy as “the degree to which individuals can obtain, process and understand basic health information and services needed to make appropriate health decisions.” Heart failure patients tend to have high morbidity and mortality rates, and while often are hospitalized, much of their care is performed outside of the hospital. Using data from a retrospective cohort that included 1,547 respondents enrolled in Kaiser Permanente of Colorado with a primary discharge diagnosis, 2 secondary discharge diagnoses, or 3 or more emergency department visits with a diagnosis of heart failure, researchers sought to examine the relationship between low health literacy and mortality and hospitalization. Health literacy was measured using 3 questions that asked how often the patient a) had someone help them read hospital materials, b) had problems learning about their conditions because they had trouble reading the materials, and c) was confident in filling out forms by themselves, using a 5-point scale in which higher scores were associated with lower literacy. Patients were assigned to the low health literacy category if they had a score greater than 10. To determine the association between health literacy, Cox-proportional hazard models were constructed. The researchers found that nearly 18% of respondents had low health literacy, and these individuals tended to be older, poorer, and less educated, as well as more likely to have a coexisting illness. Unadjusted mortality and hospitalization rates were higher among patients with low health literacy, but after adjusting for demographic characteristics, low health literacy was only significantly associated with mortality (17.6% vs. 6.3%; HR, 1.97 [95% CI, 1.3 – 2.97]; p = .001). Further analyses revealed differences in the association between low health literacy and hospitalization differed by living situation, such that low health literacy was not significantly associated with hospitalization among independently living patients, but was associated with lower hospitalization rates among residential patients. The authors posit that health literacy might impact health outcomes through several processes, including doctor-patient communication, the patients’ health actions outside the health system, and adherence to treatment recommendations, and conclude that the study justifies “further investigation of health literacy as a potential modifiable risk factor for adverse outcomes in heart failure.” (Peterson PN, Shetterly SM, Clarke CL, et al. “Health literacy and outcomes among patients with heart failure.” Journal of the American Medical Association. 2011; 305(16): 1695-1701). 17. Persistent Racial Disparities in Survival After Heart Transplantation A recent study from Circulation examined racial and ethnic disparities in mortality rates among patients after receiving a heart transplant, and found that black heart transplant recipients had higher mortality rates than white and other minority heart transplant recipients. Using data from the United Network of Organ Sharing, the authors performed a retrospective cohort study, identifying patients who underwent heart transplantation between October 1987 and February 2009, to examine the relationship between race and mortality and to determine relationship between race and other outcomes and their relationship to mortality. The final sample consisted of 39,075 heart transplant recipients, of whom 79% were white, 13% were black, 5% were Latino, 2% were Asian, and 0.4% were American Indian or Alaska Native. Minority patients tended to be younger, have higher rates of comorbid conditions, and were more often women. Minority patients also tended to differ in their reason for transplantation nonischemic cardiomyopathy vs. ischemic cardiomyopathy for white patients. The authors analyzed one-year and five year mortality rates and found that at both time points, black recipients had a significantly higher mortality rate than the rate for any other racial or ethnic population. Mortality rates did not differ significantly between white and other minority recipients at the one-year follow-up, but rates were higher for Hispanics compared to whites at the 5-year follow-up. The results were similar for unadjusted and multivariable adjustment for recipient, transplantation, and socioeconomic variables. The authors noted that the cause of death for black patients was more likely to be graft failure or a cardiovascular cause (57.9%) than it was for whites (37.8%), but blacks were less likely to die of infection or malignancy (19.9%) than were whites (33.0%). Furthermore, hospitalization rates, organ rejection, and noncompliance with immunosuppressive medication were higher among black patients than white, Hispanic, or other patients. The authors noted that lower intensity immunosuppressant among black patients contributed to disparities in longer-term survival which may result from biological factors or socioeconomic factors, and suggested that “the persistent disparity in mortality might be eliminated if the reason for less adequate immunosuppression among black recipients could be identified.” (Liu V, Bhattacharya J, Weill D, et. al. “Persistent racial disparities in survival after heart transplantation.” Circulation. 2011; 123(15): 1642-1649). 18. Socioeconomic Disparities for Hearing-Impaired Children in the United States Families of hearing-impaired children live closer to the poverty level and are less able to afford some medical services than families of children without hearing loss, according to a recent study published in the journal Laryngoscope. This study focused on the socioeconomic status and healthcare access and utilization of families with children with and without loss of hearing. Using data collected from the National Health Interview Survey between 1997 and 2003, the authors grouped children into three categories: “Good hearing” (GOOD), “a little trouble hearing” (LIT), and “a lot of trouble hearing” or are “deaf” (A LOT/D). The authors used seven variables to assess for socioeconomic status and healthcare access and utilization of which included ratio of income to poverty level, affordability of health care services, and source of care. The final sample size consisted of 76,012 children, of whom 3.1% reported to have some degree of hearing loss. The authors found that children who had a lot of hearing loss or were deaf were more likely to report poorer health status, belong to Medicaid, and have parents with lower levels of education than other children in the survey. The ratio of family income to the poverty level was higher for families of children with GOOD hearing than families with children of LIT or A LOT/D. However, after adjusting for sociodemographic characteristics, these outcomes did not remain statistically significant. The odds ratio of a child living below the poverty level was higher for children who were A LOT/D (1.70; 1.28-2.26) compared to those who were LIT (1.51; 1.33-1.71). The results remained statistically significant for those who were LIT, but not for those who have A LOT/D after adjusting for sociodemographic characteristics. Children who had a “lot of trouble hearing” and a “little trouble hearing” had a higher odds ratio of being unable to afford prescription medication, mental health care, and dental care compared to those with good hearing. These findings remained statistically significant even after adjusting for sociodemographic characteristics. Furthermore, the authors found no differences when evaluating the odds of not having a source of sick or routine care, and no statistical significance was found even after adjusting for sociodemographic characteristics. The authors concluded that the study has important policy implications, illustrating the necessity for measure that can improve access and affordability of services to children with hearing loss. (Boss EF, Niparko JK, Gaskin DJ, et. al. “Socioeconomic disparities for hearing-impaired children in the united states.” Laryngoscope. 2011; 121(4): 860-866). 19. Despite Improved Quality of Care in the Veterans Affairs Health System, Racial Disparity Persists for Important Clinical Outcomes The Veterans Affairs (VA) health care system underwent substantial improvements in care during 1995-1999, however racial health disparities persist in processes of care and health outcomes, many of which can by explained by within-facility disparities, according to a recent study published in Health Affairs. Using data from the External Peer Review Program, which collects annual data from a random sample of veterans who have been enrolled in the VA health system for at least two years, the authors analyzed six quality indicators which measured processes of care (e.g. screenings) and four measured clinical outcomes (e.g. cholesterol level). The final sample included 1,126,254 veterans (955,047 white and 171,207 black) whose data were collected between 2000 and 2009. The authors calculated the disparity for each measure as the difference in unadjusted national performance scores between white and blacks. They found that with the exception of mammography, the performance rates improved for white and black enrollees over time improved on each quality indicator, with the largest improvement occurring for annual eye exams. On this measure, white patients saw a 22 percentage point increase while black patients saw a 23 percentage point increase. There was less than a two percentage point difference between white and black patients for five of the six care processes indicators. Conversely, the disparity for all four of the intermediate outcome indicators was greater than four percentage points. Reductions in racial disparity for three quality indicators whose initial disparity was greater than 5 percentage points were observed. They included blood glucose control, blood pressure control, and colorectal cancer screening. VA medical centers that served at least twenty black veterans and evaluated for an outcome measure were found to have a median disparity of ten percentage points. When the authors added a VA medical center-level indicator variable, there was no significant change in adjusted disparities, indicating that the average racial disparity within VA medical centers was similar in magnitude to the disparity at the national level. The authors suggested that in order to address racial and ethnic disparities in health care quality, “it is critical to understand the relative contributions of within-facility disparities and between-facility disparities.” (Trivedi AN, Grebla RC, Wright SM, et. al. “Despite improved quality of care in the veterans affairs health system, racial disparity persists for important clinical outcomes.” Health Affairs. 2011; 30(4): 707-715). 20. Insurance Status and Racial Differences in Uterine Cancer Survival: A Study of Patients in the National Cancer Database A recent study from the journal of Gynecologic Oncology examined the effect of a patient’s insurance status and race on uterine cancer survival, and found large differences in survival rates between uninsured and privately insured patients and between African American and white patients. Using data from the National Cancer Database, a hospital-based cancer registry jointly sponsored by the American Cancer Society and the American College of Surgeons, the authors analyzed data from women ages 18 to 99 with stages I, II, or III uterine cancer in either 2000 or 2001, to better understand the role of insurance has in survival of uterine cancer and to better understand the impact of health insurance on racial and ethnic disparities in survival. The researchers used Kaplan-Meier survival curves to estimate four year survival rates and Cox proportional hazards to estimate hazard ratios (HR) and confidence intervals. Compared to white patients, African American and Hispanic patients were more likely to be uninsured and to reside in lower-SES zip codes. African Americans were also more likely to be diagnosed with a later stage tumor compared to white patients. African Americans (15.99%) were less likely to receive cancer directed surgery than whites (7.25%), Hispanics (9.75%), and other patients (6.64%). The four-year survival rate varied by both tumor stage and race and ethnicity. Patients were less likely to survive with increasing cancer stage, and black and Hispanic patients has lower survival rates than whites in unadjusted models. In multivariate models adjusting for age and facility factors, the hazard ratio of death among African Americans was 2.35 (95% CI 2.20-2.51) and 1.31 (95% CI 1.15-1.50) for Hispanics. After adjusting for zip code and level of education, the hazard ratio for Hispanics was no longer statistically significant and decreased 24% for African Americans. The four-year observed survival rate varied by insurance status with privately insured patients having higher survival rates than those who were uninsured, Medicaid insured, and Medicare insured; the relative survival rates followed the same pattern. In the stage-specific analyses among patients receiving surgery, African Americans had a higher risk of death at each stage as did younger Medicare patients. The authors concluded that the largest contributors to African American vs. white survival disparities in this study were clinical factors, including stage at diagnosis, grade, and histopathology, whereas access to care was a smaller contributor. (Fedewa SA, Lerro C, Chase D, et. al. “Insurance status and racial differences in uterine cancer survival: A study of patients in the National Cancer Database.” Gynecologic Oncology. 2011; doi:10.1016/j.ygyno.2011.03.010). 21. Migration from Mexico to the United States and Subsequent Risk for Depressive and Anxiety Disorders Mexican migrants are more likely have first onset of any depressive or anxiety disorder than Mexican non-migrants, according to a recent study published in the Archives of General Psychiatry. Few studies have focused on the effect of migration on Mexican migrant workers while controlling for family-level pre-migration factors. Using information gathered from the epidemiological surveys of psychiatric disorder, the Mexico National Comorbidity Survey, and other assessments, the authors identified 2,519 nonmigrant family members of migrants in Mexico and 554 Mexican migrants in the United States to compare the lifetime prevalence of disorders between the two groups by age and gender. Mexican migrants were more likely to be male and in the middle aged groups (26-35 and 36-45 years) than were family member of migrants. Mexican migrants in the United States had a significantly higher lifetime prevalence of depressive or anxiety disorder (17.4% vs. 11.7%), for depressive disorders as a group (11.0% vs. 8.2%), and for anxiety disorders as a group (10.1% vs. 6.2%). Among the four specific anxiety disorders assessed, migrants had a higher prevalence for every type of disorder. Adjusting for age and sex, migrants had a higher odds ratio (1.42; 95% CI, 1.04-1.94) of being higher risk for first onset of any depressive or anxiety disorder than were nonmigrant family members of migrants. The youngest birth cohort (ages 18-25 years) of migrants were at highest risk for depressive and anxiety disorders after migration compared to those in the 26-35 years, 36-45 years, and greater than 46 years categories. This group had the highest odds ratio for depressive disorder (4.37), anxiety disorder (3.40) compared to the overall group, 1.16 and 1.78 respectively. The authors noted that the study provides evidence of an adverse effect of migration on mental health among Mexican migrants to the United States. (Breslau J, Borges G, et al. “Migration from Mexico to the United States and subsequent risk for depressive and anxiety disorders: a cross-national study.” Archives of General Psychiatry. 2011; 68(4): 428-433). 22. Promoting Access and Reducing Expected Out-of-Pocket Prescription Drug Costs for Vulnerable Medicare Beneficiaries The authors of a study recently published in the journal Medical Care examined the effectiveness of an intervention that uses pharmacy advocates, and found that programs targeted to vulnerable Medicare beneficiaries may be useful in reducing expected out-of-pocket costs for this population. Medicare Part D has been helpful to many Medicare beneficiaries in need of medications, but it presents some serious difficulties to beneficiaries who receive the low-income subsidy (LIS) and other vulnerable populations. The researchers undertook this study to see if they could lower expected annual out-of-pocket costs for vulnerable beneficiaries in California who were identified via community outreach. Vulnerable beneficiaries were defined as those with incomes below 300 percent of the federal poverty level. Outreach events were held at a variety of settings that serve vulnerable Medicare beneficiaries including low-income clinics, housing complexes, and community centers. Beneficiaries were asked to complete a structured interview with a pharmacy student that was available in 6 languages. In addition to the survey, each beneficiary was given a personalized plan search to show them their current plan, LIS status, and expected out-of-pocket costs. Eventually, 1.437 beneficiaries received Part D counseling during open enrollment, of whom 1,300 were identified as low-income and largely people of color (n=1042). A few beneficiaries were not receiving the LIS who were eligible. Following the intervention, 390 beneficiaries who were not enrolled in the least costly plan switched at the time of intervention, and their mean expected OOP Part D costs dropped from $382.50 to $122.00. The authors noted that while the cost of the plan is not the only consideration for Medicare beneficiaries, is it and important factor. They conclude that “targeted outreach interventions can be successful in identifying beneficiaries who may be eligible for the LIS” and that “there is a need to support training programs to assist Medicare beneficiaries, especially vulnerable patients, in making appropriate drug plan and medication choices.” (Cutler TW, Stebbins MR, Smith AR, et al. “Promoting access and reducing expected out-of-pocket prescription drug costs for vulnerable Medicare beneficiaries.” Medical Care. 2011; 49(4): 343-347). 23. Crowd-out and Exposure Effects of Physical Comorbidities on Mental Health Care Use: Implications for Racial-Ethnic Disparities in Access According to a study published in Health Services Research, the presence of physical comorbidities does not decrease the initiation of mental health care following a primary care provider visit, but physical comorbidities do cause more primary care visits, which in turn increases the initiation of mental health care. Prior research has indicated that primary care physicians (PCP) are less likely to address mental health problems when physical symptoms are present. At the same time, the presence of physical problems may lead to increased contact with the health care system. Thus comorbidities could either result in an increased likelihood of mental health care via the “exposure” hypothesis, or result in a decreased likelihood through the “crowd-out” hypothesis. Using data from the 2000-2007 Medical Provider and Household Components of the Medical Expenditure Panel Survey (MEPS), researchers sought to determine which hypothesis was correct, and then looked at the role the prevailing hypothesis has on racial and ethnic disparities. The study population included individuals with no mental health care visits in the pre-period, who were in the lowest third with regards to the mental health component of SF-12, who identified as non-Hispanic white, Latino, and African American adults, and who had at least one PCP visit in the postperiod. “Crowd-out” was defined as having a mental health visit within 30 days of the first, second, and third nonmental health PCP visit in the postperiod, and “exposure” was examined by looking at the initiation of mental health care after any nonmental health PCP visit in the postperiod. Predicted probabilities of mental health care use with and without adjusting for comorbidities were used to assess the relationship between comorbidities and mental health care disparities. Analyses were conducted on a final sample of 11,496 individuals. Unadjusted analyses found that black respondents regardless of the number of comorbidities they had, were less likely to initiate mental health care than their white counterparts. Similar findings were observed for Latinos, but only for those with one comorbid condition. There was no difference between whites, blacks or Latinos when crowd-out was analyzed. In contrast, there was evidence of the exposure hypothesis among whites and Latinos with multiple comorbidities and Latinos with one comorbidity were more likely to initiate mental health care. The researchers noted there was variation in the racial and ethnic disparities depending on whether comorbidities were adjusted for or not. Specifically, adjusting for comorbidities led the black-white disparity to increase from 9.2 percent to 9.7 percent, while the Latino-white disparity decreased from 8.9 percent to 8.4 percent. The authors conclude by suggesting three potential pathways through which racial and ethnic disparities in access to mental health care may arise and be addressed, including the increased exposure to the health care system that arises from comorbidities results improves the initiation of mental heath care. (Cook BL, McGuire TG, Alegria M, et al. “Crowd-out and Exposure Effects of Physical Comorbidities on Mental Health Care Use: Implications for Racial-Ethnic Disparities in Access.” Health Services Research. 2011 Mar 17; doi: 10.1111/j.1475-6773.2011.01253.x). The Digital Divide and Access to Health Information Online
Source: Based on the results of The Washington Post, the Kaiser Family Foundation, and Harvard University Race and Recession Survey, conducted January 27-February 9, 2011. The Affordable Care Act calls for a greater reliance on the internet as a means of communicating health and coverage information, yet variations in the current usage of the internet by some populations have important implications for implementation. Six in 10 adults overall say they have ever used the Internet to access health information, and access differs by race and income. Forty-three percent of Hispanics report having ever used the Internet to access health information, while 56 percent of blacks and 65 percent of whites report doing so. The differences are even more striking among those with lower incomes. Just three in ten Hispanics with incomes under $40,000 say they have ever used the Internet to access health information, compared with 44 percent of blacks and half of whites with similar incomes. To learn more about the digital divide and access to health information online, please see The Digital Divide and Access to Health Information Online. |
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This free, monthly update synthesizes news coverage from hundreds of print and broadcast news sources related to health and health care issues affecting underserved and racial and ethnic communities. 
