- Email: [email protected]
Health Disparities in Chronic Diseases: Where the Money Is
Health Disparities in Chronic Diseases: Where the Money Is ERROL D. CROOK, MD; MOSHA PETERS, MD
ABSTRACT: Chronic diseases account for three-quarters of the U.S. health care expenditures and a majority of early deaths and lost of productive years of life. Health disparities exist among the common chronic diseases, such as hypertension, diabetes mellitus, HIV/AIDS, cancer, cardiovascular disease, and obesity, with ethnic minorities and the poor having higher incidence or worse outcomes. Strategies to eliminate these disparities
in chronic diseases need to be multidisciplinary and focus on increasing access to all aspects of health care, including prevention. This article discusses the impact of health disparities on chronic diseases and offers some factors to consider for solutions to the problem. KEY INDEXING TERMS: Health disparities; Chronic diseases; African American; Preventive health. [Am J Med Sci 2008;335(4):266–270.]
D
2 or more of these common ailments in a single individual, particularly in the health disparate populations in our region.
isparities exist in the incidence and outcomes of several chronic diseases.1,2 These disparities have been present for several decades but their impact has significantly increased in many disease areas. Clearly, there are disparities in the incidence of diseases like sickle cell anemia and cystic fibrosis along ethnic or racial lines for genetic reasons. Moreover, there are disparities in much more common diseases for reasons that are not fully understood. The advances in medicine over the last several decades have greatly impacted the course of many common chronic diseases and have changed their prognosis from being quite pessimistic to rather optimistic. For the purposes of this discussion, we will deal with chronic diseases where health may be maintained for several years with appropriate therapy and where we may have the most impact. In addition, we will focus our discussion on issues affecting African American and rural populations, as those are the health disparate populations that predominate in the Upper Gulf Coast Region of the United States. The complications of these diseases may be delayed for years or avoided altogether, if appropriate therapy is available and applied. These diseases often cluster, and it is more common than not to find
From the Department of Medicine and Center for Healthy Communities, University of South Alabama College of Medicine, Mobile, Alabama. Submitted December 13, 2007; accepted in revised form January 8, 2008. This work was supported by NIH/NCMHHD5 grant R24 MD001094-02 (EDC). Correspondence: Errol D. Crook, MD, Department of Internal Medicine, University of South Alabama College of Medicine, Mastin 400-A, 2451 Fillingim Street, Mobile, AL (E-mail: ecrook@ usouthal.edu).
266
Impact of Chronic Diseases Chronic diseases are the leading cause of death and disability in the United States.2,3 They account for 7 of every 10 deaths and affect the quality of life of 90 million Americans. The impact of chronic diseases on mortality is seen at early ages, as chronic diseases account for one-third of the years of potential life lost before age 65. At least 10% of Americans have a severe limitation in their daily activity due to a chronic disease process. In economic terms, the costs of chronic diseases are enormous.2,3 At least three-quarters of the nation’s $1.4 trillion health care costs are for care of individuals with chronic diseases. Cardiovascular disease, diabetes, arthritis, and smoking account for $300 billion, $132 billion, $82 billion, and $75 billion in costs, respectively.2 Moreover, many individuals with chronic diseases have excess lost of years of productive life resulting in significant loss of potential income for their families.2 This loss of income in an adult who functions as a head of household or significant contributor to family income puts the health of the entire family at risk, as it may result in poorer access to health insurance (and therefore, health care), quality education, and safe neighborhoods. Clearly, eliminating disparities in chronic diseases will have a major economic impact. This impact will be seen in reduction of health care costs, but perhaps more importantly, will also be seen in increased earnings over a lifetime and lower poverty rates, particularly for ethnic minorities. April 2008 Volume 335 Number 4
Crook and Peters
Table 1. Common Chronic Diseases in Adults in the United States
Treated as Chronic Diseases Before 1950 Heart Disease* Hypertension* Asthma/Chronic Obstructive Lung Disease Liver Disease Arthritis Diabetes*⫹
Relative Recent Additions to List of Treated Chronic Diseases Stroke* Obesity* Cancer* HIV/AIDS and Hepatitis C* Mental Illness Dyslipidemia
* Chronic diseases where major disparities exist among ethnic minorities in incidence and/or outcomes. ⫹ While treatment was available for diabetes before 1950, outcomes were generally poor, therefore it can be considered a relative new comer to the treated chronic disease list.
Importantly, many of these diseases are preventable. Implementing healthy lifestyle practices, including healthy diet, physical activity, responsible sexual behavior, and avoidance of tobacco, harmful and illegal drugs significantly decrease the incidences and complications of these disease processes. Maintaining an active lifestyle and avoidance of becoming overweight or use of tobacco lead to an 80% reduction in the likelihood of developing many of our major common diseases.2,4 Chronic Diseases: A New Paradigm Table 1 lists many of the common chronic diseases that are seen in United States adults. In all of these diseases, disparities in incidences and complications exist. In general, the trends for these disparities are similar across the disease areas, such that ethnic minorities, particularly African Americans and Hispanics, and people in lower social economic groups are much more likely to suffer from these diseases and have worse outcomes.1,2,4 In addition, the elderly, the fastest growing segment of the population of the United States, also has higher incidence and more complications from these processes.5 We note that diseases such as obesity, cancer, HIV/AIDS, dyslipidemia, mental illness, hepatitis C, stroke, and diabetes should be considered relative newcomers to the list of chronic diseases. Although many of these diseases, like stroke, diabetes, and cancer, have been around for almost as long as man, the prognosis from these diseases was quite unfavorable until recently. A few decades ago, strokes were much more likely to be fatal, cancer had a uniformly very poor prognosis, and survival with diabetes for long period of times was uncommon, making the label of chronic disease a misnomer. For example, in 1950 stroke death rates were 220 to 240 per 100,000 in African Americans and 160 to 275 per 100,000 in whites, but dropped to 75 and 50 per THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
100,000 in African Americans and whites, respectively, in 2002.6 Incidence rates have not been similarly reduced, resulting in more individuals surviving with stroke and its many complications. Despite the decrease in mortality rates in both African Americans and whites, a disparity clearly remains. Similar trends can be seen for cardiovascular disease.6 HIV/AIDS and hepatitis C are newcomers to the disease landscape with their discoveries in the 1980s. Advanced scientific technology resulted in the speedy discovery of their pathophysiology, risk factors, and effective treatment modalities to allow for prolonged survival, and, hence, the label of a chronic disease. Approaching obesity, dyslipidemia, endstage renal disease, and mental illness as chronic diseases has gained favor only in the last 3 to 4 decades as their incidence has increased and effective treatments have become available. For example, the demonstration that dialysis was feasible in the community and the commitment to make that procedure available to individuals with endstage renal disease occurred less than 40 years ago. Health Disparities in Chronic Diseases—Special Considerations Table 2 lists a number of factors that are important considerations when discussing health disparities in chronic diseases, particularly among African Americans in the Southeast United States. In general, ethnic minorities and the poor are more likely to have lack of awareness of common chronic diseases and their risk factors.1,2 This results in diagnosis when the disease is more advanced and preventive strategies are less likely to be effective. National programs in hypertension, diabetes, HIV/ AIDS, and cancer awareness are ongoing and, in many cases, successful. For example, the hypertension education initiatives over the last 4 decades were successful and have resulted in awareness
Table 2. Some Important Factors Contributing to Health Disparities in Chronic Diseases Late diagnosis due to limitations in disease awareness Disparities in quality of care for African Americans and poor Less likely to reach treatment goals/standards Less likely to have access to new technology for diagnosis and treatment Limitations in cultural competence among health care providers Special concerns in rural populations Higher rates of poverty Lack of access to providers, technology, and procedures Disparities in quality of care as outlined above Low levels of confidence in health care provider and health care system among health disparate populations Low levels of provider satisfaction/positive affect when caring for health disparate populations
267
Chronic Diseases and Health Disparities
rates of hypertension in African Americans being similar to those of whites.7 A major concern is the quality of care received once individuals are diagnosed with a chronic disease. In many cases, guidelines exist that outline treatment strategies and targets for those strategies (so-called “best practices”). These guidelines are based on the best evidence available as interpreted by international experts. However, despite these “best practice” recommendations, many individuals in health disparate populations receive care that is of lower quality. Several studies have demonstrated that African Americans, in particular, are less likely to receive proven therapy including highly technical and innovative procedures or to achieve recommended treatment targets in the areas of diabetes, hypertension, cancer, cardiovascular disease, HIV/ AIDS, and mental illness.8 –10 In rural areas similar trends are observed, with both whites and African Americans being affected. Moreover, incidence and control rates of hypertension and diabetes are worse in rural areas when compared with urban areas.11,12 In rural areas, timely access, particularly to highly technical procedures, is clearly limited, but lower incomes also play a major role in these worse outcomes. Finally, it is important to point out that achieving treatment targets is significantly more important than simply initiating treatment. For example, it is clear that treatment of hypertension, diabetes, and HIV/AIDS is not adequate unless blood pressure, hemoglobin A1C, and HIV viral load are lowered to suggested goals, respectively. Evidence shows that African American patients are more likely to receive their health care from a small percentage of physicians.13 These physicians are quite likely to be African American themselves and are unlikely to care for a significant number of white patients. Although these physicians may share cultural background with their patients, clearly an advantage, they are less likely to be board certified and to feel that they can provide high quality care. Providers for African American patients reported more difficulties in getting access to subspecialists, to technical equipment, and to nonemergent admission to hospitals. The data are not all bad, however, as African American patients with HIV/ AIDS had shorter delays in receiving antiretroviral therapy if their provider was African American.14 In this study, African American patients with African American providers were more likely to be women, to have less than a high school education, have annual income less than $10,000, to be on Medicaid, and live in the Southeastern United States. This demonstrates that the population with the greatest challenges is being cared for by a small subset of the U.S. health care workforce. Cultural competence is clearly important in addressing the disparities in chronic diseases. As mentioned, many of these diseases are preventable with 268
simple healthy lifestyle practices. Complications of these diseases are significantly lowered with early diagnosis through appropriate screening programs and appropriate treatment. In addition, new treatment strategies allow for significant improvement in survival even when serious disease progression and complications have occurred. Success in implementing these strategies is dependent upon successful communication of their importance to the individual patient. Having some knowledge of and appreciation for the cultural background of the patient greatly enhances the likelihood that the patient will follow recommendations. Concordance of ethnicity between patient and provider should increase the likelihood of shared cultural background. Unfortunately, the numbers of African Americans and Hispanics graduating from United States medical schools are significantly below the percentage of the these groups in the general population.15 Similar trends are noted in nursing and dentistry. Therefore, all providers will be challenged to achieve cultural competence for their respective patient population. This represents a great challenge, as African American patients are more likely to have encounters where the provider is verbally dominant and patient-centered communication is lacking.16 Perhaps more telling is the observation that, in patient or physician interactions where the patient is African American, both patients and their providers report lower rates of positive affect.16 Conclusions and Possible Solutions to Health Disparities in Chronic Diseases The elimination of health disparities in the most common chronic diseases will require a gigantic, multidisciplinary effort. It is appropriate to concentrate efforts on chronic diseases, as this is where the largest impact on health disparities will be seen. Several interventions or factors that may contribute to the solution to this problem are listed in Table 3. The major challenge to eliminating health disparities in chronic diseases is improving access. Improved access to preventive health will facilitate early diagnosis and instruction in preventive practices. This may be the greatest challenge, as the number of physicians working in primary care is not adequate. Clearly, it will be necessary to effectively use nurse practitioners, physician assistants, registered nurses, and lay health advisors or community health advocates to facilitate appropriate access. Prevention is clearly the most cost effective method for dealing with chronic diseases and the disparities seen with them.1–3 Interventions that are relatively simple, such as smoking cessation and appropriate exercise and nutrition, will have enormous impact.1–3 Unfortunately, many health disparate populations do not live in neighborhoods where physical activity is an option, nutritious food items April 2008 Volume 335 Number 4
Crook and Peters
Table 3. Some Solutions to Health Disparities in Chronic Disease Management Electronic health records with Widely implement treatment treatment and screening guidelines and focus on reminders treating to goals Develop healthy communities Programs to improve to facilitate exercise and cultural competency of good nutrition providers Patient centered encounters Improved patient education Appropriately trained providers programs Identity and train novel Multidisciplinary care teams providers Focus on Prevention Lay health advisors/ Comprehensive state, community health county and city plans advocates Increase access to primary care providers and proven diagnostic and treatment regimens Loan forgiveness Substantial changes in reimbursement structure (pay for maintenance of health and cognitive efforts equal to or better than procedures) Universal access to proven pharmaceutical therapies Development of fair chronic disease management programs
are available, or smoking cessation will be supported. Implementing and supporting prevention strategies in the workplace or through health insurance are options that have been successful.17 Moreover, prevention strategies targeting specific highrisk populations have to be implemented. For example, a specific focus on the risk of HIV/AIDS and obesity and their consequences in young African American females is clearly necessary. These strategies will have to be monitored and revised to maximize their impact in local markets. Although preventive efforts are essential and deserve much more support, the high prevalence of these chronic diseases in the U.S. population requires that we have continued efforts focusing on the delivery of high quality care to those with disease. There has been debate regarding return on investment in employer-based or insurer-based disease management programs. Similarly, pay for performance (P4P) initiatives to “insure” quality of care have met with mixed reviews.18 Unfortunately, these initiatives are often discussed as vehicles to achieve immediate cost savings rather than interventions to improve long-term health (and the resulting cost saving that will come). In addition, there is reticence to invest the resources needed to implement these programs in a way that will be fair to all patients and providers. Clearly, health disparate populations and the providers who cater to them will require more resources on the front end to meet the standards outlined in current treatment guidelines.10 –12,18 As meeting these standards is essential to eliminating the disparities seen in chronic disease outcomes, the focus needs to be on how to get appropriate resources to those health disparate populations to reach these goals. Too often the conversation THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
has focused on the negative aspect of the potential for financially punitive actions for not meeting preset goals. Such an emphasis on the negative has created an atmosphere where those likely to care for health disparate populations start to consider other options. Programs facilitating expansion of primary care services (using physician extenders and multidisciplinary care teams), appropriate distribution of subspecialists and technology, and improved communication between providers are essential.19 Because health care in the United States is generally delivered via one-on-one provider or patient interactions, we must make sure that both providers and patients value and have confidence in these encounters. Assuring cultural competence, compassion for the challenges of life in health disparate populations, and high quality care for all individuals will facilitate this type of an environment. In conclusion, the disparities in incidence and outcomes in the most common chronic diseases in the United States are the major contributors to the overall health disparity burden. Eliminating health disparities in these chronic diseases will require great effort, but the payoff to the society is enormous. Reduced health care costs, increased years of productivity, and greater stability of atrisk communities will be the result of such efforts. The payoff is too large to ignore and can be achieved since we already know how to reduce the impact of these diseases. A focus on health disparities in chronic diseases will improve the health of all Americans. References 1. Smedley BD, Stith AY, Nelson AR, eds. Unequal treatment: confronting racial and ethnic disparities in health care. Washington (DC): Institute of Medicine, The National Academies Press; 2002. 2. Centers for Disease Control. National Center for Chronic Disease Prevention and Health Promotion. Chronic disease overview. Available at: www.cdc.gov/nccdphp/overview. Accessed July 2006. 3. Strong K, Mathers C, Leeder S, et al. Preventing chronic disease: how many lives can we save? Lancet 2005;366: 1578 – 82. 4. Jones DW, Chambliss LE, Folsom AR, et al. Risk factors for coronary heart disease in African Americans: the atherosclerosis risk in communities study, 1987–1997. Arch Intern Med 2002;162:2565–71. 5. From baby boom to elder boom: providing health care for an aging population. Washington (DC): Watson Wyatt Worldwide; 1996. Available at: www.cdc.gov. Accessed July 2006. 6. National Heart Lung and Blood Institute. Morbidity and mortality chartbook 2004. Washington (DC): National Institutes of Health; 2004. 7. Giles T, Aranda JM Jr, Suh D-C, et al. Ethnic/racial variations in blood pressure awareness, treatment, and control. J Clin Hypertens 2007;9:345–54. 8. Trivedi AN, Zaslavsky AM, Schneider EC, et al. Trends in the quality of care and racial disparities in Medicare managed care. N Engl J Med 2005;353:692–700.
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Chronic Diseases and Health Disparities
9. Schneider EC, Zaslavsky AM, Epstein AM. Racial disparities in the quality of care for enrollees in medicare managed care. JAMA 2002;287:1288 –94. 10. Hargraves JL, Cunningham PJ, Hughes RG. Racial and ethnic differences in access to medical care in managed care plans. Health Serv Res 2001;36:853– 68. 11. Quandt SA, Bell RA, Snively BM. Ethnic disparities in glycemic control among rural older adults with type 2 diabetes. Ethn Dis 2005;15:656 – 63. 12. Mainous AG III, King DE, Garr DR. Race, rural residence, and control of diabetes and hypertension. Ann Fam Med 2004;2:563– 68. 13. Bach PB, Pham HH, Schrag D, et al. Primary care physicians who treat blacks and whites. N Engl J Med 2004;351:575–84. 14. King WD, Wong MD, Shapiro MF, et al. Does racial concordance between HIV-positive patients and their physicians affect the time to receipt of protease inhibitors? J Gen
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15. 16. 17. 18. 19.
Intern Med 2004;19:1146 –53. Available at: www.aamc.org. Accessed July 2006. American Association of Medical Colleges. Medical school graduates 2005. Available at: www.aamc.org. Accessed July 2005. Johnson RL, Roter D, Powe NR, et al. Patient race/ ethnicity and quality of patient-physician communication during medical visits. Am J Public Health 2004;94:2084 –90. Fouad MN. A hypertension control program tailored to unskilled and minority workers. Ethnic Dis 2000;6:439 –53. Rosenthal MB, Frank RG, Li Z, et al. Early experience with pay-for-performance: from concept to practice. JAMA 2005;294:1788 –93. Jenkins RG, Ornstein SM, Niebert PJ, et al. Quality improvement for prevention of cardiovascular disease and stroke in an academic family medicine center: do racial differences in outcome exist? Ethn Dis 2006;16:132–7.
April 2008 Volume 335 Number 4
ABSTRACT: Chronic diseases account for three-quarters of the U.S. health care expenditures and a majority of early deaths and lost of productive years of life. Health disparities exist among the common chronic diseases, such as hypertension, diabetes mellitus, HIV/AIDS, cancer, cardiovascular disease, and obesity, with ethnic minorities and the poor having higher incidence or worse outcomes. Strategies to eliminate these disparities
in chronic diseases need to be multidisciplinary and focus on increasing access to all aspects of health care, including prevention. This article discusses the impact of health disparities on chronic diseases and offers some factors to consider for solutions to the problem. KEY INDEXING TERMS: Health disparities; Chronic diseases; African American; Preventive health. [Am J Med Sci 2008;335(4):266–270.]
D
2 or more of these common ailments in a single individual, particularly in the health disparate populations in our region.
isparities exist in the incidence and outcomes of several chronic diseases.1,2 These disparities have been present for several decades but their impact has significantly increased in many disease areas. Clearly, there are disparities in the incidence of diseases like sickle cell anemia and cystic fibrosis along ethnic or racial lines for genetic reasons. Moreover, there are disparities in much more common diseases for reasons that are not fully understood. The advances in medicine over the last several decades have greatly impacted the course of many common chronic diseases and have changed their prognosis from being quite pessimistic to rather optimistic. For the purposes of this discussion, we will deal with chronic diseases where health may be maintained for several years with appropriate therapy and where we may have the most impact. In addition, we will focus our discussion on issues affecting African American and rural populations, as those are the health disparate populations that predominate in the Upper Gulf Coast Region of the United States. The complications of these diseases may be delayed for years or avoided altogether, if appropriate therapy is available and applied. These diseases often cluster, and it is more common than not to find
From the Department of Medicine and Center for Healthy Communities, University of South Alabama College of Medicine, Mobile, Alabama. Submitted December 13, 2007; accepted in revised form January 8, 2008. This work was supported by NIH/NCMHHD5 grant R24 MD001094-02 (EDC). Correspondence: Errol D. Crook, MD, Department of Internal Medicine, University of South Alabama College of Medicine, Mastin 400-A, 2451 Fillingim Street, Mobile, AL (E-mail: ecrook@ usouthal.edu).
266
Impact of Chronic Diseases Chronic diseases are the leading cause of death and disability in the United States.2,3 They account for 7 of every 10 deaths and affect the quality of life of 90 million Americans. The impact of chronic diseases on mortality is seen at early ages, as chronic diseases account for one-third of the years of potential life lost before age 65. At least 10% of Americans have a severe limitation in their daily activity due to a chronic disease process. In economic terms, the costs of chronic diseases are enormous.2,3 At least three-quarters of the nation’s $1.4 trillion health care costs are for care of individuals with chronic diseases. Cardiovascular disease, diabetes, arthritis, and smoking account for $300 billion, $132 billion, $82 billion, and $75 billion in costs, respectively.2 Moreover, many individuals with chronic diseases have excess lost of years of productive life resulting in significant loss of potential income for their families.2 This loss of income in an adult who functions as a head of household or significant contributor to family income puts the health of the entire family at risk, as it may result in poorer access to health insurance (and therefore, health care), quality education, and safe neighborhoods. Clearly, eliminating disparities in chronic diseases will have a major economic impact. This impact will be seen in reduction of health care costs, but perhaps more importantly, will also be seen in increased earnings over a lifetime and lower poverty rates, particularly for ethnic minorities. April 2008 Volume 335 Number 4
Crook and Peters
Table 1. Common Chronic Diseases in Adults in the United States
Treated as Chronic Diseases Before 1950 Heart Disease* Hypertension* Asthma/Chronic Obstructive Lung Disease Liver Disease Arthritis Diabetes*⫹
Relative Recent Additions to List of Treated Chronic Diseases Stroke* Obesity* Cancer* HIV/AIDS and Hepatitis C* Mental Illness Dyslipidemia
* Chronic diseases where major disparities exist among ethnic minorities in incidence and/or outcomes. ⫹ While treatment was available for diabetes before 1950, outcomes were generally poor, therefore it can be considered a relative new comer to the treated chronic disease list.
Importantly, many of these diseases are preventable. Implementing healthy lifestyle practices, including healthy diet, physical activity, responsible sexual behavior, and avoidance of tobacco, harmful and illegal drugs significantly decrease the incidences and complications of these disease processes. Maintaining an active lifestyle and avoidance of becoming overweight or use of tobacco lead to an 80% reduction in the likelihood of developing many of our major common diseases.2,4 Chronic Diseases: A New Paradigm Table 1 lists many of the common chronic diseases that are seen in United States adults. In all of these diseases, disparities in incidences and complications exist. In general, the trends for these disparities are similar across the disease areas, such that ethnic minorities, particularly African Americans and Hispanics, and people in lower social economic groups are much more likely to suffer from these diseases and have worse outcomes.1,2,4 In addition, the elderly, the fastest growing segment of the population of the United States, also has higher incidence and more complications from these processes.5 We note that diseases such as obesity, cancer, HIV/AIDS, dyslipidemia, mental illness, hepatitis C, stroke, and diabetes should be considered relative newcomers to the list of chronic diseases. Although many of these diseases, like stroke, diabetes, and cancer, have been around for almost as long as man, the prognosis from these diseases was quite unfavorable until recently. A few decades ago, strokes were much more likely to be fatal, cancer had a uniformly very poor prognosis, and survival with diabetes for long period of times was uncommon, making the label of chronic disease a misnomer. For example, in 1950 stroke death rates were 220 to 240 per 100,000 in African Americans and 160 to 275 per 100,000 in whites, but dropped to 75 and 50 per THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
100,000 in African Americans and whites, respectively, in 2002.6 Incidence rates have not been similarly reduced, resulting in more individuals surviving with stroke and its many complications. Despite the decrease in mortality rates in both African Americans and whites, a disparity clearly remains. Similar trends can be seen for cardiovascular disease.6 HIV/AIDS and hepatitis C are newcomers to the disease landscape with their discoveries in the 1980s. Advanced scientific technology resulted in the speedy discovery of their pathophysiology, risk factors, and effective treatment modalities to allow for prolonged survival, and, hence, the label of a chronic disease. Approaching obesity, dyslipidemia, endstage renal disease, and mental illness as chronic diseases has gained favor only in the last 3 to 4 decades as their incidence has increased and effective treatments have become available. For example, the demonstration that dialysis was feasible in the community and the commitment to make that procedure available to individuals with endstage renal disease occurred less than 40 years ago. Health Disparities in Chronic Diseases—Special Considerations Table 2 lists a number of factors that are important considerations when discussing health disparities in chronic diseases, particularly among African Americans in the Southeast United States. In general, ethnic minorities and the poor are more likely to have lack of awareness of common chronic diseases and their risk factors.1,2 This results in diagnosis when the disease is more advanced and preventive strategies are less likely to be effective. National programs in hypertension, diabetes, HIV/ AIDS, and cancer awareness are ongoing and, in many cases, successful. For example, the hypertension education initiatives over the last 4 decades were successful and have resulted in awareness
Table 2. Some Important Factors Contributing to Health Disparities in Chronic Diseases Late diagnosis due to limitations in disease awareness Disparities in quality of care for African Americans and poor Less likely to reach treatment goals/standards Less likely to have access to new technology for diagnosis and treatment Limitations in cultural competence among health care providers Special concerns in rural populations Higher rates of poverty Lack of access to providers, technology, and procedures Disparities in quality of care as outlined above Low levels of confidence in health care provider and health care system among health disparate populations Low levels of provider satisfaction/positive affect when caring for health disparate populations
267
Chronic Diseases and Health Disparities
rates of hypertension in African Americans being similar to those of whites.7 A major concern is the quality of care received once individuals are diagnosed with a chronic disease. In many cases, guidelines exist that outline treatment strategies and targets for those strategies (so-called “best practices”). These guidelines are based on the best evidence available as interpreted by international experts. However, despite these “best practice” recommendations, many individuals in health disparate populations receive care that is of lower quality. Several studies have demonstrated that African Americans, in particular, are less likely to receive proven therapy including highly technical and innovative procedures or to achieve recommended treatment targets in the areas of diabetes, hypertension, cancer, cardiovascular disease, HIV/ AIDS, and mental illness.8 –10 In rural areas similar trends are observed, with both whites and African Americans being affected. Moreover, incidence and control rates of hypertension and diabetes are worse in rural areas when compared with urban areas.11,12 In rural areas, timely access, particularly to highly technical procedures, is clearly limited, but lower incomes also play a major role in these worse outcomes. Finally, it is important to point out that achieving treatment targets is significantly more important than simply initiating treatment. For example, it is clear that treatment of hypertension, diabetes, and HIV/AIDS is not adequate unless blood pressure, hemoglobin A1C, and HIV viral load are lowered to suggested goals, respectively. Evidence shows that African American patients are more likely to receive their health care from a small percentage of physicians.13 These physicians are quite likely to be African American themselves and are unlikely to care for a significant number of white patients. Although these physicians may share cultural background with their patients, clearly an advantage, they are less likely to be board certified and to feel that they can provide high quality care. Providers for African American patients reported more difficulties in getting access to subspecialists, to technical equipment, and to nonemergent admission to hospitals. The data are not all bad, however, as African American patients with HIV/ AIDS had shorter delays in receiving antiretroviral therapy if their provider was African American.14 In this study, African American patients with African American providers were more likely to be women, to have less than a high school education, have annual income less than $10,000, to be on Medicaid, and live in the Southeastern United States. This demonstrates that the population with the greatest challenges is being cared for by a small subset of the U.S. health care workforce. Cultural competence is clearly important in addressing the disparities in chronic diseases. As mentioned, many of these diseases are preventable with 268
simple healthy lifestyle practices. Complications of these diseases are significantly lowered with early diagnosis through appropriate screening programs and appropriate treatment. In addition, new treatment strategies allow for significant improvement in survival even when serious disease progression and complications have occurred. Success in implementing these strategies is dependent upon successful communication of their importance to the individual patient. Having some knowledge of and appreciation for the cultural background of the patient greatly enhances the likelihood that the patient will follow recommendations. Concordance of ethnicity between patient and provider should increase the likelihood of shared cultural background. Unfortunately, the numbers of African Americans and Hispanics graduating from United States medical schools are significantly below the percentage of the these groups in the general population.15 Similar trends are noted in nursing and dentistry. Therefore, all providers will be challenged to achieve cultural competence for their respective patient population. This represents a great challenge, as African American patients are more likely to have encounters where the provider is verbally dominant and patient-centered communication is lacking.16 Perhaps more telling is the observation that, in patient or physician interactions where the patient is African American, both patients and their providers report lower rates of positive affect.16 Conclusions and Possible Solutions to Health Disparities in Chronic Diseases The elimination of health disparities in the most common chronic diseases will require a gigantic, multidisciplinary effort. It is appropriate to concentrate efforts on chronic diseases, as this is where the largest impact on health disparities will be seen. Several interventions or factors that may contribute to the solution to this problem are listed in Table 3. The major challenge to eliminating health disparities in chronic diseases is improving access. Improved access to preventive health will facilitate early diagnosis and instruction in preventive practices. This may be the greatest challenge, as the number of physicians working in primary care is not adequate. Clearly, it will be necessary to effectively use nurse practitioners, physician assistants, registered nurses, and lay health advisors or community health advocates to facilitate appropriate access. Prevention is clearly the most cost effective method for dealing with chronic diseases and the disparities seen with them.1–3 Interventions that are relatively simple, such as smoking cessation and appropriate exercise and nutrition, will have enormous impact.1–3 Unfortunately, many health disparate populations do not live in neighborhoods where physical activity is an option, nutritious food items April 2008 Volume 335 Number 4
Crook and Peters
Table 3. Some Solutions to Health Disparities in Chronic Disease Management Electronic health records with Widely implement treatment treatment and screening guidelines and focus on reminders treating to goals Develop healthy communities Programs to improve to facilitate exercise and cultural competency of good nutrition providers Patient centered encounters Improved patient education Appropriately trained providers programs Identity and train novel Multidisciplinary care teams providers Focus on Prevention Lay health advisors/ Comprehensive state, community health county and city plans advocates Increase access to primary care providers and proven diagnostic and treatment regimens Loan forgiveness Substantial changes in reimbursement structure (pay for maintenance of health and cognitive efforts equal to or better than procedures) Universal access to proven pharmaceutical therapies Development of fair chronic disease management programs
are available, or smoking cessation will be supported. Implementing and supporting prevention strategies in the workplace or through health insurance are options that have been successful.17 Moreover, prevention strategies targeting specific highrisk populations have to be implemented. For example, a specific focus on the risk of HIV/AIDS and obesity and their consequences in young African American females is clearly necessary. These strategies will have to be monitored and revised to maximize their impact in local markets. Although preventive efforts are essential and deserve much more support, the high prevalence of these chronic diseases in the U.S. population requires that we have continued efforts focusing on the delivery of high quality care to those with disease. There has been debate regarding return on investment in employer-based or insurer-based disease management programs. Similarly, pay for performance (P4P) initiatives to “insure” quality of care have met with mixed reviews.18 Unfortunately, these initiatives are often discussed as vehicles to achieve immediate cost savings rather than interventions to improve long-term health (and the resulting cost saving that will come). In addition, there is reticence to invest the resources needed to implement these programs in a way that will be fair to all patients and providers. Clearly, health disparate populations and the providers who cater to them will require more resources on the front end to meet the standards outlined in current treatment guidelines.10 –12,18 As meeting these standards is essential to eliminating the disparities seen in chronic disease outcomes, the focus needs to be on how to get appropriate resources to those health disparate populations to reach these goals. Too often the conversation THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
has focused on the negative aspect of the potential for financially punitive actions for not meeting preset goals. Such an emphasis on the negative has created an atmosphere where those likely to care for health disparate populations start to consider other options. Programs facilitating expansion of primary care services (using physician extenders and multidisciplinary care teams), appropriate distribution of subspecialists and technology, and improved communication between providers are essential.19 Because health care in the United States is generally delivered via one-on-one provider or patient interactions, we must make sure that both providers and patients value and have confidence in these encounters. Assuring cultural competence, compassion for the challenges of life in health disparate populations, and high quality care for all individuals will facilitate this type of an environment. In conclusion, the disparities in incidence and outcomes in the most common chronic diseases in the United States are the major contributors to the overall health disparity burden. Eliminating health disparities in these chronic diseases will require great effort, but the payoff to the society is enormous. Reduced health care costs, increased years of productivity, and greater stability of atrisk communities will be the result of such efforts. The payoff is too large to ignore and can be achieved since we already know how to reduce the impact of these diseases. A focus on health disparities in chronic diseases will improve the health of all Americans. References 1. Smedley BD, Stith AY, Nelson AR, eds. Unequal treatment: confronting racial and ethnic disparities in health care. Washington (DC): Institute of Medicine, The National Academies Press; 2002. 2. Centers for Disease Control. National Center for Chronic Disease Prevention and Health Promotion. Chronic disease overview. Available at: www.cdc.gov/nccdphp/overview. Accessed July 2006. 3. Strong K, Mathers C, Leeder S, et al. Preventing chronic disease: how many lives can we save? Lancet 2005;366: 1578 – 82. 4. Jones DW, Chambliss LE, Folsom AR, et al. Risk factors for coronary heart disease in African Americans: the atherosclerosis risk in communities study, 1987–1997. Arch Intern Med 2002;162:2565–71. 5. From baby boom to elder boom: providing health care for an aging population. Washington (DC): Watson Wyatt Worldwide; 1996. Available at: www.cdc.gov. Accessed July 2006. 6. National Heart Lung and Blood Institute. Morbidity and mortality chartbook 2004. Washington (DC): National Institutes of Health; 2004. 7. Giles T, Aranda JM Jr, Suh D-C, et al. Ethnic/racial variations in blood pressure awareness, treatment, and control. J Clin Hypertens 2007;9:345–54. 8. Trivedi AN, Zaslavsky AM, Schneider EC, et al. Trends in the quality of care and racial disparities in Medicare managed care. N Engl J Med 2005;353:692–700.
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9. Schneider EC, Zaslavsky AM, Epstein AM. Racial disparities in the quality of care for enrollees in medicare managed care. JAMA 2002;287:1288 –94. 10. Hargraves JL, Cunningham PJ, Hughes RG. Racial and ethnic differences in access to medical care in managed care plans. Health Serv Res 2001;36:853– 68. 11. Quandt SA, Bell RA, Snively BM. Ethnic disparities in glycemic control among rural older adults with type 2 diabetes. Ethn Dis 2005;15:656 – 63. 12. Mainous AG III, King DE, Garr DR. Race, rural residence, and control of diabetes and hypertension. Ann Fam Med 2004;2:563– 68. 13. Bach PB, Pham HH, Schrag D, et al. Primary care physicians who treat blacks and whites. N Engl J Med 2004;351:575–84. 14. King WD, Wong MD, Shapiro MF, et al. Does racial concordance between HIV-positive patients and their physicians affect the time to receipt of protease inhibitors? J Gen
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Intern Med 2004;19:1146 –53. Available at: www.aamc.org. Accessed July 2006. American Association of Medical Colleges. Medical school graduates 2005. Available at: www.aamc.org. Accessed July 2005. Johnson RL, Roter D, Powe NR, et al. Patient race/ ethnicity and quality of patient-physician communication during medical visits. Am J Public Health 2004;94:2084 –90. Fouad MN. A hypertension control program tailored to unskilled and minority workers. Ethnic Dis 2000;6:439 –53. Rosenthal MB, Frank RG, Li Z, et al. Early experience with pay-for-performance: from concept to practice. JAMA 2005;294:1788 –93. Jenkins RG, Ornstein SM, Niebert PJ, et al. Quality improvement for prevention of cardiovascular disease and stroke in an academic family medicine center: do racial differences in outcome exist? Ethn Dis 2006;16:132–7.
April 2008 Volume 335 Number 4