Today we continue our historical look back to the origins of Healthcare Disparities. The last blog discussed the international origins. Today's blog will focus on the US recognition.
In the United States, scientific evidence from several lines of inquiry examining outcomes and patterns of health care began to converge in the late 1970's and early 1980's to suggest differential health outcomes across patient groups and the importance of "nonbiologic" social, environmental and cultural factors in determining health outcomes. Medical researchers demonstrated that large variability in services provided and patient outcomes existed between clinical practices in different parts of the country, despite treating clinically similar patients. Prior to this, it was largely assumed by some that all practices provided essentially the same care to patients with similar illnesses. As public awareness grew, the US government released a report documenting that, while the overall health of the nation was relatively good, major differences existed in “the burden of death and illness experienced by blacks and other minority Americans as compared with the nation's population as a whole.
The secretary of the Department of Health and Human Services then established a task force on black and minority health—the first time that the US government formed a group of experts to conduct a comprehensive study of minority health problems. In 1985, release of the report of the task force significantly raised awareness of the disparate health of the country’s minority groups as compared to the white majority population. In addition large epidemiologic studies like the Harvard Medical Practice Study emerged, documenting that a significant portion of practice variability could be classified as substandard care and that there was a correlation between substandard care and hospitals treating substantial numbers of poor and minority patients. By the late 1990s, the scientific evidence seemed to indicate that issues of disparity, practice variation, substandard care, and socioenvironmental determinants of health may all be related to the quality of health care experienced by patients.
Health Disparities are generally defined as population differences in environmental exposures, health care access, utilization, or quality, health status, or health outcomes. Within the US health care system these differences have most convincingly been demonstrated across racial and ethnic lines (whites vs. minorities); however, disparities based on other categorizations have also been described, including geography, gender, socioeconomic status and age. Health disparities are generally thought to be related to the health care system and other social factors. To help bring clarity to these issues, the Institute of Medicine released the first of several reports highlighting and summarizing the scientific evidence concerning issues of differential health status, culture, behavior, communication, substandard care/medical errors, and health care quality. The work of the IOM on disparity issues culminated with the 2003 release of a report entitled “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” which found that, within the United States, even among individuals with access to healthcare, significant racial and ethnic disparities indeed existed and were related to historic and contemporary social and economic inequality, discrimination, and a fragmented US system of health care. Portions of this blog were taken from the article entitled eHealth Solutions for healthcare disparities by MC Gibbons.
Thursday, February 25, 2010
Tuesday, February 23, 2010
In the Begining of Disparities
The International Origins of Disparities
Over the past decade, a rapidly expanding body of scientific evidence has been put forth documenting differences in health status among US racial and ethnic groups. Evidence has also mounted suggesting that these differences may be related to both medical and nonmedical determinants. Internationally, however, neither the evidence nor the realization of a link between nonmedical sociobehavioral factors and health outcomes is new. The earliest reported observation of a hypothesized association between socioenvironmental risk factors and health outcomes occurred in Italy over three centuries ago when Bernardino Ramazzini detailed an unusually high frequency of breast cancer in Catholic nuns. Not long thereafter, in 1775, British surgeon Sir Percival Pott reported a cluster of scrotal cancer cases among British chimney sweeps.
By the mid 19th century, large-scale epidemiologic evidence began to corroborate these early observations. In 1840, Edwin Chadwick, British civil servant and statistician, demonstrated mortality differentials between the social classes living in Liverpool, England. Chadwick asserted that these differences were likely due to poverty and lifestyle factors common to the poorer working classes. German physician Rudolph Virchow went a step further when, in 1849, he asserted that because diseases of the populace are traceable to defects in society, the focus of medicine should shift from changing the individual to that of changing the society. Finally, in France, French physician Louis Villerme recommended improving school and working conditions as social interventions that would reduce class differences in mortality. Thus, in Europe, by the beginning of the 20th century, the existence of class variations in morbidity and mortality were clearly evident in the scientific literature.
Throughout the 20th century the study of social class differences in health status continued across Europe, especially in Britain were epidemiologists began using decennial census data to evaluate national mortality trends. The insights gained from these analyses enabled them to construct an occupational social class grading system that correlated inversely with infant mortality. It also was the basis of the claim made by the Registrar General of Britain that at least 40% of British infant mortality was entirely preventable if the social conditions of poor infants could be elevated to that of upper-class infants.
Two British researchers, Titmuss and Logan, evaluated regional class–based mortality trends and documented that the disparity in infant mortality rates between upper- and lower-class infants continued to increase from 1910 to 1950. This data, along with the Depression and World War II, encouraged the British government, in 1942, to respond by instituting the welfare state and promoting several policy initiatives designed to address the “five giants of Want, Disease, Ignorance, Squalor and Idleness”. Despite this government investment, however, problems attributable to social inequalities and inadequate access to health care persisted. In fact, by the mid 1970s, some 30 years later, the evidence seemed to indicate that the problems were still increasing and that the health of British citizens was slipping behind that of other industrialized nations. Thus, in 1977, the British government formed the Research Working Group on Inequalities in Health and selected Sir Douglas Black as its chair. The committee’s report, issued three years later in 1980, became known as the Black Report, and it represents the first attempt by a national government to systematically study, understand, and explain health inequalities. In summary, the health improvement recommendations of the report emphasized the need to improve the physical and the social environment in which the poor and lower classes lived.
My next blog will discuss the origins of Healthcare Disparities in the US. Portions of this post were taken from the article eHealth Solutions for Healthcare Disparities published in the Journal of Medical Internet Research in 2005 by MC Gibbons.
Over the past decade, a rapidly expanding body of scientific evidence has been put forth documenting differences in health status among US racial and ethnic groups. Evidence has also mounted suggesting that these differences may be related to both medical and nonmedical determinants. Internationally, however, neither the evidence nor the realization of a link between nonmedical sociobehavioral factors and health outcomes is new. The earliest reported observation of a hypothesized association between socioenvironmental risk factors and health outcomes occurred in Italy over three centuries ago when Bernardino Ramazzini detailed an unusually high frequency of breast cancer in Catholic nuns. Not long thereafter, in 1775, British surgeon Sir Percival Pott reported a cluster of scrotal cancer cases among British chimney sweeps.
By the mid 19th century, large-scale epidemiologic evidence began to corroborate these early observations. In 1840, Edwin Chadwick, British civil servant and statistician, demonstrated mortality differentials between the social classes living in Liverpool, England. Chadwick asserted that these differences were likely due to poverty and lifestyle factors common to the poorer working classes. German physician Rudolph Virchow went a step further when, in 1849, he asserted that because diseases of the populace are traceable to defects in society, the focus of medicine should shift from changing the individual to that of changing the society. Finally, in France, French physician Louis Villerme recommended improving school and working conditions as social interventions that would reduce class differences in mortality. Thus, in Europe, by the beginning of the 20th century, the existence of class variations in morbidity and mortality were clearly evident in the scientific literature.
Throughout the 20th century the study of social class differences in health status continued across Europe, especially in Britain were epidemiologists began using decennial census data to evaluate national mortality trends. The insights gained from these analyses enabled them to construct an occupational social class grading system that correlated inversely with infant mortality. It also was the basis of the claim made by the Registrar General of Britain that at least 40% of British infant mortality was entirely preventable if the social conditions of poor infants could be elevated to that of upper-class infants.
Two British researchers, Titmuss and Logan, evaluated regional class–based mortality trends and documented that the disparity in infant mortality rates between upper- and lower-class infants continued to increase from 1910 to 1950. This data, along with the Depression and World War II, encouraged the British government, in 1942, to respond by instituting the welfare state and promoting several policy initiatives designed to address the “five giants of Want, Disease, Ignorance, Squalor and Idleness”. Despite this government investment, however, problems attributable to social inequalities and inadequate access to health care persisted. In fact, by the mid 1970s, some 30 years later, the evidence seemed to indicate that the problems were still increasing and that the health of British citizens was slipping behind that of other industrialized nations. Thus, in 1977, the British government formed the Research Working Group on Inequalities in Health and selected Sir Douglas Black as its chair. The committee’s report, issued three years later in 1980, became known as the Black Report, and it represents the first attempt by a national government to systematically study, understand, and explain health inequalities. In summary, the health improvement recommendations of the report emphasized the need to improve the physical and the social environment in which the poor and lower classes lived.
My next blog will discuss the origins of Healthcare Disparities in the US. Portions of this post were taken from the article eHealth Solutions for Healthcare Disparities published in the Journal of Medical Internet Research in 2005 by MC Gibbons.
Sunday, February 21, 2010
Sunday, February 14, 2010
Medical Homes and Healthcare Disparities
Among the many ideas for potential solutions for what ails our healthcare system is an idea referred to as Patient Centered Medical Homes. No, this does not refer to changes in the building codes that might improve health outcomes. Rather it refers to a model of healthcare delivery that facilitates partnerships between patients, their personal physicians and family members. The concept is not new. It was originally introduced in the late 1960’s, but it was not until 25 years later in 1992, that the American Academy of Pediatrics first defined what a medical home actually was. Ten years later in 2002 that definition was revised and expanded. That same year the nations Family Medicine physicians introduced the recommendation that every person should have a medical home where patients could obtain all needed high quality services in the same place, in settings that are patient oriented and physician driven. By 2005 an “Advanced Medical Home” model was developed that involved, among other things, the use of electronic decision support tools and health information technology for healthcare providers. In 2006 IBM and eventually some 500 other business organizations began promoting the Medical Home as an important model to help improve health and drive down healthcare costs for the nations largest businesses through what became known as the Patient-Centered Primary Care Collaborative. Finally in 2007 the nations leading primary care physician’s organizations came together and released the “Joint Principles” of the Patient-Centered Medical Home. These principles are 1) each patient should have a single personal physician that ideally would be with that person from birth to death. 2) The personal physician is the leader of a team of individuals who collectively care for patients. 3) the personal physician is responsible for all aspects of a patient’s healthcare needs or arranging needed services found elsewhere 4) All healthcare is coordinated and integrated across care settings (hospitals, nursing homes and home health agencies) 5) Quality and Safety of services is a priority that is enhanced via HIT tools for physician decision support 6) Care is available whenever a patient needs it, regardless of the patient’s ability to pay 7) Physician reimbursement and payment enhancements should accompany and reward improved outcomes and additional investments. Undoubtedly these 7 principles would lead to improvements in our healthcare system. Indeed several early studies suggest a benefit, and now through the stimulus funds from the US government, considerable funds are pouring out to finance and encourage the initial investments, start up costs and sustainability of medical homes throughout the country. But what impact will this model have on healthcare disparities? Several authors have suggested that it would reduce disparities, however the scientific basis for this assertion appears weak at best, and a close inspection, strongly suggests that it is unlikely that this model alone will improve disparities. However we can have cautious optimism, if we go forward including in the patient centered medical home model, what we already know will help reduce disparities in healthcare outcomes. Click back for my future blogs when I will discuss the challenges faced and promising strategies for going forward and reducing healthcare disparities within the context of the Patient Centered Medical Home.
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