Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement

“Ensuring the delivery of high-quality, patient-centered care requires understanding the needs of the populations served. The nation’s health care data infrastructure does not provide the necessary level of detail to understand which groups are experiencing health care disparities or would benefit from targeted quality improvement efforts. Categories for collection and methods of aggregation for reporting race, ethnicity, and language data vary. Challenges to improving data quality include non-standardized categories, a lack of understanding of why data are collected, health information technology (HIT) limitations, and a lack of sufficiently descriptive response categories, among others. Throughout the course of this report, the subcommittee addresses these challenges as it recommends a standardized approach to eliciting race, ethnicity, and language data and defines a standard set of categories for these data.”
Read the report brief at: http://www.iom.edu/Object.File/Master/72/817/Race%20Ethnicity%20report%20brief%20FINAL%20for%20web.pdf
The full report can be accessed at: http://www.nap.edu/catalog.php?record_id=12696

Analysis of Social Determinants of Health and Health Inequities: A Multi-Country Event on Approaches and Policy

Kosice, Slovakia 12-17 October 2009
Routine monitoring of health inequities and the social determinants of health are critical to improving population health and in reducing avoidable difference in health opportunities and risks. However, this area remains generally limited or marginal within health intelligence functions and mainstream policy practice.
The WHO Regional Office for Europe through its Office for Investment for Health and Development (WHO Venice Office) is organizing a multi-country event, in collaboration with the Faculty of Medicine of P.J. Safarik University and the Kosice Institute for Society and Health (KISH), focusing on applied research and policy analysis on social determinants of health and health inequities.
Aims
1. Provide a forum for policy-makers, planners and analysts specifically from countries of central and Eastern Europe (CCEE) the Baltic states and Balkans republics, to debate, test and apply know-how, tools and practical techniques to monitor and analyze social inequities in health. 2. Strengthen and guide existing capacity and intelligence in using evidence and analytical tools to advance national and sub-national strategies and targets to reduce social inequities in health.
Thematic areas include
Contemporary issues in the research and analysis of Social Determinants of Health and Health Inequities (SDHI) Explanatory frameworks for social inequities in health Health equity surveillance - data availability and equity stratifiers in routine statistics and reporting Approaches and methods in analysis of social determinants of health and health inequities. Ethnicity in research and policy Translation of research findings into policy and programs. Equity focused policy analyses and option generation Economic analyses and incentives for addressing social determinants of health. Public awareness of Social Inequities
Event website: http://www.lf.upjs.sk/omek/ http://www.euro.who.int/socialdeterminants/news/20090714_1

Health Reform Briefing: “Health Equity: A Moral and Economic Imperative!”

On September 17, 2009, The Joint Center for Political and Economic Studies Health Policy Institute partnered with Drexel University School of Public Health’s Center for Health Equality and Health Management Associates to analyze major health reform legislation by assessing the implications for racial and ethnic minorities.
The Joint Center is also working with Johns Hopkins University Bloomberg School of Public Health’s Center for Health Disparities Solutions to weigh the economic benefits of addressing health disparities against the cost of programs to reduce them.
Participants Included:
The Honorable Kathleen Sebelius, Secretary, U.S. Department of Health and Human Services
Ralph B. Everett, Esq., President and CEO, Joint Center for Political and Economic Studies
Brian D. Smedley, Ph.D., Vice President and Director, Health Policy Institute, Joint Center for Political and Economic Studies
Dennis P. Andrulis, Ph.D., MPH, Director, Center for Health Equality and Associate Dean of Research, Drexel University
Darrell Gaskins, Ph.D., Associate Professor of Health Economics, African American Studies Department,University of Maryland, College Park
Thomas A. LaVeist, Ph.D., Director of the Johns Hopkins University Bloomberg School of Public Health’s Center for Health Disparities Solutions
View the event webcast at following the link below:
http://www.jointcenter.org/hpi/events/health-reform-briefing-%E2%80%9Chealth-equity-moral-and-economic-imperative%E2%80%9D

Income, Poverty, and Health Insurance Coverage in the United States: 2008

“This report presents data on income, poverty, and health insurance coverage in the United States based on information collected in the 2009 and earlier Annual Social and Economic Supplements (ASEC) to the Current Population Survey (CPS) conducted by the U.S. Census Bureau.
Data presented in this report indicate the following:
• Real median household income fell between 2007 and 2008, and the decline was widespread. Median income fell for family and nonfamily households, native- and foreign-born households, households in 3 of the 4 regions, and households of each race category and those of Hispanic origin.1 These declines in income coincide with the recession that started in December 2007.2
• The poverty rate increased between 2007 and 2008.
• The percentage of uninsured in 2008 was not statistically different from 2007, while the number of uninsured increased between 2007 and 2008.
These results, though widespread, were not uniform across groups. For example, between 2007 and 2008, real median income was statistically unchanged for households maintained by a person 65 years old and over but declined for households maintained by people of all other age group categories. Additionally, the poverty rate increased for children under 18 and for people 18 to 64 but remained statistically unchanged for people 65 and over; and the percentage of uninsured for non-Hispanic Whites, Asians, and Hispanics increased, while the percentage of uninsured for Blacks was not statistically diff erent.3
These results are discussed in more detail in the three main sections of this report—income, poverty, and health insurance coverage. Each section presents estimates by characteristics such as race, Hispanic origin, also derive economic well-being from noncash benefits, such as food stamps and housing subsidies, and they have reductions in disposable income due to taxes and increases in disposable income due to refundable tax credits. The official poverty thresholds were developed more than 40 years ago and have been criticized for not taking into account rising standards of living, expenses such as child care that are necessary to hold a job, variations in medical costs across population groups, and geographic differences in the cost of living.”
The full report can be accessed at:
http://www.census.gov/prod/2009pubs/p60-236.pdf
For additional information on the source of the data and accuracy of the estimates in the report, visit: http://www.census.gov/hhes/www/p60_236sa.pdf

Education Matters for Health

“Education can influence health in many ways. An issue brief, prepared by the Robert Wood Johnson Foundation Commission to Build a Healthier America, examines three major interrelated pathways through which educational attainment is linked with health—health knowledge and behaviors; employment and income; and social and psychological factors, including sense of control, social standing and social support. In addition, this brief explores how educational attainment affects health across generations, examining the links between parents’ education—and the social and economic advantages it represents—and their children’s health and social advantages, including opportunities for educational attainment.”
Access the brief by following the link below:
http://www.rwjf.org/files/research/commission2009eduhealth.pdf

Understanding Health Inequalities

(image source)
Understanding Health Inequalities
Graham H (ed).
2nd ed. Open University Press, 2009.

http://www.mcgraw-hill.co.uk/html/0335234593.html

“Understanding Health Inequalities second edition provides an accessible and engaging exploration of why the opportunity to live a long and healthy life remains profoundly unequal.

Hilary Graham and her contributors outline the enduring link between people’s socioeconomic circumstances and their health and tackle questions at the forefront of research and policy on health inequalities. These include:
* How health is influenced by circumstances across people's lives and by the areas in which they live
* How health is simultaneously shaped by inequalities of gender, ethnicity and socioeconomic position
* How policies can impact on health inequalities

All the chapters have been specially written for the new edition by internationally-recognized researchers in social and health inequalities. The book provides an authoritative guide to these fields as well as presenting new research.”

Book blurb:

"Thoroughly updated and revised, this new edition of Understanding Health Inequalities, edited by Hilary Graham, remains a welcome and timely contribution. Replete with thoughtful essays on health inequities analyzed in relation to societal structure, social position and geography ... the volume provides important insights into how class, racial/ethnic, gender, and spatial health inequities are produced - and how they can be rectified. The world economic crisis launched by the implosion of unregulated financial markets in the fall of 2008 only serves to underscore the volume's central conclusion: that government regulation and intervention, premised on a commitment to equity, is essential for tackling health inequalities. Health professionals, students, and any and all working for healthy and sustainable ways of living will benefit from this collection." Nancy Krieger, Harvard School of Public Health, USA

Contributors
Karl Atkin, Mel Bartley, G. David Batty, David Blane, Bo Burstrom, Danny Dorling, Anne Ellaway, Hilary Graham, Barbara Hanratty, Kate Hunt, Saffron Karlsen, Catherine Law, Sally Macintyre, James Nazroo, Naomi Rudoe, Bethan Thomas, Rachel Thomson, Margaret Whitehead

Towards the Elimination of Cancer Disparities

Medical and Health Perspectives
Koh, Howard K. (Ed.)
2009, XII, 384 p. 28 illus., Hardcover
ISBN: 978-0-387-89442-3
Online version available

http://www.springer.com/biomed/cancer/book/978-0-387-89442-3


“The societal burden of cancer is one of the major public health challenges of our time, yet that burden is not equally shared by all. Troubling disparities have been documented not only by racial/ethnic group but also by social class, insurance status, geography, and a host of other factors. Furthermore, such disparities represent the end result of a constellation of forces stemming from both within the health care system and outside of it. Many currently existing cancer disparities are preventable.

To date, few publications capture the breadth and depth of the dimensions of cancer disparities from both the clinical and public health perspective. This volume broadens concepts of disparities beyond traditional race/ethnicity discussions to explore a more systematic analysis of how, where, and why disparities occur across the cancer continuum. We will also analyze the issue of social disparities with respect to certain major cancers, with emphasis on the particular role of socioeconomic position.

This volume reflects the work of a number of experts in cancer disparities, led by members of the Executive Committee of the Program-in-Development for the Dana Farber / Harvard Cancer Center. In particular, this volume updates and expands an earlier 2005 monograph on the topic published in the journal Cancer Causes and Control (Nancy Krieger PhD, Editor).

Written for:

Those working in the cancer, from basic researchers to clinicians, and public health professionals as well as the educated general public.”

Structural Interventions for addressing Chronic Health Problems

Mitchell H. Katz.
JAMA. 2009;302(6):683-685.

The chronic health problems of obesity, diabetes, heart disease, and cancer commonly affect adults living in developed countries and are both difficult to treat and costly, leading experts to stress the importance of prevention.1 Elimination of the 3 behavioral risk factors of sedentary lifestyle, poor diet, and smoking would decrease mortality by 35%.2

But how do we get individuals to exercise more, eat better, and stop smoking?

Health education has been effective in diminishing these risk factors, especially smoking, but education alone is unlikely to bring further progress. In fact, it would be difficult to find a sedentary obese smoker who did not know that he should exercise more, eat less, and stop smoking.

Intensive one-to-one and group behavioral interventions have been demonstrated to increase activity, reduce obesity, and promote smoking cessation, but effects have been modest and difficult to maintain. Moreover, translating these findings into practice has been hampered by insufficient funding and difficulty reaching those persons in greatest need.

Structural interventions offer a complementary approach to improving health by focusing on changing the physical, social, and economic environment. The interventions are structural in that, unlike individualized interventions, persons do not enroll or even know that they are participating.

Structural interventions are not a new idea. The increase in longevity that occurred in the early 20th century was largely due to physical improvements in the environment (e.g., sewage treatment) and at work sites (e.g., safer equipment). Other successful structural interventions include seat belts in cars, road safety standards, elimination of toxins such as lead in paint and gasoline, and water fluoridation. What is new, and potentially more challenging, is the use of structural interventions for chronic diseases.

Full article available at: JAMA. 2009; 302(6):683-685.

Low Life Expectancy in the United States: Is the Health Care System at Fault?

Samuel H. Preston, Jessica Y. Ho.
NBER Working Paper No. 15213. Issued in August 2009.

Abstract

Life expectancy in the United States fares poorly in international comparisons, primarily because of high mortality rates above age 50. Its low ranking is often blamed on a poor performance by the health care system rather than on behavioral or social factors. This paper presents evidence on the relative performance of the US health care system using death avoidance as the sole criterion. We find that, by standards of OECD countries, the US does well in terms of screening for cancer, survival rates from cancer, survival rates after heart attacks and strokes, and medication of individuals with high levels of blood pressure or cholesterol. We consider in greater depth mortality from prostate cancer and breast cancer, diseases for which effective methods of identification and treatment have been developed and where behavioral factors do not play a dominant role. We show that the US has had significantly faster declines in mortality from these two diseases than comparison countries. We conclude that the low longevity ranking of the United States is not likely to be a result of a poorly functioning health care system.

Excerpts

...The health care system could be performing exceptionally well in identifying and administering treatment for various diseases, but a country could still have poor measured health if personal health care practices were unusually deleterious. This is not a remote possibility in the United States, which had the highest level of cigarette consumption per capita in the developed world over a 50-year period ending in the mid-80's (Forey et al. 2002). Smoking in early life has left an imprint on mortality patterns that remains visible as cohorts age (Preston and Wang 2006; Haldorsen and Grimsrud 1999). One recent study estimated that, if deaths attributable to smoking were eliminated, the ranking of US men in life expectancy at age 50 among 20 OECD 2 countries would improve from 14th to 9th, while US women would move from 18th to 7th (Preston, Glei, and Wilmoth 2009). Recent trends in obesity are also more adverse in the United States than in other developed countries (OECD 2008 ; Cutler, Glaeser, and Shapiro 2003)...

The fact that Canada had for many years the second highest consumption of cigarettes per adult (Forey et al. 2002) makes it appear that geographic factors, perhaps related to conditions for growing or importing tobacco, had more to do with consumption patterns than did health systems. And public health authorities were not passive in the US. The US Surgeon General's (1964) report on the health hazards of cigarette smoking was the first major indictment of the habit by a government authority and it was quickly followed up with a massive anti-smoking media campaign (Cutler and Glaeser 2006). The US had the largest reduction in manufactured cigarettes consumed per adult of any country between 1970 and 2000 (Forey et al. 2002). Some of that decline was likely attributable to public health efforts (Cutler and Glaeser 2006)...

Summary

We have demonstrated that mortality reductions from prostate cancer and breast cancer have been exceptionally rapid in the United States relative to a set of peer countries. We have argued that these unusually rapid declines are attributable to wider screening and more aggressive treatment of these diseases in the US. It appears that the US medical care system has worked effectively to reduce mortality from these important causes of death.

This conclusion is consistent with other evidence that we have reviewed on the performance of the US health care system: screening for other cancers also appears unusually extensive; 5-year survival rates from all of the major cancers are very favorable; survival rates following heart attack and stroke are also favorable (although one-year survival rates following stroke are not above average); the proportion of people with elevated blood pressure or cholesterol levels who are receiving medication is well above European standards.

These performance indicators pertain primarily to what happens after a disease has developed. It is possible that the US health care system performs poorly in preventing disease in the first place. Unfortunately, there are no satisfactory international comparisons of disease incidence. Individuals report a higher prevalence of cancer and cardiovascular disease in the United States than in Europe, and biomarkers confirm the higher prevalence of many disease syndromes in the US compared to England and Wales. Higher disease prevalence is prima facie evidence of higher disease incidence, although it could also be produced by better identification (e.g., through screening programs) or better survival. The history of exceptionally heavy smoking in the US, and the more recent massive increase in obesity, suggest that a high disease incidence in the US could not be laid entirely at the feet of the health care system.

Evidence that the major diseases are effectively diagnosed and treated in the US does not mean that there may not be great inefficiencies in the US health care system. A list of prominent charges include fragmentation, duplication, inaccessibility of records, the practice of defensive medicine, misalignment of physician and patient incentives, limitations of access for a large fraction of the population, and excessively fast adoption of unproven technologies (Garber and Skinner, 2008; Cebul et al. 2008; Commonwealth Fund 2008). Some of these inefficiencies have been identified by comparing performance across regions of the United States. Of course, the fact that certain regions do poorly relative to others does not imply that the US does poorly relative to other countries. And many of the documented inefficiencies of the US health care system add to its costs rather than harm patients.

Just as we are not addressing issues of efficiency on the production side, we are not treating patient welfare as the main outcome. Practices that produce greater longevity do not necessarily enhance well-being. This potential disparity is central to the controversy involving PSA testing, which uncovers many cancers that would never kill patients but whose treatment often produces adverse side effects.

The question that we have posed is much simpler: does a poor performance by the US health care system account for the low international ranking of longevity in the US? Our answer is, "no".

Full paper can be purchased at the following link:
http://papers.nber.org/papers/w15213

Population and Health Policies

T. Paul Schultz
Yale University
“…….The program evaluation literature for population and health policies is in flux, with many disciplines documenting biological and behavioral linkages from fetal development to late life mortality, chronic disease, and disability, though their implications for policy remain uncertain. Both macro and micro economics seek to understand and incorporate connections between economic development and the demographic transition.
The focus here is on research methods, findings, and questions that economists can clarify regarding the causal relationships between economic development, health outcomes, and reproductive behavior, which operate in many directions, posing problems for identifying causal pathways. The connection between conditions under which people live and their expected lifespan and health status refers to “health production functions”.
The relationships between an individual’s stock of health and productivity, well being, and duration of life encompasses the “returns to health human capital”. The control of reproduction improves directly the well being of women, and the economic opportunities of her offspring. The choice of population policies may be country specific and conditional on institutional setting, even though many advances in biomedical and public health knowledge, including modern methods of birth control, are now widely available.
Evaluation of a policy intervention in terms of cost-effectiveness is typically more than a question of technological efficiency, but also the motivation for adoption, and the behavioral responsiveness to the intervention of individuals, families, networks, and communities. Well-specified research strategies are required to address
(1) the economic production of health capacities from conception to old age,
(2) the wage returns to increasing health status attributable to policy interventions,
(3) the conditions affecting fertility, family time allocation, and human capital investments, and
(4) the consequences for women and their families of policies which change the timing as well as number of births………”
Read the full article at: http://www.econ.yale.edu/growth_pdf/cdp974.pdf