from diabetes disparities to diabetes health equity george rust, md, mph, faafp, facpm father of dan...
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From Diabetes Disparities to Diabetes
Health Equity
George Rust, MD, MPH, FAAFP, FACPM Father of Dan & Christina, Husband of Cindy,
Professor of Family MedicineDirector, National Center for Primary Care
National Center for Primary Care at Morehouse School of Medicine
Health Disparities
“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”
-- Martin Luther King, Jr.
Disparities in Prevalence
Ma Y et al. All-Cause, Cardiovascular, and Cancer Mortality Rates in Postmenopausal White, Black, Hispanic, and Asian Women With and Without Diabetes in the United States: The Women's Health Initiative, 1993–2009 Am. J. Epidemiol. (2013) 178 (10): 1533-1541 online September 17, 2013
Primary Care Community Health Centers Impact on Uninsured ED Visits
0
200
400
600
800
1000
1200
1400
1600
1800
Rate per 100,000
uninsured
Rates of ED Visits Among the Uninsured
in Counties with and without a CHC
CHC
No CHC
31% Excess
62% Excess
No CHC = 37% Excess ED Visits
Disparities in Hospitalizations
Adult admissions for uncontrolled diabetes without complications per 100,000 population by race/ethnicity, 2001. http://archive.ahrq.gov/qual/nhdr04/fullreport/RQual.htm
Racial-ethnic Disparities and
Rural-Urban Differences
Excess Cost Due to Racial Variation in Hospital Admissions by Disease
(mid-range estimate)
Excess Hospital Admissions(mid-range)
Hospital Charges Attributable to Excess Hospital Admissions (mid-range)
Payer Costs Attributable to Excess Hospital Admissions (mid-range)
Asthma 2,044 $28,687,330 $13,339,608.45
Diabetes 3,955 $92,172,057 $42,860,006.51
Heart Disease 5,021 $187,289,234 $87,089,493.81 >Coronary
Artery Disease 1,287 $65,156,724 $30,297,876.66
>Congestive Heart Failure 5,868 $162,561,372 $75,591,037.98
HIV 1,644 $76,784,134 $35,704,622.31
$
Drivers of Health Disparities
Health Potential
Health Potential
Food, Water, Housing, & Health Behaviors
Social
Determ
inants
Access to Care
Adoption S-Curve
Isolated or disenfranchised or non-majority cultural groups
Diabetes Health Equity
• Equality in Risk • Equality in Pre-Disposing Conditions• Equality in Prevalence • Equality in Treatment• Equality in Self-Management• Equality in Complication Rates• Equality in Adverse Outcomes• Equality in Survival
Does Equal Treatment Mean Treating Everyone the Same?
Encouraging an hour a day of physical activity for children is different in a high-crime, resource-constrained urban neighborhood than it is in a wealthy upper-income neighborhood with lots of safe playgrounds.
Does Equal Treatment Mean Treating Everyone the Same?
• Providing linguistically-appropriate services for immigrants and linguistically-isolated families takes more conscious effort and resources than it does for English-language families.
Holding Ourselves Accountable to Achieve Equality in Outcomes
• Community Level Metrics • Mortality• Hospital Bed-Days• Preventable Adverse Events (e.g., amputations)
• Practice-Level Data• ED Visits• Hospital Bed-Days
• Person-Level Feedback• Missed refills• Inadequate Care• ED Visit yesterday!
29 babies saved!!!29 babies saved!!!
Disparities are not Inevitable!Disparities are not Inevitable!
Decline represents 29 infant deaths prevented (expected vs. actual)
Emergency Emergency RoomRoom
Primary Primary CareCare
Mental Mental Health Health
Business & Business & Community Community
Leaders Leaders
HospitalsHospitals Faith Faith CommunitiesCommunities
Cohesive, Comprehensive, Integrated Local Health Systems
• Patient-Centered Primary Care Home
• Chronic Disease Care Management
• Integrated Behavioral Health
• Built on Community Strengths & Partnerships
• Consistently High Quality Care
• Optimal Outcomes
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