the influence of race, cultural, and psychosocial factors on disparities in processes and outcomes...
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The Influence of Race, Cultural, and Psychosocial Factors on Disparities in
Processes and Outcomes of Care for Spinal Cord Injury
Larissa Myaskovsky, PhD
Associate Professor of Medicine, Psychiatry and Clinical and Translational Science
University of Pittsburgh School of Medicineand
VA Pittsburgh Healthcare System
Collaborators and Research Team
• Michael L. Boninger, MD• Kelly H. Burkitt, PhD• Michael J. Fine, MD• Shasha Gao, PhD• David Gater, MD• Sam Phillips, PhD• Ann Spungen, PhD• Galen Switzer, PhD
• Kellee Bornemann• Jemy Delikat• Devra Greenwald, MPH• Jewel Moore• Kel Morin• Michelle Oyster, MS• Debbie Wetzler
Funding Sources
• Department of Education− National Institute of Disability and Rehab
Research (NIDRR)
• VA– CHERP Pilot Study– Rehabilitation Research and Development
Division (VA RR&D)
Presentation Topics
• A health service research perspective• Why are health services researchers
interested in Spinal Cord Injury (SCI)?• Brief epidemiology of SCI• Race and culture in SCI• Research findings (hot off the presses!)
Health Services Research
Social Factors
Financing Systems
Organizational Structures and
ProcessesHealth
Technologies
Personal Behavior
1. Access to healthcare
2. Quality and cost of healthcare
3. Health and well-being
CHERP Model to Advance Health Equity Research
Detecting• Define health disparities
• Define vulnerable populations
• Measure disparities in vulnerable populations
• Consider selection effects and confounding factors
Understanding • Identify determinants of health disparities at the following levels:
• Patient/individual
• Provider
• Clinical encounter
• Healthcare system
Reducing
• Intervene
• Evaluate
• Translate anddisseminate
• Change policy
First Generation Second Generation Third Generation
Kilbourne et al, Am J Public Health 2006
Conceptualizing Disparities in Health and Health Care
Healthcare Disparities
Processes of careStructure of care
Health Disparities Medical Complications
MortalityFunctional status
Quality of life
ProviderKnowledgeAttitudes
Communication
PatientDemographicsBiology/Genes
Preferences
SystemAccessibilityOrganization
Quality
EnvironmentGeography Poverty Segregation Social norms
Why are Health Services Researchers Interested in Spinal Cord Injury?
• High incidence and prevalence rate– 12,000 new cases each year (incidence)– Prevalence of SCI in 2013 = 273,000 (range =
238,000 – 332,000)
www.nscisc.uab.edu
Why are Health Services Researchers Interested in Spinal Cord Injury?
• High incidence and prevalence rate• Changing demographics
SCI Demographics Over Time
1973-1979 Since 20100
10
20
30
40
50
60
70
80
90
28.7
42.6
81.8 80.7
14.2
24.4
Age at injury (years) Gender (% male) Race (% AA)
www.nscisc.uab.edu
Why are Health Services Researchers Interested in Spinal Cord Injury?
• High incidence and prevalence rate• Changing demographics• Exemplar of life-long, team-based, patient-
focused care
Life-Long Care in Multiple Domains
Functional Medical ComplicationsPsychologicalCommunity Integration and Employment
Team-Based and Patient-Focused Care
Why are Health Services Researchers Interested in Spinal Cord Injury?
• High incidence and prevalence rate• Changing demographics• Exemplar of life-long patient-focused team-based
care• Multiple under-explored research foci
– Measurement development– Psychological, social, and behavioral predictors of
outcomes– Disparities in processes of care and patient outcomes
Disparities in SCI
Racial and ethnic disparities in health and health-related quality of life (QOL) are well-documented
Cultural factors health disparities» Perceived discrimination and racism» Healthcare system distrust» Health literacy» Communication with provider
These factors may be especially critical in SCI care
Race and Culture in SCI
Study Goals• Identify and compare race differences in cultural
and psychosocial factors in Veterans and non-Veterans with SCI
• Investigate and compare race differences in wheelchair quality and quality of life (QOL): – Participation– Life satisfaction or satisfaction with service– Perceived health status
• Determine how demographic, medical, cultural and psychosocial factors are associated with racial disparities in wheelchair quality and QOL
Methods• Design: Two cross-sectional multi-site studies
using structured questionnaires• Setting: Six National Spinal Cord Injury Model
Systems centers (NSCIMS) and three VA Spinal Cord Injury centers (VA SCI)
• Eligibility criteria:– Age > 16 years– SCI with discernable neurological impairments– Use a power or manual wheelchair >1 year as primary
means of mobility– Non-ambulatory except for exercise purposes
Independent Measures
• Demographics (e.g., race, gender, age)
• Medical factors (e.g., SCI level)
• Cultural factors– Experience of discrimination – Perceived racism– Healthcare system distrust – Health literacy– Communication with provider
• Psychosocial factors– Anxiety – Depression
Cultural Factors - Examples
• Experience of discrimination - “Treated with less courtesy than other people because of your race or ethnicity.”
• Perceived racism - “Doctors treat people from racial or ethnic minorities the same as white people.”
• Healthcare system distrust - “The health care system covers up its mistakes.”
• Communication with provider -“Sometimes, my doctors do not listen to me.”
Outcomes• Wheelchair Quality - VA SCI participants only
• Craig Handicap Assessment and Reporting Technique Short Form (CHART-SF) - physical independence, cognitive independence, mobility, occupational functioning, social integration
• Satisfaction with Life Scale - NSCIMS
• Satisfaction with Service - VA SCI
• Perceived health status: – 2 items from the SF-36 - NSCIMS
– Veterans SF-12 - VA SCI
Implications for 3rd Generation Research
Detecting• Define health disparities
• Define vulnerable populations
• Measure disparities in vulnerable populations
• Consider selection effects and confounding factors
Understanding • Identify determinants of health disparities at the following levels:
• Patient/individual
• Provider
• Clinical encounter
• Healthcare system
Reducing
• Intervene
• Evaluate
• Translate anddisseminate
• Change policy
First Generation Second Generation Third Generation
