Health Disparities

More on social determinants of health: What are they, why are we talking about them so much, what’s happening now?

By M2|2018-06-15T19:32:48+00:00June 15th, 2018|Health Care Trends, Health Disparities, Health Information Technology, Health Reform, Innovation, Public Health, Social Determinants of Health, Uncategorized|

More on social determinants of health: What are they, why are we talking about them so much, what’s happening now?

Here at M2, we spend a lot of time thinking about the social determinants of health (SDH), or the nonmedical factors that can affect a person’s overall health and health outcomes. We have blogged recently about this issue, and . The issue is gaining momentum and we are seeing more articles and studies addressing how to better incorporate SDH into programs and technologies; for example, former CMS administrator Andy Slavitt recently announced his new venture capital firm will focus on companies in this area. Another recent article highlights the opportunities for technology entrepreneurs as adoption rates for SDH technologies are projected to increase over the next ten years. Today we are taking a close look at a recent position paper from the American College of Physicians (ACP).

SDH are defined as “the conditions in which people are born, grow, work, live, age, and the wider set of forces and systems shaping the conditions of daily life”. In other words, “where a person is born and the social conditions they are born into can affect their risk factors for premature death and their life expectancy,” the ACP notes in its recent paper.

SDH are “responsible for most health inequalities,” the ACP says; the paper examines the complex issues involved and provides recommendations on “better integration of social determinants into the health care system while highlighting the need to address systemic issues hindering health equity.”

The paper was drafted by the ACP’s Health and Public Policy Committee, and the ACP notes that it is charged with addressing “issues that affect the health care of the U.S. public and the practice of internal medicine and its subspecialties.”

“Understanding and addressing social factors that affect health outcomes is a pressing issue for physicians and medical professionals,” the ACP says. The group is issuing a set of recommendations “to empower stakeholders to advocate for policies aimed at eliminating disparities and establishing health equity among all persons.”

The paper features nine policy recommendations. Most notably, these include: integrating SDH into medical education at all levels; adequately funding federal, state, tribal, and local agencies in their efforts to address social determinants of health; developing best practices for utilizing electronic health record (EHR) systems as a tool to improve health without adding to the administrative burden on physicians; and adjusting quality payment models and performance measurement assessments to reflect the “increased risk associated with caring for disadvantaged patient populations.”

Expanding on one of the recommendations above – the importance of EHRs and collecting data – the paper notes that in 2014, a National Academies of Science committee identified 12 social determinants to be included in EHRs as part of meaningful use stage 3, and issued recommendations on standardizing collection of measures of these social determinants. Several behavioral and social domains are currently collected: tobacco use; alcohol use; race/ethnicity; and residential address, which is geocoded.

The report says that in terms of racism and health equity, the ACP’s policy on racial and ethnic health disparities “acknowledges that addressing social determinants of health is a key component to increasing health equity among racial and ethnic populations.”

Social determinants “can exacerbate health care disparities among racial or ethnic groups,” the paper says. “Socioeconomic status, race, and ethnicity are connected in a complex, multidimensional way and may affect a person’s health independently or in combination.” As an example, the ACP notes that Latina women experience a greater incidence of cervical cancer and higher mortality rates than non–Latina women. Access to care for Latina women is also affected, as they are more likely to lack health insurance than white non-Latina women.

SDH has been a bit of a buzzword for a while in public health circles, but it may finally be time for SDH to influence policy, as seen by ACP’s efforts. “Why now?” many are wondering. As proof points pile up, and more people gain an understanding of what SDH are, the concept is gaining momentum and being included in more discussions.

For example, it’s interesting that one of the largest physician groups has developed policy positions on SDH. This may be an indication that physicians in general are realizing the significant role that SDH play in individuals’ health. Incorporating an understanding of SDH into not only the practice of medicine, but also into the tools and incentives that drive patient care, would be welcome steps in helping to reduce the negative health outcomes related to SDH.

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An Alternative to Opioids? Other Interventions Show Significant Improvements in Pain and Physical Function For Disadvantaged Populations

By M2|2018-04-10T19:27:24+00:00April 10th, 2018|Chronic pain, Evidence-Based Medicine, Health Disparities, Insurance, Social Determinants of Health, Uncategorized, What do we pay for and why|

An Alternative to Opioids? Other Interventions Show Significant Improvements in Pain and Physical Function For Disadvantaged Populations

Pain is a common, yet difficult to treat condition; it is one of the top reasons people go to the doctor. Opioids are commonly prescribed to treat pain; opioids are quite effective but addictive. The use of cognitive behavioral therapy (CBT) is known to be efficacious in addressing chronic pain; however, its benefit in disadvantaged populations is not well understood.

To help shed light on this question, a team led by Beverly Thorn, University of Alabama, conducted a study to evaluate the efficacy of literacy-adapted and simplified group CBT versus group pain education (EDU) versus usual care.

The randomized controlled trial enrolled 290 adults with chronic pain symptoms. Most had incomes at or below the poverty level, and about one-third read below a fifth grade level. Many participants were taking opioids at the beginning of the study.

Both the CBT and EDU were delivered in ten weekly 90-minute group sessions. Participants in all three groups reported their pain levels and physical functioning via questionnaires at baseline, ten weeks, and six months.

The study, funded by the Patient-Centered Outcomes Research Institute and published in the Annals of Internal Medicine, found that patients in the CBT and EDU groups had greater decreases in pain intensity scores between baseline and post-treatment than participants receiving usual care.

However, while treatment gains were still present in the EDU group at six-month follow-up, these gains were not maintained in the CBT group, Thorn, et al., say.

Regarding the secondary outcome of physical function, those in the CBT and EDU interventions had greater post-treatment improvement than patients who received usual care; this progress was maintained at six-month follow-up. Changes in depression, another secondary outcome, did not differ between either the CBT or EDU group and those receiving usual care, the researchers state.

This study highlights the fact that when done correctly, i.e., when materials are adjusted and tailored to a patient’s reading level, there are non-opioid interventions like behavioral therapy and education that work. While it is probably easier to prescribe opioids for pain, given the increasing severity of the opioid addiction epidemic, insurers really should consider these effective alternative treatments which positively impact pain. Why NOT prescribe effective, non-addictive treatment whenever possible?

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ICYMI: The CVS-Aetna Proposed Merger Could be Public Health Rocket Fuel

By M2|2017-12-07T01:22:04+00:00December 6th, 2017|Health Care Trends, Health Disparities, Insurance, Public Health, Retail Health, Social Determinants of Health, Uncategorized|

ICYMI: The CVS-Aetna Proposed Merger Could be Public Health Rocket Fuel

Sunday, December 3, CVS Health announced it will acquire health insurer Aetna for $69 billion. Lowering the cost of care by enabling a broader range of treatment in retail clinic settings, of which CVS Health has more than 1,100 in 33 states, is one of the obvious rationales of the combination. But what struck me in the comments of the merging companies’ CEOs was how much they sound like public health professors. Social determinants of health? Health as a path to fulfillment? What have they done with the business people? In case you missed it…

Mark Bertolini Really Cares About the Whole Person

Aetna Chairman and CEO Mark T. Bertolini has been talking publicly for quite some time about the importance of thinking about people not as patients, but more holistically. In September, in an interview with Dennis Berman, the Wall Street Journal financial editor, he said, “We believe the only way to truly disrupt the cost of health care … is to go into the homes and meet the social determinants that are now driving as much as 60 percent of life expectancy of Americans.”

What Bertolini has had to say now that the merger is official is straight-up public health speak. On CNBC Monday morning, when explaining the vision of the merger, Bertolini sounded like a philosopher: “Most people,” he explained, “find their health is a barrier to the life they want to live.” Indeed.

Larry Merlo is Fixated on Unmet Need

Larry J. Merlo, President and CEO of CVS Health, reminded anyone who was paying attention something that we in public health have known for a long time, but surprised the CNBC reporters, “You look at chronic disease in this country today, about half of all Americans have at least one of those chronic diseases. It’s accounting for 80% of the health care costs.”

Merlo further explains, “there’s billions of dollars every year on unnecessary and avoidable spending because people are not following…care plans.” Merlo’s solution, to be executed in part with the announced merger, is to address the unmet need the traditional health care system is creating, but CVS Health knows first-hand because patients come through its doors with health care needs that aren’t being met.

We “lack the element of convenience and coordination…that is the unmet need we are talking about,” says Merlo.

We Are All Public Health

As a public health student, educator and professional, I am public health. This merger discussion shows we are all public health. Georges C. Benjamin, M.D. Executive Director, American Public Health Association wrote in 2015, “Today, the biggest threats to the health and longevity of Americans are preventable diseases. These are the diseases that are burying us in preventable suffering, as well as crippling our communities with mountains of avoidable medical bills. The root causes of many of these health threats are inextricably linked to the social determinants of health and the conditions that shape a person’s opportunity to attain good health and adopt healthy behaviors. These social determinants include access to safe housing, good jobs with living wages, quality education, affordable health care, nutritious foods, and safe places to be physically active. They also include racism, discrimination, and bias.”

To see such similar language from Mark Bertolini and Larry Merlo in the CVS-Aetna merger discussion to date shows that the leaders of what could become the largest health care company in the U.S. are thinking differently about the broken U.S. health care system. Near the end of the investor call about the merger, an analyst asked whether the combined entity planned to be a person’s primary care physician. Bertolini answered: “The real important part here is that you have to understand that almost 60% of Americans don’t have a regular doctor.”

When you connect these dots, you can really see the big picture come together. The CVS-AET vision is bigger than managing the pharmacy benefit.

Will it work? Hard to say at this early stage. Should consumers want it to work? Absolutely. A health care company with a public health lens that focuses on health well before a person shows up at the doctor and prioritizes convenience, coordination, and social determinants of health would be a welcome change for individuals, families, and employers. Score one for public health.

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Quality of Treatment for Migraine Doesn’t Seem To Differ By Race, But Opioid Prescribing for Migraines is Still Too High

By M2|2017-10-08T11:16:59+00:00September 28th, 2017|Chronic pain, Evidence-Based Medicine, Health Disparities, Uncategorized|

Quality of Treatment for Migraine Doesn’t Seem To Differ By Race, But Opioid Prescribing for Migraines is Still Too High

Headaches are one of the main reasons patients seek health care advice, and racial and ethnic differences exist. For example, migraine in African Americans is more frequent, more severe, more likely to become chronic, and associated with more depression and lower quality of life versus non-Hispanic whites. Given these disparities, researchers at the University of Michigan set out to determine whether there are also racial differences in the quality of migraine treatment.

In a study published in Cephalalgia, researchers reported that approximately 40% of patients received no preventive medications – prophylactic treatments – though that is the recommended approach for most patients. Further, “among patients that receive a prophylactic agent, it is almost twice as likely that they will receive exclusively agents with low-quality evidence as it is that they will receive agents with only high-quality evidence.”

As for race or ethnic differences in prophylactic treatment, however, patients were treated similarly: 41.3% of African Americans (AA) received no prophylactic treatments from 2006 to 2013, compared to 40.8% of non-Hispanic whites (NHW), and 41.2% of Hispanic (HI) patients.

For patients who needed first-line treatment (also called “abortive treatment”), as with preventive medication, the University of Michigan researchers did not find relevant differences across ethnicities or races, but they did find nearly 40% of patients did not receive a first-line treatment when it was indicated. And similar to the prescribing pattern for preventive medications, when a first-line treatment was prescribed, it was more likely to be one with low-quality evidence.

“This shows an underuse of medications with high-quality evidence,” first author Larry Charleston IV, M.D., M.Sc., an assistant professor of neurology at the University of Michigan Medical School said. “Even for patients being prescribed an abortive medication, we found 27 percent of them were given at least one low-quality abortive medication. Better options do exist.”

The data “suggest that there are major opportunities to improve the quality of headache medication prescribing in the United States, as less than a quarter of migraine patients received all high-quality abortive or prophylactic medications.”

Perhaps most disturbingly, migraine patients “receive prescriptions for opioids about as commonly as they receive prescriptions for medications with high-quality evidence for migraine treatment,” the researchers found.

Looking at the use of opiates, 15.2% of all patients had a prescription for opiates, but there were no racial differences, Larry Charleston and James Burke, University of Michigan, say. In other words, the “investigation into racial disparities in migraine treatment came up empty, but instead it found a different concern that reaches across populations” – opioid overuse, as noted in an article in Lab Report.

The findings on opioid overuse come at a time when opiate-related mortality is “rapidly increasing in the United States,” the study authors note.

“The argument against opiate use for migraine is strengthened by the observation that it is associated with more severe headache-related disability, symptomology, comorbidities (depression, anxiety, and cardiovascular disease and events), greater need to see health care providers and high risk for medication overuse headache. Moreover, most evidence suggests that opiates are, if anything, less effective than non-opiate alternatives,” according to the researchers.

“Given the considerable risks of opiates and the lack of evidence of increased efficacy, opiates should be used rarely, if ever, for migraine,” they conclude. “Interventions to reduce opiate use in the migraine population are urgently needed.”

This overuse of opiates and underuse of less risky, more effective therapies is another example of practitioners ignoring evidence-based medicine. What’s different about this particular example is that it involves opioids, at a time when the opioid abuse crisis has become so critical that the President recently declared it a national emergency. This seems to be an area ripe for educating physicians or for health plans to provide appropriate parameters for prescribing of migraine therapies, to ensure opioids are prescribed only for patients who truly need them.

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Health disparities disproportionately drive hospital readmissions

By M2|2017-10-09T02:04:45+00:00December 6th, 2016|Health Disparities, Social Determinants of Health, Uncategorized|

Health disparities disproportionately drive hospital readmissions

Health disparities, as opposed to medical treatments, are disproportionately driving hospital readmission rates, resulting in higher penalties for safety net hospitals, according to a study published in the journal Surgery.

Elizabeth Hechenbleikner, MD, MedStar Georgetown University Hospital, et al., studied readmissions after colorectal surgery. The authors evaluated outcomes and patient factors in more than 168,000 colorectal surgery patients treated in 374 California hospitals from 2004-2011, using the State Inpatient Database and American Hospital Association Hospital Survey data. They performed sequential logistic regression analyses to determine the associations between minority-serving hospital status and readmissions.

As noted by MedPage Today, 30-day, 90-day, and repeated readmission rates in minority-serving/safety net hospitals were 13.6%, 20.1%, and 4%, respectively. In comparison, the overall readmission rates were 11.6%, 17.4%, and 3%, respectively.

Patient-level factors, such as race, income, and insurance status accounted for up to 65% of the increase in odds for readmission at minority-serving hospitals.

On the other hand, hospital-level factors, such as procedure volume and procedure type, accounted for up to 40% of the increase. Notably, inpatient mortality was also significantly higher at minority-serving hospitals (4.9%) compared to non-minority-serving hospitals (3.8%).

Study co-author Waddah B. Al-Refaie, MD, also of MedStar Georgetown University Hospital, said in an accompanying statement that CMS holds all hospitals to the same readmission standard.

CMS established the Hospital Readmission Reduction Program (HRRP) in 2012 in an attempt to reduce higher-than-expected readmission rates for six conditions: heart attacks, heart failure, pneumonia, COPD, and hip and knee replacement. “To date, it has penalized more than half of the nation’s hospitals for failing to meet expectations, imposing more than $500 million in fines,” Al-Refaie says.

“These findings suggest that CMS should account for patient socio-economic factors when they compare readmission rates,” he says. If patient-level factors “are not balanced out, we fear minority-serving hospitals will face substantial, crippling financial penalties, and may end up being selective about the patients they admit.”

In addition, the study authors highlight the need for addressing patient-level factors in order to “shape quality improvement interventions to decrease readmissions.”

Indeed, some part of the system has to be concerned about addressing these social determinants of health. Instead of pointing to “unfair” fines for safety net hospitals, these hospitals would serve patients better by addressing the readmissions themselves.

For example, hospitals could partner with local community health organizations to help address these patients’ socioeconomic factors and work to find ways to ensure patients are actually recovering well from surgery, and therefore do not need to be readmitted.

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