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Equity in Health and Health Care

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Defining Terms

Health Equity: Valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.

Health Disparity: Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.

Source: HealthyPeople 2020

Our researchers actively seek to understand and address racial and ethnic disparities, social determinants of health

From its founding 75 years ago, Kaiser Permanente has held equity and inclusiveness for all its members, and the health of its communities, as guiding principles. And for nearly 60 years, the Division of Research has sought answers to support those goals.

In recent years, our investigators have sought to illuminate the social, biological, and environmental factors that contribute to racial and ethnic health disparities. And going a step farther, they identify evidence-based interventions to eliminate those differences.

This research portfolio is consistent and expanding. Investigators across our organization have taken variation by race, ethnicity, and health into account on a wide variety of topics, from medication adherence to diabetes prevalence to access to advanced surgeries.

We have long been focused on understanding the social drivers of health that have led to an increased risk for chronic health conditions, decreased access to medical care, and poorer health outcomes for our most vulnerable populations.

We know that:

Health Disparities Examples

  • A study showed starting annual colorectal cancer screening at age 45 in African Americans finds colorectal cancers at a rate similar to when screening starts after age 50” the age most guidelines currently recommend.
  • African American patients who were born in 1928 in states with the highest infant mortality rates among African American people faced a 86 percent higher risk of dementia than among white people born in states without high infant mortality rates.
  • Hypertension is devastating to communities of color, particularly among Blacks, where males have the highest hypertension death rates of any other racial, ethnic, or gender group.
  • Diabetes occurs 3 times more often among normal-BMI Native Hawaiians and Pacific Islanders than normal-BMI whites.
  • communities of historically underrepresented groups are disproportionately impacted by a lack of economic opportunity, living under sustained financial strain that creates barriers to good health.
  • inequities and disparities that have existed for people of historically underrepresented groups” women, the poor, and other marginalized groups” have been made more visible by the COVID-19 pandemic, with data showing that Latinx and African Americans are disproportionately affected by the disease as well as by its economic impacts.

The Division of Research will continue this mission to provide the data that allows high-quality health care to be accessible to everyone, no matter their social, economic, racial, or ethnic background.

Kaiser Permanente Resources on Equity

Equality for All: Greg Adams, chairman and CEO, Kaiser Permanente

Equity, Inclusion, and Diversity Permanente Medicine Fact Sheet

Highlighted Recent Research

2020

Early colorectal cancer screening benefits African Americans: Kaiser Permanente study supports starting screening at age 45 among this higher-risk population

A study by researchers at Kaiser Permanente Northern California showed starting annual colorectal cancer screening at age 45 in African Americans can find colorectal cancers at a rate similar to that seen when screening starts after age 50 — the age most guidelines currently recommend.

2019

Kaiser Permanente reduces racial disparities in who gets minimally invasive hysterectomies: Racial gap nearly disappears during project to train surgeons and establish best practices

Kaiser Permanente's northern California hospitals significantly increased minimally invasive surgery for hysterectomy and found the change also reduced racial disparities in the types of hysterectomies patients get.

How to reduce racial disparities in surgery: Podcast

National figures show white women are more likely to get an advanced, minimally invasive version of hysterectomy than are Black women and Hispanic women. Kaiser Permanente Northern California found much of that difference disappeared when it carried out a quality improvement project.

Chronic disease prevalence varies by Asian subgroup, Kaiser Permanente research finds: Findings suggest value in identifying Asian patients' ethnic backgrounds in medical records

Asian-Americans from different parts of Asia have very different cardiovascular risk factors and chronic conditions such as diabetes, hypertension, and heart disease, research from the Kaiser Permanente Division of Research suggests. The study, published in BMC Public Health, used electronic health record (EHR) data for 1.4 million adults aged 45 to 84 who were Kaiser Permanente Northern California members during 2016.

Minority racial and ethnic groups get diabetes at lower weights: Diabetes occurs 3 times more often among normal-BMI Native Hawaiians and Pacific Islanders than normal-BMI whites, Kaiser Permanente research finds

Being overweight or obese is commonly associated with diabetes, but a Kaiser Permanente study finds the connection differs widely by race or ethnicity. Members of racial and ethnic minority groups were much more likely to have diabetes or prediabetes at lower weights — even at normal or below-normal body mass index (BMI), according to research published in Diabetes Care.

Large study links genetic marker of aging to greater neighborhood deprivation: Kaiser Permanente and UCSF researchers find strong connection between which neighborhood a person lives in, how much education they have, and the length of their telomeres

A large Kaiser Permanente study has identified links between a genetic marker of aging, how much education a person has, and the degree of socioeconomic deprivation in their neighborhood. Genetics research suggests that longer telomeres — the "end caps" of DNA that keep strands of chromosomes from unraveling — mean more years of healthy life ahead.

More Highlighted Research ≫

 Related Studies

 

 

Building an Evidence Case for Capturing Educational Attainment in the EHR as a Social Determinant of HealthGP0|#8972db04-092d-4473-b1f1-caf7dfbeecd4;L0|#08972db04-092d-4473-b1f1-caf7dfbeecd4|Gordon, Nancy;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae4Educational attainment is an important social determinant of health, but it is not included in the electronic health records of a majority of adults. When the information is available, it is frequently not captured in a way that makes it easy to use in large data-only studies. This study will build evidence for the value of including educational attainment as a discrete categorical variable in electronic health records by examining the association of educational attainment with prevalence of chronic health conditions, obesity and smoking, quality metrics, and use of health care services and the patient portal among Medicaid enrollees aged 25-64 and a cohort of Medicare-aged (65-89 years) adults. The study will also examine differences by education across and within race/ethnic groups and within age groups, adjusted for sex and race/ethnicity. Lastly, we will evaluate different cut-points for educational attainment to make recommendations on ways to dichotomize education as a risk predictor.GP0|#8972db04-092d-4473-b1f1-caf7dfbeecd4;L0|#08972db04-092d-4473-b1f1-caf7dfbeecd4|Gordon, Nancy;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae42021-02-02T18:05:38Z
Tools for Outpatient and Population Management of SARS-COV-2 Infection (TOPS2)GP0|#57f55c8f-1303-44ef-b573-29e3a74e6641;L0|#057f55c8f-1303-44ef-b573-29e3a74e6641|Escobar, Gabriel;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae4This project aims to improve The Permanente Medical Group's capability for outpatient and population management of adults with COVID-19. It will identify the spatial, temporal, and racial distribution of coronavirus infections; characterize the clinical progression of coronavirus infection; and synthesize these findings to develop both simple predictive models and job aids that can help clinicians in the outpatient setting and complex risk adjustment models for population management. The tools we develop will help general internists and family practitioners predict the likely temporal and clinical trajectory of patients initally seen as outpatients or in the emergency department.GP0|#57f55c8f-1303-44ef-b573-29e3a74e6641;L0|#057f55c8f-1303-44ef-b573-29e3a74e6641|Escobar, Gabriel;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae42021-02-02T18:00:49Z
Barriers to Obstetric/Gynecological Health Care for Women with Autism Spectrum DisordersGP0|#74fe5b63-0035-42b5-a8fc-8382321e0418;L0|#074fe5b63-0035-42b5-a8fc-8382321e0418|Ames, Jennifer;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae4This study will identify the sociodemographic and health factors associated with low utilization of obstetrics/gynecology services among adult women with autism spectrum disorders and explore whether these women are at higher risk of adverse maternal and birth outcomes than women who do not have autism spectrum disorder.GP0|#74fe5b63-0035-42b5-a8fc-8382321e0418;L0|#074fe5b63-0035-42b5-a8fc-8382321e0418|Ames, Jennifer;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae42021-02-02T17:58:47Z
An Electronic Health Record-Based Tool to Identify Newly Diagnosed Breast Cancer Patients at Risk of Low Social SupportGP0|#24eb7b6a-b6e1-4447-ae3e-df9a7a47513e;L0|#024eb7b6a-b6e1-4447-ae3e-df9a7a47513e|Kroenke, Candyce;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae4Goals of the project are to: 1) Identify terms from content in the EHR, based on theory and prior literature, and informed by clinical stakeholders in BC care, that measure structural and/or functional social support, have been associated with BC treatment and outcomes, and could be extracted through code or natural language processing (NLP); 2) Develop an EHR-based social support measure, EHR-SUPPORT, using data from structured, semi-structured, and unstructured (through NLP) sources that help identify patients at risk of low social support, overall and by race/ethnicity, and validate the measure against published social support measures; and 3) Evaluate associations of EHR-SUPPORT and its component variables with BC treatment outcomes (surgery delays, chemotherapy delays, nonadherence to hormonal therapy) and BC-specific and total mortality, overall and by race/ethnicity. In an exploratory aim, we propose to: Explore, with clinician stakeholders, workflow and information technology requirements to implementing EHR-SUPPORT.GP0|#24eb7b6a-b6e1-4447-ae3e-df9a7a47513e;L0|#024eb7b6a-b6e1-4447-ae3e-df9a7a47513e|Kroenke, Candyce;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae42020-10-21T17:21:50Z
Patient experiences with Value-Based Insurance Designs (VBID) in Kaiser Permanente: Plan Knowledge and Medication BehaviorGP0|#94e66130-bbcd-4141-8611-a9e267a5eb7c;L0|#094e66130-bbcd-4141-8611-a9e267a5eb7c|Reed, Mary;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae4The study will examine patient knowledge and experience in a Value-based insurance designs plan by surveying 1,000 patients newly enrolling in a VBID plan. The survey will collect patient knowledge of their plan, patient-reported medication behavior (including specific cost barriers to adherence and financial burden, and preferences for receiving additional education/nudges about medication costs and hypothetical behavior changes with free preventive medications.GP0|#94e66130-bbcd-4141-8611-a9e267a5eb7c;L0|#094e66130-bbcd-4141-8611-a9e267a5eb7c|Reed, Mary;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae42020-08-21T07:00:00Z
Age- and race/ethnic-based disparities in diabetes outcomes among younger adults with newly diagnosed Type 2 DiabetesGP0|#170c785f-c4f5-49c0-b254-f00c9a08695b;L0|#0170c785f-c4f5-49c0-b254-f00c9a08695b|Gopalan, Anjali;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae4This study will conduct focus groups with KPNC members (age 45) with newly diagnosed Type 2 diabetes to learn about members’ experiences with this new diagnosis and to identify early facilitators of and barriers to effective diabetes management in this group. GP0|#170c785f-c4f5-49c0-b254-f00c9a08695b;L0|#0170c785f-c4f5-49c0-b254-f00c9a08695b|Gopalan, Anjali;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae42020-08-21T07:00:00Z

 Recent Publications

 

 

No Title2861412/16/2020 11:33:12 PMhttps://divisionofresearch.kaiserpermanente.org/sites/DORCatalog/Lists/Publications/AllItems.aspxFalseLittle is known about the timing of preclinical heart failure (HF) development, particularly among blacks. The primary aims of this study were to delineate age-related left ventricular (LV) structure and function evolution in a biracial cohort and to test the hypothesis that young-adult LV parameters within normative ranges would be associated with incident stage B-defining LV abnormalities over 25 years, independent of cumulative risk factor burden. We analyzed data from the Coronary Artery Risk Development in Young Adults Study. Participants (N=2,833) were 45% black, 56% female, with mean baseline age 30.1 years. We used generalized estimating equation logistic regression to estimate age-related probabilities of stage B LV abnormalities (remodeling, hypertrophy, or dysfunction) and logistic regression to examine risk-factor-adjusted associations between baseline LV parameters and incident abnormalities. We used Cox regression to assess whether baseline LV parameters associated with incident stage B LV abnormalities were also associated with incident clinical (stage C/D) HF events over >25 years' follow-up. Probabilities of stage B LV abnormalities at ages 25 and 60 years were 10.5% (95% CI, 9.4-11.8%) and 45.0% (42.0-48.1%), with significant race-sex disparities; e.g., at age 60: black men 52.7% (44.9-60.3%), black women 59.4% (53.6-65.0%), white men 39.1% (33.4-45.0%), and white women 39.1% (33.9-44.6%). Over 25 years, baseline LV end-systolic dimension/height was associated with incident systolic dysfunction (adjusted odds ratio per 1-SD higher: 2.56 [1.87-3.52]), eccentric hypertrophy (1.34 [1.02-1.75]), concentric hypertrophy (0.69 [0.51-0.91]), and concentric remodeling (0.68 [0.58-0.79]); baseline LV mass/height2.7 was associated with incident eccentric hypertrophy (1.70 [1.25-2.32]), concentric hypertrophy (1.63 [1.19-2.24]), and diastolic dysfunction (1.24 [1.01-1.52]). Among the entire cohort with baseline echocardiographic data available (N=4097; 72 HF events), LV end-systolic dimension/height and mass/height2.7 were significantly associated with incident clinical HF (adjusted hazard ratios per 1-SD higher: 1.56 [95% CI, 1.26-1.93] and 1.42 [1.14-1.75], respectively). Stage B LV abnormalities and related racial disparities were present in young adulthood, increased with age, and were associated with baseline variation in indexed LV end-systolic dimension and mass. Baseline indexed LV end-systolic dimension and mass were also associated with incident clinical HF. Efforts to prevent the LV abnormalities underlying clinical HF should start from a young age.Age-Related Development of Cardiac Remodeling and Dysfunction in Young Black and White Adults: the Coronary Artery Risk Development in Young Adults Study33212181J Am Soc Echocardiogr. 2020 Nov 16.Sidney, Stephen
No Title2878812/16/2020 11:33:14 PMhttps://divisionofresearch.kaiserpermanente.org/sites/DORCatalog/Lists/Publications/AllItems.aspxFalseThe Affordable Care Act (ACA) has increased insurance coverage for people with HIV (PWH) in the United States. To inform health policy, it is useful to investigate how enrollment through ACA Exchanges, deductible levels, and demographic factors are associated with health care utilization and HIV clinical outcomes among individuals newly enrolled in insurance coverage following implementation of the ACA. Among PWH newly enrolled in an integrated health care system (Kaiser Permanente Northern California) in 2014 (N = 880), we examined use of health care and modeled associations between enrollment mechanisms (enrolled in a Qualified Health Plan through the California Exchange vs. other sources), deductibles (none, $1-$999 and > = $1000), receipt of benefits from the California AIDS Drug Assistance Program (ADAP), demographic factors, and three-year patterns of health service utilization (primary care, psychiatry, substance treatment, emergency, inpatient) and HIV outcomes (CD4 counts; viral suppression at HIV RNA < 75 copies/mL). Health care use was greatest immediately after enrollment and decreased over 3 years. Those with high deductibles were less likely to use primary care (OR = 0.64, 95% CI = 0.49-0.84, p < 0.01) or psychiatry OR = 0.59, 95% CI = 0.37, 0.94, p = 0.03) than those with no deductible. Enrollment via the Exchange was associated with fewer psychiatry visits (rate ratio [RR] = 0.40, 95% CI = 0.18-0.86; p = 0.02), but ADAP was associated with more psychiatry visits (RR = 2.22, 95% CI = 1.24-4.71; p = 0.01). Those with high deductibles were less likely to have viral suppression (OR = 0.65, 95% CI = 0.42-1.00; p = 0.05), but ADAP enrollment was associated with viral suppression (OR = 2.20, 95% CI = 1.32-3.66, p < 0.01). Black (OR = 0.35, 95% CI = 0.21-0.58, p < 0.01) and Hispanic (OR = 0.50, 95% CI = 0.29-0.85, p = 0.01) PWH were less likely to be virally suppressed. In this sample of PWH newly enrolled in an integrated health care system in California, findings suggest that enrollment via the Exchange and higher deductibles were negatively associated with some aspects of service utilization, high deductibles were associated with worse HIV outcomes, but support from ADAP appeared to help patients achieve viral suppression. Race/ethnic disparities remain important to address even among those with access to insurance coverage.Health care utilization and HIV clinical outcomes among newly enrolled patients following Affordable Care Act implementation in a California integrated health system: a longitudinal study33176760BMC Health Serv Res. 2020 Nov 11;20(1):1030. Epub 2020-11-11.Satre, Derek D||Parthasarathy, Sujaya||Silverberg, Michael J||Horberg, Michael A||Young-Wolff, Kelly C||Campbell, Cynthia I
No Title2878712/16/2020 11:13:01 PMhttps://divisionofresearch.kaiserpermanente.org/sites/DORCatalog/Lists/Publications/AllItems.aspxFalseSocial determinants of health (SDoHs) and social risks (SRs) have been associated with adverse health and healthcare utilization and racial/ethnic disparities. However, there is limited information about the prevalence of SRs in non-"safety net" adult populations and how SRs differ by race/ethnicity, age, education, and income. We analyzed weighted survey data for 16,247 White, 1861 Black, 2895 Latino, 1554 Filipino, and 1289 Chinese adults aged 35 to 79 who responded to the 2011 or 2014/2015 Kaiser Permanente Northern California Member Health Survey. We compared age-standardized prevalence estimates of SDoHs (education, household income, marital status) and SRs (financial worry, cost-related reduced medication use and fruit/vegetable consumption, chronic stress, harassment/discrimination, health-related beliefs) across racial/ethnic groups for ages 35 to 64 and 65 to 79. SDoHs and SRs differed by race/ethnicity and age group, and SRs differed by levels of education and income. In both age groups, Blacks, Latinos, and Filipinos were more likely than Whites to be in the lower income category and be worried about their financial situation. Compared to Whites, cost-related reduced medication use was higher among Blacks, and cost-related reduced fruit/vegetable consumption was higher among Blacks and Latinos. Younger adults were more likely than older adults to experience chronic stress and financial worry. Racial/ethnic disparities in income were observed within similar levels of education. Differences in prevalence of SRs by levels of education and income were wider within than across racial/ethnic groups. In this non-"safety net" adult health plan population, Blacks, Latinos, and Filipinos had a higher prevalence of social risks than Whites and Chinese, and prevalence of social risks differed by age group. Our results support the assessment and EHR documentation of SDoHs and social risks and use of this information to understand and address drivers of racial/ethnic disparities in health and healthcare use.Racial-ethnic differences in prevalence of social determinants of health and social risks among middle-aged and older adults in a Northern California health plan33147232PLoS One. 2020;15(11):e0240822. Epub 2020-11-04.Gordon, Nancy||Banegas, Matthew P
No Title2858811/30/2020 9:13:37 PMhttps://divisionofresearch.kaiserpermanente.org/sites/DORCatalog/Lists/Publications/AllItems.aspxFalseSystemic racism is a public health crisis. Systemic racism and racial/ethnic injustice produce racial/ethnic disparities in health care and health. Substantial racial/ethnic disparities in stroke care and health exist and result predominantly from unequal treatment. This special report aims to summarize selected interventions to reduce racial/ethnic disparities in stroke prevention and treatment. It reviews the social determinants of health and the determinants of racial/ethnic disparities in care. It provides a focused summary of selected interventions aimed at reducing stroke risk factors, increasing awareness of stroke symptoms, and improving access to care for stroke because these interventions hold the promise of reducing racial/ethnic disparities in stroke death rates. It also discusses knowledge gaps and future directions.Interventions Targeting Racial/Ethnic Disparities in Stroke Prevention and Treatment33104466Stroke. 2020 Nov;51(11):3425-3432. Epub 2020-10-26.Nguyen-Huynh, Mai N
No Title2084511/30/2020 9:13:21 PMhttps://divisionofresearch.kaiserpermanente.org/sites/DORCatalog/Lists/Publications/AllItems.aspxFalseThe incidence of peptic ulcer disease (PUD) has been decreasing over time with Helicobacter pylori eradication and use of acid-suppressing therapies. However, PUD remains a common cause of hospitalization in the United States. We aimed to evaluate contemporary national trends in the incidence, treatment patterns, and outcomes for PUD-related hospitalizations and compare care delivery by hospital rurality. Data from the National Inpatient Sample were used to estimate weighted annual rates of PUD-related hospitalizations. Temporal trends were evaluated by joinpoint regression and expressed as annual percent change with 95% confidence intervals (CIs). We determined the proportion of hospitalizations requiring endoscopic and surgical interventions, stratified by clinical presentation and rurality. Multivariable logistic regression was used to assess independent predictors of in-hospital mortality and postoperative morbidity. There was a 25.8% reduction (P < 0.001) in PUD-related hospitalizations from 2005 to 2014, although the rate of decline decreased from -7.2% per year (95% CI: 13.2% to -0.7%) before 2008 to -2.1% per year (95% CI: 3.0% to -1.1%) after 2008. In-hospital mortality was 2.4% (95% CI: 2.4%-2.5%). Upper endoscopy (84.3% vs 78.4%, P < 0.001) and endoscopic hemostasis (26.1% vs 16.8%, P < 0.001) were more likely to be performed in urban hospitals, whereas surgery was performed less frequently (9.7% vs 10.5%, P < 0.001). In multivariable logistic regression, patients managed in urban hospitals were at higher risk for postoperative morbidity (odds ratio 1.16 [95% CI: 1.04-1.29]), but not death (odds ratio 1.11 [95% CI: 1.00-1.23]). The rate of decline in hospitalization rates for PUD has stabilized over time, although there remains significant heterogeneity in treatment patterns by hospital rurality.Urban-Rural Disparities and Temporal Trends in Peptic Ulcer Disease Epidemiology, Treatment, and Outcomes in the United States33105195Am J Gastroenterol. 2020 Oct 22.Lam, Angela||Lee, Jeffrey K
No Title1086311/30/2020 9:13:17 PMhttps://divisionofresearch.kaiserpermanente.org/sites/DORCatalog/Lists/Publications/AllItems.aspxFalseEducational attainment is associated with late-life cognitive performance and dementia; few studies have examined diverse racial/ethnic groups to assess whether the association differs by race/ethnicity. We investigated whether the association between educational attainment and cognition differed between White, Black, Asian, and Latino participants in the Kaiser Healthy Aging and Diverse Life Experiences study (n=1348). Covariate-adjusted multivariable linear regression models examined domains of verbal episodic memory, semantic memory, and executive functioning. We observed significant effect heterogeneity by race/ethnicity only for verbal episodic memory (P=0.0198), for which any schooling between high school and college was beneficial for White, Asian, and Black participants, but not Latino participants. We found no evidence of heterogeneity for semantic memory or executive function. With the exception of Latino performance on verbal episodic memory, more education consistently predicted better cognitive scores to a similar extent across racial/ethnic groups, despite likely heterogenous educational and social experiences.Do the Benefits of Educational Attainment for Late-life Cognition Differ by Racial/Ethnic Group?: Evidence for Heterogenous Treatment Effects in the Kaiser Healthy Aging and Diverse Life Experience (KHANDLE) Study33044303Alzheimer Dis Assoc Disord. 2020 Oct 09.Eng, Chloe||Gilsanz, Paola||Whitmer, Rachel