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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


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.


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



An Electronic Health Record-Based Tool to Identify Newly Diagnosed Breast Cancer Patients at Risk of Low Social SupportGoals 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 BehaviorThe 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 DiabetesThis 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
Racial/Ethnic Disparities in Perinatal Depression Treatment UtilizationThe study will characterize racial/ethnic differences in perinatal depression treatment utilization, treatment engagement, and continued care by assembling a retrospective cohort of KPNC members entering prenatal care between 2012-2016. The study will also identify barriers to and facilitators of treatment utilization and opportunities for improvement in care delivery.GP0|#18fccf82-6f11-4a37-b04a-1d7db14865cb;L0|#018fccf82-6f11-4a37-b04a-1d7db14865cb|Avalos, Lyndsay;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae42020-08-21T07:00:00Z
Understanding racial-ethnic disparities in preterm birth sub-types and prenatal care utilizationThe study will examine racial-ethnic disparities in the risk of preterm birth overall and by preterm birth sub-types. It will also study whether the racial-ethnic disparities in preterm births and preterm birth sub-types are modified by the level of prenatal care received.GP0|#29766467-4d3a-4699-af48-e82f44bb18fa;L0|#029766467-4d3a-4699-af48-e82f44bb18fa|Hedderson, Monique;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae42020-08-21T07:00:00Z
Prevalence of Social Risks and Association of Social Risks with Health and Well-Being Among Non-Safety Net Middle-Aged and Older Adult Members in Kaiser Permanente Northern CaliforniaThis study will gather data to estimate the prevalence of several different social and financial risk factors among adults aged 35-84 and assess whether risk factor prevalence significantly differs across age, race, health status, and income groups.GP0|#c8cf53b9-4610-4262-b315-7d16bda73220;L0|#0c8cf53b9-4610-4262-b315-7d16bda73220|Grant, Richard;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae42020-08-21T07:00:00Z

 Recent Publications



No Title2301310/23/2020 12:59:23 AM describe trends in the burden of mortality due to subtypes of heart disease from 1999 to 2018 to inform targeted prevention strategies and reduce disparities. Serial cross sectional analysis of cause specific heart disease mortality rates using national death certificate data in the overall population as well as stratified by race-sex, age, and geography. United States, 1999-2018. 12.9 million decedents from total heart disease (49% women, 12% black, and 19% Heterogeneous trends in burden of heart disease mortality by subtypes in the United States, 1999-2018: observational analysis of vital statistics32816805BMJ. 2020 08 13;370:m2688. Epub 2020-08-13.Rana, Jamal S||Sidney, Stephen
No Title2301910/23/2020 12:57:07 AM determine whether women with a history of nulliparity, hypertensive disorders of pregnancy (HDP), or gestational diabetes mellitus (GDM) have a higher odds of reporting vasomotor symptoms (VMS) at midlife. A longitudinal analysis was performed with 2,249 women with pregnancy history data in the Study of Women's Health Across the Nation. Women were classified as nulliparous, no HDP/GDM, or a history of HDP/GDM. VMS (hot flashes, night sweats) were assessed separately at baseline and at each follow-up visit. VMS was recorded as any versus none; 0 , 1-5 , 6+ days in past 2 weeks. Pregnancy history was examined in relation to each VMS (hot flashes, night sweats) using generalized estimating equations adjusting for age (time-varying), site, race/ethnicity, education, financial strain, smoking, and body mass index. Models excluded women with hysterectomy/bilateral oophorectomy and observations with hormone therapy use. Women in the HDP/GDM group (n = 208, 9%) were more likely to be Black, financially strained, and overweight. Compared to women with no HDP/GDM, women with HDP/GDM had greater odds of reporting any hot flashes (OR:1.27; 95% CI:1.05-1.53). Nulliparous women had lower odds of any hot flashes (OR:0.64; 95% CI:0.51-0.80) and night sweats (OR:0.73; 95% CI:0.58-0.93) in age-adjusted models. Similar patterns were observed for frequency of hot flashes and night sweats; associations were attenuated to nonsignificance after adjusting for covariates. History of HDP/GDM may be associated with more VMS and nulliparity with fewer VMS, but not independently of sociodemographic factors. Our findings underscore the importance of social and economic disparities in both reproductive outcomes and VMS. : Video Summary: of nulliparity, hypertensive disorders of pregnancy, and gestational diabetes on vasomotor symptoms in midlife women32796290Menopause. 2020 Aug 10.Hedderson, Monique M
No Title2234710/23/2020 12:59:22 AM with chronic kidney disease (CKD) experience significantly greater morbidity than the general population. The hospitalization rate for patients with CKD is significantly higher than the general population. The extent to which neighborhood-level socioeconomic status (SES) is associated with hospitalization has been less explored, both in the general population and among those with CKD.We evaluated the relationship between neighborhood SES and hospitalizations for adults with CKD participating in the Chronic Renal Insufficiency Cohort Study. Neighborhood SES quartiles were created utilizing a validated neighborhood-level SES summary measure expressed as z-scores for 6 census-derived variables. The relationship between neighborhood SES and hospitalizations was examined using Poisson regression models after adjusting for demographic characteristics, individual SES, lifestyle, and clinical factors while taking into account clustering within clinical centers and census block groups.Among 3291 participants with neighborhood SES data, mean age was 58 years, 55% were male, 41% non-Hispanic white, 49% had diabetes, and mean estimated glomerular filtration rate (eGFR) was 44 ml/min/1.73 m. In the fully adjusted model, compared to individuals in the highest SES neighborhood quartile, individuals in the lowest SES neighborhood quartile had higher risk for all-cause hospitalization (rate ratio [RR], 1.28, 95% CI, 1.09-1.51) and non-cardiovascular hospitalization (RR 1.30, 95% CI, 1.10-1.55). The association with cardiovascular hospitalization was in the same direction but not statistically significant (RR 1.21, 95% CI, 0.97-1.52).Neighborhood SES is associated with risk for hospitalization in individuals with CKD even after adjusting for individual SES, lifestyle, and clinical factors.Neighborhood socioeconomic status and risk of hospitalization in patients with chronic kidney disease: A chronic renal insufficiency cohort study32664108Medicine (Baltimore). 2020 Jul 10;99(28):e21028.Go, Alan S
No Title2301810/23/2020 12:59:23 AM assessed cross-sectional differences in sleep quality and risk factors among Asian, Black, Latino, and White participants in the Kaiser Healthy Aging and Diverse Life Experiences (KHANDLE) Study. KHANDLE enrolled community-dwelling adults aged ≥65 years living in northern California. Participants completed a modified Pittsburgh Sleep Quality Index to measure six sleep components and a global sleep score (scored 0-24). Covariates included age, sex, central adiposity, education, income, alcohol consumption, ever smoking, physical activity, and depression. Ordinal logistic regression was used to model sleep component scores across race/ethnic groups. Linear regression was used to assess racial/ethnic differences in global sleep score and the association between risk factors and global sleep score. 1,664 participants with a mean age of 76 (SD=7) and mean global sleep score of 6 (SD=4) were analyzed. Using Latinos as reference (highest average sleep score), Blacks had an average .96 (.37, 1.54) unit higher global sleep score (worse sleep) while Asians [β: .04 (-.56, .63)] and Whites [β: .28 (-.29, .84)] did not significantly differ. Compared with Latinos, Blacks and Asians had greater odds of a worse score on the sleep duration component; Blacks and Whites had greater odds of a worse score on the sleep disturbances component; and, Whites had greater odds of a worse score on the medication component. Risk factors for poor sleep did not differ by race/ethnicity except alcohol consumption (interaction P=.04), which was associated with poor sleep in Blacks only. In this cohort, racial/ethnic differences in sleep quality were common.Racial/Ethnic Differences in Sleep Quality among Older Adults: Kaiser Healthy Aging and Diverse Life Experiences (KHANDLE) Study32742152Ethn Dis. 2020 Summer;30(3):469-478. Epub 2020-07-09.Gilsanz, Paola||Whitmer, Rachel
No Title2301110/23/2020 12:59:23 AM electronic health record (EHR) data from a systematic, primary care-based alcohol screening, brief intervention, and referral to treatment (SBIRT) initiative within a health system, we examined correlates of remission from unhealthy drinking among patients with an alcohol use disorder (AUD). We conducted a longitudinal study of 4,078 adults with AUD who screened positive for unhealthy drinking between October 1, 2015, and September 30, 2016. We extracted EHR data up to 3 years after screening until October 1, 2018. We used survival analysis to examine associations between remission (i.e., reporting abstinence or low-risk drinking at a subsequent screening) and patient characteristics, comorbidities, and treatment utilization. The median time to remission from unhealthy drinking was 1.7 years. Factors significantly associated with greater odds of remitting from unhealthy drinking during follow-up were female gender; older age (50-64 years); Black or Latino/Hispanic race/ethnicity; having more medical comorbidities; not having a comorbid drug use disorder; lower alcohol consumption levels; and receiving addiction medicine treatment before the index screening. In the first follow-up year, individuals with mental health comorbidities were more likely to remit, but those in psychiatric treatment were less likely. Receiving addiction treatment during follow-up was not associated with remission. Ethnic minorities and individuals with mental illness were more likely to remit, which is encouraging given the health disparities observed among these clinically important subgroups and warrants further research. Our findings may inform research on AUD recovery and clinical practice, as remission from unhealthy drinking is a crucial component of the early stages of recovery.Remission From Unhealthy Drinking Among Patients With an Alcohol Use Disorder: A Longitudinal Study Using Systematic, Primary Care-Based Alcohol Screening Data32800079J Stud Alcohol Drugs. 2020 Jul;81(4):436-445.Palzes, Vanessa A||Kline-Simon, Andrea H||Satre, Derek D||Sterling, Stacy A||Weisner, Constance||Chi, Felicia W
No Title1687310/23/2020 12:59:21 AM disparities in breast cancer survival are well documented, but the influence of health care institutions is unclear. We therefore examined the effect of hospital characteristics on survival. Harmonized data pooled from 5 case-control and prospective cohort studies within the California Breast Cancer Survivorship Consortium were linked to the California Cancer Registry and the California Neighborhoods Data System. The study included 9,701 patients with breast cancer who were diagnosed between 1993 and 2007. First reporting hospitals were classified by hospital type-National Cancer Institute (NCI) -designated cancer center, American College of Surgeons (ACS) Cancer Program, other-and hospital composition of the neighborhood socioeconomic status and race/ethnicity of patients with cancer. Multivariable Cox proportional hazards models adjusted for clinical and patient-level prognostic factors were used to examine the influence of hospital characteristics on survival. Fewer than one half of women received their initial care at an NCI-designated cancer center (5%) or ACS program (38%) hospital. Receipt of initial care in ACS program hospitals varied by race/ethnicity-highest among non-Latina White patients (45%), and lowest among African Americans (21%). African-American women had superior breast cancer survival when receiving initial care in ACS hospitals versus other hospitals (non-ACS program and non-NCI-designated cancer center; hazard ratio, 0.67; 95% CI, 0.55 to 0.83). Other hospital characteristics were not associated with survival. African American women may benefit significantly from breast cancer care in ACS program hospitals; however, most did not receive initial care at such facilities. Future research should identify the aspects of ACS program hospitals that are associated with higher survival and evaluate strategies by which to enhance access to and use of high-quality hospitals, particularly among African American women.Hospital Characteristics and Breast Cancer Survival in the California Breast Cancer Survivorship Consortium32521220JCO Oncol Pract. 2020 Jun;16(6):e517-e528.Kwan, Marilyn L