Kaiser Permanente’s Approach to Health Disparities · 2019-06-25 · % Positive 1. Within the...
Transcript of Kaiser Permanente’s Approach to Health Disparities · 2019-06-25 · % Positive 1. Within the...
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Kaiser Permanente’s Approach to Health Disparities
• Michael H Kanter MD
• Professor and Chair, Clinical Sciences, Kaiser Permanente School of Medicine
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Crossing the Quality Chasm - Six AimsIOM Quality of Healthcare in America
Safe
Effective
Patient Centered
Timely
Efficient
Equitable
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United States demographics
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More than half of the population will be non-white
Latino population will triple
Asian population will triple
Black population will double
White population will stay about the same
By 2050 it is projected that
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Health disparities
• Race/ethnicity
• Gender
• Age
• Socioeconomic status
• Sexual orientation
• Disability status
• Language preference
• Anything that differs among people that should not impact care
This can involve
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Health disparities
• Are unacceptable
• Occur in the context of racial and ethnic or other discrimination
• Have many sources • Health systems
• Bias – both conscious and unconscious
• Cultural
• Societal
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Factors contributing to health disparities
IntrinsicFactors
ExtrinsicFactors
Total Health
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Potential Myocardial Infarctions/Strokes Prevented
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11.2MILLIONAfrican Americans in U.S. with hypertension
6.3%
DIFFERENCEin control rate between U.S. African American and U.S. Caucasian (70.2% vs. 63.9%)
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Potential Myocardial Infarctions/Strokes Prevented
Hypothetically… If hypertension control disparity reduced to 0
705,600MILLION MORE
African Americans in control
PREVENT
1 MI or Stroke =
TREAT 36 PATIENTS
19,600 MIs or Strokes Potentially
Preventedin 5 years (11 per day!)
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Disparities
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“…Disparities in control of blood
pressure, cholesterol, and
glucose…for blacks in
Medicare…were eliminated
[by Kaiser Permanente] in 2011.”
New England Journal of Medicine; 371:24, NEJM.ORG“Racial and Ethnic Disparities among Enrolees in Medicare Advantage Plans
John Z. Ayanian MD, etal December 11,2014
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Disparities
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“The IHS[Kaiser Permanente] approach to care is associated with
higher levels of evidence-based medicine, improved survival,
and reduced colon cancer disparity gaps.”
Journal of Clinical Oncology Published Ahead of Print on January 26, 2015 as 10.1200/JCO.2014.56.8642“How Do Integrated Health Care Systems Address Racial and Ethnic Disparities in Colon Cancer?”
Kim F. Rhoades, et al
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Two Approaches to Address Disparities
Address each metric individually
• Suppose…• 500 quality measures• 300 race/ethnicity groups captured in
system• How many permutations?
Address more than one issue
• Create a highly reliable delivery system
• Language
• E disparities
• Proper location of MOBs
• Deal with social determinants of health
• Training physicians in disparities reduction
TOO MANY!
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Are health care disparities in part a manifestation of unreliable non standardized care
• Example : colon cancer screening• What if the health care system was set up such that 100% of the patient
population that needed colon cancer screening obtained it• Proactive care
• Robust outreach
• On line tools for self management
• Involvement of every place that contacts patients
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Standardization
• Contrary to the idea of physician autonomy
• May be incorrectly interpreted as inhibiting creativity and innovation
• Difficult to show that one way of doing things is better than another
• Standardized processes are not necessarily reliable
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reliability
• Standardized systems may not be reliable
• Reliable systems are standardized
• Systems that rely on human beings too much are not reliable
• Systems that rely on computers are highly reliable until they are not.
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Standardization
• The more different workflows are, the harder it is to identify and spread best practices
• Allows for easy spread if medical centers all have standardized work flows• POE
• BPAs
• Safety Net program
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In the Old Days…
• Doctors practiced medicine
• No scientific methods for practice improvement
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Lack of systems
• Most physicians open or join a “practice”
• There are few systems in place in the “practice”
• Lack of systems allows unreliable care, which then increases health care disparities
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Aim of
Improvement
Measurement
of
Improvement
Developing a
Change
Testing a
Change
Adapted from Langley, G. J., Nolan, K. M., Nolan, T. W., Norman, C. L., &
Provost, L. P. The Improvement Guide: A Practical Approach to Enhancing
Organizational Performance. San Francisco, CA: Jossey-Bass, 1996.
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Act Plan
Study Do
Institute for Healthcare Improvement
…Continued
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Quality Measure Improvement Over Time
54%
89%
45%
55%
65%
75%
85%
95%
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Hypertension Control
Adult Hypertension Control Ages 18-84, 2004-2014Source: SCPMG Department of Clinical Analysis
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Jt Comm J Qual Patient Saf 2013;39(11):484-494
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HEDIS Results
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“The Whiskey Barrel”
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Proactive Panel Support
• Panel Manager • PharmD, RN, RNP, PA
• Support Coordinator• Clerk, LVN, MA
• Scheduled Physician Time• 20 to 60 minutes per month
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Pre Visit Post VisitVisit
Office Encounter
• Pre-encounter follow-up
• Vital sign, history, social,
demographics, medication review
• Identify and flag alerts for provider for
screening and uncontrolled chronic
conditions
• Room and prepare patient for
necessary exams
Immediate:
• After visit summary, after
care instructions, follow-
up appointments, health
ed materials, how to
access info on KP.org
Future:
• Follow up contact &
appointments per provider
Proactive Identification
• Identify missing labs
(A1c, LDL, microalbumin),
screening procedures,
access management,
KP.org status, etc.
• Provide member
instructions prior to visit
• Contact member and
document encounter in
HealthConnectTM
Proactive Office Encounter (POE)
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Two Approaches to Address Disparities
Address each metric individually
• Suppose…• 500 quality measures• 300 race/ethnicity groups captured in
system• How many permutations?
Address more than one issue
• Create a highly reliable delivery system
• Language
• E disparities
• Proper location of MOBs
• Deal with social determinants of health
• Training physicians in disparities reduction
TOO MANY!
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Language disparities
LEP patients are more prone to
• Medical error
• Extra diagnostic testing
• Overly aggressive hospital admissions
• Health disparities
• Miscommunication issues2009
Language Concordance
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Language concordance
• Physicians pass a standard language test
• Physicians have option to increase the % of LEP patients in practice
• Annual incentives to qualifying concordant physicians
• 23 language fluency programs offered
Exists when a bilingual physician is fluent in the language that his/her patient prefers to speak
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Value of Language Concordance – Internal Findings
Better Blood Pressure Control With Spanish Speaking Physicians
The HTN control rate when paired with concordant MD tends to show a significant improvement of up to 2%
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2012
Quality
Measures
Non-Spanish
Speaking
Spanish
Speaking
Spanish
Speaking with
Concordant
MDs
Spanish
Speaking
with Non-
Concordant
MDs
Lipid Control
(<100 mg/dL)
with Diabetes68.3 67.7 68.1 66.4
HbA1c < 9.0%
with Diabetes 83.3 81.3 81.9 79.5 Colon Cancer
Screening 79.3 78.3 79.6 74.9
all p values are < .05
Impact of language concordance on quality
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2015*
Quality
Measures
General
Population
Screening Rate
Spanish Speaking
Member
with Non-
Concordant MDs
Spanish Speaking
Member
with Concordant
MDs
Diabetes
HbA1c < 8%66.8% 62.7% 64.8%
Controlling Blood
Pressure88.8% 88.9% 89.8%
Colon Cancer
Screening 82.7% 79.1% 83.6%
Language Concordance - Impact on Quality
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Source: Culturally Responsive Care Dept.2Q 2015 KP SCAL Equitable Care Report Language
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24.6%
32.0%33.9%
35.6% 36.0%37.8% 37.7%
43.6%
15%
25%
35%
45%
Inception 2008 2009 2010 2011 2012 2013 2014 YTD
Concordant Visits
Primary care program trends
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E disparities
• Use of patient portals is rapidly increasing.
• What if its use is not the same for all racial/ethnic groups?
• What if use of such portals improves patient outcomes?
• Are we increasing health disparities?
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Health Affairs 2010;29(7):1370-1375.
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Findings – Disparity among race/ethnic groups in access to patient portal (kp.org)
-30%-19%
-52% -48%
-23%
-60%
-40%
-20%
0%
Am
. In
dia
n/A
K N
ativ
e
Asi
an/P
acif
ic Is
lan
der
Afr
ican
Am
.
His
pan
ic
Mu
lti-
raci
al
Other factors include age, gender, disease burden, income level, education, language preference, number of doctor office visits, region, tenure with KP and distance to nearest MOB
Odds Ratio As Compared to White
White 0%
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Quality of care improvement and secure EmailMatched Control Study: Secure Email Users Vs
Non-Users
50%
60%
70%
80%
90%
100%
A1C
Scre
en
ing
A1C
Co
ntr
olled
(< 9
)
LD
L
Scre
en
ing
LD
L
Co
ntr
olled
(< 1
00)
Reti
no
path
y
Scre
en
ing
Nep
hro
path
y
Scre
en
ing
BP
Co
ntr
ol
(< 1
40/9
0 m
m
Hg
)
BP
Co
ntr
ol
(< 1
30/8
0 m
m
Hg
)
BP
Co
ntr
ol
Non Secure Email Users Secure Email Users
Matched Control Study: Secure Email Users vs Non-Users
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E disparities
▪ Disparities exist in Portal usage
▪ HEDIS scores increase in patients who started using the Portal from 1.0-7.1% more than patients who did not use the Portal
▪ HEDIS increases were similar in Non-Hispanic White, Latino, African American, and Asian populations
▪ Increasing portal useage in minorities has the potential to decrease health disparities
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Social determinants of health
• Potentially a huge lever on health disparities
• Addressing social determinants of health has an unclear path forward with boundary issues of what is the role of health care organizations and what is the role of society/communities
• Good studies on how to do this at scale are lacking
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How Many Members Have Unmet Social Needs?
52% 36% 28% 21%
Answer call Agree to takescreen
Have 1+ needs Enroll
Cold Call
ScreenIdentify Needs
Enroll
70%
78%
74%
Source: Kaiser Permanente/Health Leads Partnership
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What is the social need prevalence of top 1% at screening?
% Positive
1. Within the last 12 months, “the food that I bought just didn’t last, and I didn’t have money to get more.” 44%
2. Within the last 12 months, “I couldn’t afford to eat balanced or healthy meals.” 46%
6. Do you have difficulty arranging for transportation to or from your medical appointments? 35%
7. Do you ever have trouble making ends meet at the end of the month or worry about money matters? 60%
7a. Do you need help finding ways to pay for your utility bills? 33%7d. Do you need help finding ways to pay for medical care? 33%8. How often do you have problems learning about your medical condition because of difficulty understanding written words or numbers? 36%
11. How often do you feel lonely or isolated from those around you? 30%
Source: Kaiser Permanente/Health Leads Partnership
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Unmet Social Needs
Meet Patient Carlos
• Multiple Sclerosis
• Uncontrolled diabetes
• Multiple ED visits, hospitalizations
• Missed specialty visits
• Spanish speaking
• Financial difficulties
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After Social Needs Recognized
Patient Carlos
Improved health
Trusts health team
Keeps appointments
Medication adherence
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Example of focus on a specific conditions- high blood pressure
• Overall blood pressure control in the U.S. is suboptimal
• Over ½ of Americans with hypertension not well controlled
• Severe in African American population
• About 42% among adults
• As compared to Caucasians:
• 1.3 times greater risk of non-fatal stroke
• 3 to 6 times greater risk of fatal stroke
• 5 times greater risk for End Stage Renal Disease
Focus on African Americans
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Barriers to accomplishing these components among African Americans
• Failure to intensify therapy
• Patient-clinician relationship• Duration/frequency of relationship
• Patient satisfaction
• Health care access• Non-attendance at scheduled visits
• Non-adherence to medicines/labs
• Patient • Knowledge
• Diet/exercise
• Support/resources
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approaches to hypertension disparities reduction• Salt questionnaire
• Tailored communication training to build trust
• Community outreach activities
• Storytelling by videos
• African American group hypertension visits
• Use of barber shops in African American neighborhoods
• Targeted panel management
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Improving patient-provider communications and interactions
Four Habits
• Invest in the beginning
• Elicit patient’s perspective
• Demonstrate empathy
• Invest in the end
AIDET®
• Acknowledge and Introduce
• Duration
• Explanation
• Thank
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Decrease in hypertension control disparity
5.7%
4.7%
4.3%
3.4%
2.0%
3.0%
4.0%
5.0%
6.0%
Jun-11 Jun-12 Jun-13 Sep-14
Disparity decreased between Kaiser Permanente Southern California members whose hypertension is controlled (African-American and white)
Source: Pharmacy Analytical Service, Kaiser Permanente, Southern California – Data not yet published
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Intellectual and Developmental Disabilities
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Public reporting of disparities
• Should publicly reported quality measures be adjusted for race/ethnicity or socioeconomic status?
• Readmission rates?
• Patient satisfaction/ratings?
• There are hundreds of quality measures that are publicly reported.
• Public reporting of quality has been associated with improvements in care
• public reported metrics by race/ethnicity is rarely done
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Approach to disparities
• Start somewhere based on magnitude of disparity, clinical importance, and perceived ability to reduce disparity
• Create robust measurement system
• Use existing systems if appropriate
• Create just culture
• Remove any political ideology
• Disparities reduction is a quality issue
• Be humble49
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Core components of success and improvement in overcoming disparities
• Actionable and current data; registries
• Clear clinical algorithms• With expectations that they be followed• Simplifying regimens to enhance patient adherence
• Clinical interventions tailored to needs and expectations of priority populations
• Dissemination and adoption of practices that make a difference in the patient experience and patient interaction
• Supporting multi-disciplinary teams to take on the issue• With accountabilities
• Considering and factoring in community-level education, outreach, and engagement50
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Conclusion
• It is possible to measure health disparities and decrease them over time.
• Medical delivery systems are just beginning this journey.
• Public reporting and transparency of disparity data could be helpful
• Every day we wait on reducing disparities,people unfairly have adverse health outcomes.
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