Allen Fremont

Gender, Time Use, and Health

One of the continuing paradoxes facing social epidemiologists concerns sex differences in morbidity and mortality. Although women live longer than men, they apparently get sick more. We hypothesize that womens higher morbidity levels result from less paid work and lower wages combined with more hours spent in household labor, child care, and helping others, and fewer hours of leisure and sleep. Men and women hold different social roles; men hold most of the highly rewarding roles. We operationalize social roles as time commitments to various role-related activities. This approach provides interval-level measures such as time spent in caring for children instead of simple dichotomies such as parent/nonparent. We find that when gender differences in social roles are controlled, being male is associated with poorer health than being female. We conclude that if gender roles were more equal, women would experience better health than men, more consistent with their greater longevity.

Racial and Ethnic Disparities in Care The Perspectives of Cardiologists

Background—Despite extensive documentation of racial and ethnic disparities in care, provider awareness of disparities has been thought to be low. To be effective, educational efforts for physicians must consider providers’ knowledge and beliefs about what causes disparities and what can be done about them. Methods and Results—We conducted a Web-based survey of 344 cardiologists to determine their level of awareness of disparities and views of underlying causes. Responses were assessed by means of 5-point Likert scales. Thirty-four percent of cardiologists agreed that disparities existed in care overall in the US healthcare system, and 33% agreed that disparities existed in cardiovascular care. Only 12% felt disparities existed in their own hospital setting, and even fewer, 5%, thought disparities existed in the care of their own patients. Despite this, most respondents rated the strength of the evidence about disparities as “very strong” or “strong.” Respondents identified many potential causes for disparities in care but were more likely to endorse patient and system level factors (eg, insurance status or adherence) rather than provider level factors. Conclusions—Cardiologists’ awareness of disparities in care remains low, and awareness is inversely proportional to proximity to their own practice setting.

Lay patient navigator program implementation for equal access to cancer care and clinical trials: essential steps and initial challenges.

Disparities in cancer detection, treatment, and outcomes among racial/ethnic minorities and low‐income patients are well documented. One way to reduce these disparities is to use patient navigators to address barriers to care. However, little information about optimal characteristics of navigator programs or considerations for those interested in setting up such programs is available.

Developing predictive models of health literacy.

INTRODUCTIONLow health literacy (LHL) remains a formidable barrier to improving health care quality and outcomes. Given the lack of precision of single demographic characteristics to predict health literacy, and the administrative burden and inability of existing health literacy measures to estimate health literacy at a population level, LHL is largely unaddressed in public health and clinical practice. To help overcome these limitations, we developed two models to estimate health literacy.METHODSWe analyzed data from the 2003 National Assessment of Adult Literacy (NAAL), using linear regression to predict mean health literacy scores and probit regression to predict the probability of an individual having ‘above basic’ proficiency. Predictors included gender, age, race/ethnicity, educational attainment, poverty status, marital status, language spoken in the home, metropolitan statistical area (MSA) and length of time in U.S.RESULTSAll variables except MSA were statistically significant, with lower educational attainment being the strongest predictor. Our linear regression model and the probit model accounted for about 30% and 21% of the variance in health literacy scores, respectively, nearly twice as much as the variance accounted for by either education or poverty alone.CONCLUSIONSMultivariable models permit a more accurate estimation of health literacy than single predictors. Further, such models can be applied to readily available administrative or census data to produce estimates of average health literacy and identify communities that would benefit most from appropriate, targeted interventions in the clinical setting to address poor quality care and outcomes related to LHL.

Patient-centered processes of care and long-term outcomes of myocardial infarction

OBJECTIVE: To examine whether patients’ experiences with nontechnical aspects of care such as patient education and discharge planning are associated with long-term outcomes.DESIGN: Observational cohort study.SETTING: Twenty-three New Hampshire hospitals during 1996 and 1997.PARTICIPANTS: Acute myocardial infarction (AMI) patients (N=2,272) enrolled prior to discharge.MEASUREMENTS: Surveys asking about problems with care and health were mailed to patients 1, 3, and 12 months after discharge. Patients were stratified into “worse” or “better” care groups on the basis of their hospital care problem score. Outcomes included self-reported overall health, physical health, mental health, chest pain, and shortness of breath. Other clinical measures were obtained from hospital discharge abstracts.MAIN RESULTS: The 1-, 3-, and 12-month surveys were returned by 1,346 (59.2%), 1,046 (46%), and 964 (42.4%) enrolled patients, respectively. The primary analytic cohort consisted of the 762 patients who completed both the 1- and 12-month surveys. After adjustment for postdischarge health status and other clinical factors, patients experiencing worse hospital care had lower ratings of overall health (48.4 vs 52.5 on 100-point scale; P=.02) and physical health (59.7 vs 68.4; P<.001), and were more likely to have chest pain (odds ratio [OR], 1.6; confidence interval [CI], 1.0 to 2.4; P=.04) 12 months after their AMI than other patients. However, differences in reports of chest pain were reduced if patients reporting worse hospital care had better experiences with subsequent ambulatory care.CONCLUSIONS: Patients’ experiences with nontechnical processes of AMI hospital care are associated with long-term outcomes; however the association between a negative hospital experience and subsequent chest pain may be offset by more positive outpatient experiences.

Using the Census Bureau’s surname list to improve estimates of race/ethnicity and associated disparities

Commercial health plans need member racial/ethnic information to address disparities, but often lack it. We incorporate the U.S. Census Bureau’s latest surname list into a previous Bayesian method that integrates surname and geocoded information to better impute self-reported race/ethnicity. We validate this approach with data from 1,921,133 enrollees of a national health plan. Overall, the new approach correlated highly with self-reported race-ethnicity (0.76), which is 19% more efficient than its predecessor (and 41% and 108% more efficient than single-source surname and address methods, respectively, P < 0.05 for all). The new approach has an overall concordance statistic (area under the Receiver Operating Curve or ROC) of 0.93. The largest improvements were in areas where prior performance was weakest (for Blacks and Asians). The new Census surname list accounts for about three-fourths of the variance explained in the new estimates. Imputing Native American and multiracial identities from surname and residence remains challenging.

Building Bridges Between Medical Care and Public Health

Medicine and public health have been likened to trains on parallel tracks -- with windows facing opposite directions, looking out on the same landscape. As described by HHS Secretary Donna Shalala, those on the medical train see the individual trees: the subtle differences in size, color, age and health. Those aboard the public health train see the forest: populations of similar trees, growing together and weathering the same storms.1 While the two have potentially complementary perspectives, efforts to improve care – as well as personal and population health – are hampered by lack of communication and coordination between medical and public health professionals and fragmented data systems. Differing perspectives and disconnected data have also hindered effectiveness of shared efforts between health professionals and other stakeholders, including community-based organizations and health plans. While the call for greater synergy between health care and public health is hardly new, emerging technologies and the urgent need for health reform create the opportunity and imperative for them to come together.

The National Health Plan Collaborative to Reduce Disparities and Improve Quality

BACKGROUND Despite numerous reports and initiatives, progress in reducing racial/ethnic disparities in health care has been slow. The National Health Plan Collaborative (NHPC), a novel public-private partnership between nine health plans covering approximately 95 million lives, leading learning and research organizations, the Agency for Healthcare Research and Quality, and the Robert Wood Johnson Foundation, was established in December 2004 to address these disparities. PROGRESS TO DATE The health plans were able to overcame initial challenges in obtaining information on race/ethnicity of their enrollees and examined their diabetes performance measure to assess disparities in care. By February 2006, the initial nine plans that had joined the NHPC progressed from focusing solely on data collection and management issues and were engaged in outreach activities to members, providers, or community or had completed capacity development for disparities work. Five plans had implemented one or more pilot interventions. Plans also addressed unanticipated challenges, such as sorting through large amounts of data to target disparities. CHALLENGES AND LESSONS LEARNED Because many of the plans are complex national entities with varying regional and departmental structures, simply achieving coordination of disparities activities across the organization has been a major challenge and, in many cases, a major breakthrough. CONCLUSIONS The NHPC represents a model of shared learning and innovation through which health plans are tackling racial/ethnic disparities. Now that most of the plans have some data on their enrollees with diabetes and have begun targeting disparities, they want to capitalize on their collective industry strength to influence policy on issues related to disparities.

Bridging the gap between basic science and clinical practice: a role for community clinicians

BackgroundTranslating the extraordinary scientific and technological advances occurring in medical research laboratories into care for patients in communities throughout the country has been a major challenge. One contributing factor has been the relative absence of community practitioners from the US biomedical research enterprise. Identifying and addressing the barriers that prevent their participation in research should help bridge the gap between basic research and practice to improve quality of care for all Americans.MethodsWe interviewed over 200 clinicians and other healthcare stakeholders from 2004 through 2005 to develop a conceptual framework and set of strategies for engaging a stable cadre of community clinicians in a clinical research program.ResultsLack of engagement of community practitioners, lack of necessary infrastructure, and the current misalignment of financial incentives and research participation emerged as the three primary barriers to community clinician research participation. Although every effort was made to learn key motivators for engagement in clinical research from interviewees, we did not observe their behavior and self-report by clinicians does not always track with their behavior.ConclusionsA paradigm shift involving acknowledgement of the value of clinicians in the context of community research, establishment of a stable infrastructure to support a cohort of clinicians across time and research studies, and realignment of incentives to encourage participation in clinical research is required.

IMPROVING WOMEN'S QUALITY OF CARE FOR CARDIOVASCULAR DISEASE AND DIABETES: THE FEASIBILITY AND DESIRABILITY OF STRATIFIED REPORTING OF OBJECTIVE PERFORMANCE MEASURES

Despite growing recognition of significant morbidity and mortality among women from cardiovascular disease, management of primary and secondary cardiac risk factors continues to be suboptimal for many women. Although there is a good deal of room to improve the care for cardiovascular disease and diabetes in men, existing gender differences in performance suggest much can be gained by specifically assessing and monitoring quality of care for these conditions in women. In this paper, we describe recent work showing gender differences in quality of ambulatory care in managed care plans with some plans having substantial gender differences on widely used measures of the quality of primary and secondary prevention of cardiac disease. We then discuss potential benefits of and barriers to routine reporting of objective measures of the quality of care, such as Health Plan Employer Data and Information Set (HEDIS) measures, by health plans.