Dominic Mack

Mitigating the Health Effects of Disasters for Medically Underserved Populations: Electronic Health Records, Telemedicine, Research, Screening, and Surveillance

The Regional Coordinating Center for Hurricane Response (RCC) collaborated with the EXPORT Centers (Centers of Excellence in Partnerships for Community Outreach, Research on Health Disparities and Training) to rebuild, revitalize, and improve the health care infrastructure in the Gulf Coast states damaged by Hurricanes Katrina and Rita. This initiative aims to enhance the provision of health care by installing Electronic Health Records and Telepsychiatry systems throughout the Gulf Coast. Through the EXPORT Centers, the RCC plans to perform screening and surveillance projects within the communities and develop research projects focused on eliminating health disparities affecting underserved populations in the region. Another goal is to establish partnerships with EXPORT Centers, Community Health Centers, and other essential primary care practices in hurricane-ravaged communities. Through these partnerships, the overarching goal is to create a balanced health care system model that academic institutions can integrate into preventive care for emergency planning and research.

Paths to Success: Optimal and Equitable Health Outcomes for All

U.S. health disparities are real, pervasive, and persistent, despite dramatic improvements in civil rights and economic opportunity for racial and ethnic minority and lower socioeconomic groups in the United States. Change is possible, however. Disparities vary widely from one community to another, suggesting that they are not inevitable. Some communities even show paradoxically good outcomes and relative health equity despite significant social inequities. A few communities have even improved from high disparities to more equitable and optimal health outcomes. These positive-deviance communities show that disparities can be overcome and that health equity is achievable. Research must shift from defining the problem (including causes and risk factors) to testing effective interventions, informed by the natural experiments of what has worked in communities that are already moving toward health equity. At the local level, we need multi-dimensional interventions designed in partnership with communities and continuously improved by rapid-cycle surveillance feedback loops of community-level disparities metrics. Similarly coordinated strategies are needed at state and national levels to take success to scale. We propose ten specific steps to follow on a health equity path toward optimal and equitable health outcomes for all Americans.

Disparities in Primary Care EHR Adoption Rates

This study evaluates electronic health record (EHR) adoption by primary care providers in Georgia to assess adoption disparities according to practice size and type, payer mix, and community characteristics. Frequency variances of EHR “Go Live” status were estimated. Odds ratios were calculated by univariate and multivariate logistic regression models. Large practices and community health centers (CHCs) were more likely to Go Live (>80% EHR adoption) than rural health clinics and other underserved settings (53%). A significantly lower proportion (68.9%) of Medicaid predominant providers had achieved Go Live status and had a 47% higher risk of not achieving Go Live status than private insurance predominant practices. Disparities in EHR adoption rates may exacerbate existing disparities in health outcomes of patients served by these practices. Targeted support such as that provided to CHCs would level the playing field for practices now at a disadvantage.

Missed policy opportunities to advance health equity by recording demographic data in electronic health records.

The science of eliminating health disparities is complex and dependent on demographic data. The Health Information Technology for Economic and Clinical Health Act (HITECH) encourages the adoption of electronic health records and requires basic demographic data collection; however, current data generated are insufficient to address known health disparities in vulnerable populations, including individuals from diverse racial and ethnic backgrounds, with disabilities, and with diverse sexual identities. We conducted an administrative history of HITECH and identified gaps between the policy objective and required measure. We identified 20 opportunities for change and 5 changes, 2 of which required the collection of less data. Until health care demographic data collection requirements are consistent with public health requirements, the national goal of eliminating health disparities cannot be realized.

Using Appendiceal Perforation Rates to Measure Impact of a Disaster on Healthcare System Effectiveness

ObjectivesTo understand baseline inequities in appendiceal perforation rates and the impact of hurricane destruction on the healthcare system with respect to perforation rates and racial disparities. MethodsWe used claims data extracted from Medicaid Analytic Extract files to identify appendicitis diagnoses in children and adolescents based on International Classification of Diseases-9 codes and appendectomy procedures based on Current Procedural Terminology codes in the hurricane-affected states of Mississippi and Louisiana. County-level summary data obtained from 2005 Area Resource Files were used to determine high and low hurricane-affected areas. We estimated logistic regression models, mutually adjusting for race, sex, and age, to examine disparities and mixed logistic regression models to determine whether county-level effects contributed to perforation rates. ResultsThere were nine counties in the high-impact area and 133 counties in the low-impact area. Living in the high- or low-impact area was not associated with a statistically different rate of perforation before or after Hurricane Katrina; however, living in the high-impact area was associated with a change from a lower risk (odds ratio [OR] 0.62) of perforation prehurricane to a higher risk (OR 1.14) posthurricane compared with those living in the low-impact areas. African Americans had statistically higher perforation rates than whites in the high-impact areas both before (OR 1.46) and after (OR 1.71) Hurricane Katrina. ConclusionsHealth professionals and hospital systems were able to maintain effective levels of care before and after Hurricane Katrina; however, perforation rates in African Americans suggest ongoing racial disparities during disasters.

Developing a framework for integrating health equity into the learning health system

While there have been gains in the overall quality of health care, racial and ethnic disparities in health outcomes continue to persist in the United States. The Learning Health System (LHS) has the potential to significantly improve health care quality using patient‐centered design, data analytics, and continuous improvement. To ensure that health disparities are also being addressed, targeted approaches must be used. This document sets forth a practical framework to incorporate health equity into a developing LHS. Using a case study approach, the framework is applied to 2 projects focused on the reduction of health disparities to highlight its application.

Overweight in School-Aged Children Associated With Emotional and Behavioral Difficulties: Results From a National Sample

OBJECTIVE To determine whether there is an association between perceived pediatric overweight and emotional/behavioral difficulties among children ages 4 to 17 years in the United States. DESIGN A cross-sectional study SETTING Interview of an adult knowledgeable about a childs emotional and physical health. All statistical analyses were completed using SPSS 17.0. PARTICIPANTS A total of 7096 noninstitutionalized children aged 4 to 17 years identified in the 2007 National Health Interview Survey. OUTCOME MEASURES Included in the 2007 National Health Interview Survey were 7096 noninstitutionalized children aged 4 to 17 years. After controlling for age, gender, race, poverty status, education of mother, family structure, and health status, this study found that 7.4% of the children appeared to be overweight and 5.2% had emotional/behavioral difficulties. It also found that caregivers who indicated that their child had a problem with being overweight were more likely to report that the child experienced emotional/behavioral difficulties compared to caregivers who did not report perceived overweight in their child. Characteristics of the children most frequently reported to be overweight included Hispanic race, older children (ages 15-17 years), and those with higher poverty rates and poorer health status. CONCLUSION The continual increase in pediatric overweight and associated emotional/behavioral difficulties suggests a need for replicable interventions that teach child caregivers to recognize and prevent overweight among vulnerable populations.