Health/care Disparities Research Program

Mission Statement:

The Health/care Disparities Research Program fosters the conduct of high quality research to understand and alleviate inequities in health care, and to ensure the provision of exceptional health care without exception.  The program also facilitates the training of a new generation of health care equity researchers.  Program faculty are intellectual advocates for and leaders of health equity research both locally – within our own institution and city – and nationally.   The Program is dedicated to understanding and addressing disparities in health and health care.

Affiliations:

Section of General Internal Medicine

Research group

Nancy Kressin, PhD, Director

Karen Lasser, MD, MPH, Clinician Investigator

Amresh Hanchate, PhD, Assistant Professor

Lisa Marks, Research Coordinator

Publications:

Click here for Nancy Kressin’s publications

Click here for Karen Lasser’s publications

Click here for Amresh Hanchate’s publications

Grand Rounds:

We occasionally host speakers about current disparities issues.  Check the Grand Rounds page for the list of past speakers and topics (when possible, we will also post a recording of their talk and their slides).

Click here for our Grand Rounds Page

Current Projects:

1) Center for Health Insurance Reform, Cardiovascular Outcomes, and Disparities

Principal Investigator: Nancy Kressin (Center PI)

Project #1  ”The Effects of Massachusetts Health Reform on Cardiovascular Outcomes and Disparities” PIs: Karen Lasser & Amresh Hanchate

Project #2 “Did Massachusetts Health Reform Reduce Disparities in Outcomes after Venous Thromboembolism, and at What Cost?” PIs: Adam Rose & Alok Kapoor

Sponsor:  NIH/NHLBI

Massachusetts (MA) is the site of a key policy-relevant natural experiment, whereby recent legislation has resulted in nearly all (97%) of the state’s residents obtaining health insurance; it is thus the ideal setting in which to monitor and evaluate cardiovascular health outcomes, and disparities in such outcomes, associated with this policy change.  Research to examine the impact of this natural experiment is needed to understand its effects on patient outcomes, including access to and use of care for cardiovascular conditions, clinical events, mortality, quality of life and costs associated with such use of care. Integral to the MA legislation was a goal to reduce racial and ethnic disparities in health; racial/ethnic, gender, language, and socioeconomic disparities in care and outcomes have been well documented by us and others.  They are cause for great public health concern, and reducing disparities while improving outcomes has been proposed as a crucial goal for the national health promotion and disease prevention agenda, as described in Healthy People 2010.Within MA, the primary focus among policy makers has been on maximizing the proportion of the population who are now covered by insurance, and less on whether or how having insurance will affect individuals’ use/receipt of care, or on health outcomes related to insurance or use of care.  We seek to understand the effects of MA health reform on health care and outcomes, and in disparities in each, through several research projects which share a common underlying question: Will expanded insurance coverage in MA be associated with improved health outcomes?

2) The Effects of Massachusetts Healthcare Reform on Access to Care and Disparities

Principal Investigator:  Amresh Hanchate and Karen Lasser
Sponsor:  Rx Foundation (Cambridge MA)

Closely related to the Center grant, we are comparing changes in MA vs. other states pre and post MA health reform.

Specific Aims:

  • Hospital admission rates, and racial/ethnic disparities in such rates, and associated changes in inpatient costs for ambulatory care sensitive conditions including diabetes, pneumonia, asthma and COPD.
  • Thirty-day readmission rates, and racial/ethnic disparities in such rates, and associated changes in inpatient costs for pneumonia.
  • Rates, and disparities in such rates, of referral-sensitive procedures, namely hip and knee replacement.
3) Massachusetts Health Disparities Monitoring System

Principal Investigators: Nancy Kressin & Bill Adams (Pediatrics)
Sponsor: NIH/NHLBI

Massachusetts (MA) is the scene of one of the most significant natural experiments in health reform in the nation, and is the ideal setting in which to monitor and evaluate the cardiovascular disease (CVD) and risk factor disparities associated with such policy changes, in addition to those wrought by the current economic downturn. We are developing an extensive, de-identified, easily accessible database including information about child and adult residents using clinical data from:1) New England’s largest safety net hospital, Boston Medical Center (BMC), and its affiliated community health centers (CHCs); 2) another large academic tertiary care system, University of Massachusetts Medical Center (U Mass) in central MA whose patient population is more white and middle class; and 3) claims data from the BMC Health Plan (BMCHP), the largest statewide “Commonwealth Care” insurer, the new insurance product for low income individuals.

Specific Aims:

  • Develop a powerful infrastructure to monitor cardiovascular risk factors and outcomes.
  • Explore the effects of health reform and the economic downturn on disparities in health outcomes.
  • Develop strategies for sharing tools and communicating results to policy makers, health care providers, and the  research community.
4) Racial and Ethnic Disparities in Incidence and Inpatient Outcomes of Acute Stroke

Principal Investigator: Amresh Hanchate

Sponsor: NIH/NINDS

We intend to identify and assess which potential factors influence “excess” risk of stroke incidence and adverse hospital outcomes for Non-Hispanic whites, non-Hispanic blacks and Hispanics.  We propose to use data on all inpatient discharges during 2005-2007 from nine states (AZ, CA, FL, MA, NJ, NY, PA, SC and TX) with sizable minority populations.

Specific Aims:

  • Estimate age and sex adjusted rates of the following indicators of acute stroke incidence and hospitalization outcomes by race/ethnic and SES cohorts of incidence rates for acute ischemic and hemorrhagic stroke, and outcomes for hospitalization (inpatient mortality, neurological impairment and length of hospital stay)
  • Estimate the differences in prevalence across racial/ethnic and SES stratified cohorts of the indicators of the following potential factors: physiological risk factors (hypertension, diabetes), health behavior (smoking, exercise), geography (area-level primary care physician supply, distance to nearest hospital), hospital characteristics (volume of stroke patients) and access to care indicators (inadequate insurance, poverty, public assistance)
  • Estimate the influence of the potential factors on “excess” rates of incidence and hospitalization outcomes among SES cohorts within same racial or ethnic group

 

5) Primary Care-based Patient Navigation to Promote Smoking Cessation Treatment

Principal Investigator: Karen Lasser

Sponsor:  BU Department of Medicine

Cigarette smoking is a highly significant health threat, responsible for more than 430,000 deaths each year.  Low-income persons and racial/ethnic minorities are at particularly high risk, smoking at greater rates and having greater tobacco-related morbidity and mortality than other persons. Yet poor and minority smokers are less likely to receive advice to stop smoking or to use tobacco cessation services. Using non-physician members of the health care team as patient navigators to connect low-income and minority smokers to evidence-based tobacco treatment services is a promising approach.  Patient navigators are lay persons from the community, working as paid employees, who are trained to guide patients through the health care system to receive services.  Information on the efficacy of patient navigation to connect vulnerable patients to smoking cessation services is needed.  We are conducting a pilot study to determine the feasibility and acceptability of Patient Navigation. We will recruit 30 adult smokers engaged in primary care and conduct assessments at baseline and at 3 months.

Specific Aims:

  • To develop a system of patient navigation in a primary care clinic setting, to promote engagement in smoking cessation treatment for poor and minority smokers
  • To determine whether patient navigation increases the rates at which primary care patients engage in smoking cessation treatment
  • To determine whether patient navigation increases rates at which primary care patients quit smoking, defined as biochemically verified self-report of 7-day point prevalence at six months.
6)  National Estimates for Inpatient Care, Outcomes & Hospital Effect among Hispanics

Principal Investigator: Amresh Hanchate
Sponsor:  NIH/NIMHD

Hispanics now form the largest ethnic or racial minority in the US. Evidence based on national surveys or death records indicates significant differences in health behaviors and risk compared to non-Hispanic Whites or non-Hispanic Blacks. Hispanics are also at greater risk for healthcare access barriers due to higher rates of uninsurance, poverty and inadequate health literacy. However, little is known about inpatient care access, quality or discharge outcomes among Hispanics nationally. This is largely due to poor identification of Hispanic subjects in national inpatient care data sources. This gap in knowledge limits the ability “to set and monitor national objectives, to formulate policy, and to design legislation to address the disparities”.

 We are to using a novel approach of combining state inpatient discharge (SID) data along with census population data to obtain representative estimates of inpatient care utilization for Hispanic adults and contrast them with those for non-Hispanic Whites and non-Hispanic Blacks. We are examining SID data (2010-11) from 15 states that together account for over 87 percent of the national Hispanic adult population.

We are examining a range of inpatient care indicators of distinct domains of care. As indicators of access to care,  using the ACSC conditions identified by Agency for Healthcare Research Quality (AHRQ) Prevention Quality Indicators (PQIs) (e.g., diabetes and hypertension) and AHRQ referral sensitive surgeries (e.g., percutaneous transluminal coronary angioplasty [PTCA] and knee replacement). To evaluate quality and patient outcomes we use AHRQ Inpatient Quality Indicators (IQI), comprising of eight surgical (e.g., esophageal resection) and six medical admission conditions (e.g., acute myocardial infarction [AMI]).

Our aims are to estimate the following indicators for Hispanics, non-Hispanic Blacks and non-Hispanic Whites aged ≥ 18: (a) population-level rates of admission for PQIs, referral sensitive surgeries and IQIs and (b) risk-adjusted rates of inpatient mortality, 30-day mortality and 30-day readmissions following admission for IQI medical or surgical admission. We will also estimate the extent to which differences in risk-adjusted rates Hispanics are associated with the hospitals where they are treated.

7) Insurance Instability and Disparities in Chronic Disease Outcomes

Principal Investigators: Nancy Kressin, Boston Medical Center and Karen Freund, Tufts Medical Center
Sponsor: NIH/NIMHD

Racial and ethnic health disparities in the processes and outcomes of chronic disease care are pervasive, well documented, and consistently linked to health insurance coverage. Insurance instability (the frequency of switches in insurance coverage or gaps without coverage), may contribute to disparities in outcomes of chronic disease care. With the explicit goal of reducing disparities, Massachusetts (MA) Health Insurance Reform has now extended comprehensive health insurance coverage to 98% of the state’s residents, with disproportionately greater gains in coverage among racial/ethnic minorities and the poor. To examine if MA insurance reform has lessened health disparities through increased insurance stability, our specific aims are:

Aim 1: To examine changes in insurance instability pre- and post-reform, overall and comparing racial/ethnic specific minority populations to whites. We hypothesize that (a) Insurance instability decreased in the post-reform period and (c) Insurance instability decreased more for racial/ethnic minorities.

Aim 2: To examine whether patients receiving care post-insurance reform had better processes of chronic disease management and improved health outcomes, compared with patients receiving care pre-insurance reform, and whether such patterns vary by race/ethnicity. We hypothesize that improvements in processes and outcomes of chronic disease management were greater among racial/ethnic minorities who benefited the most from insurance reform, resulting in reduced disparities.

Aim 3: To assess whether patients with more favorable insurance stability had better processes of chronic disease care and improved health outcomes compared to patients with less favorable insurance stability, and whether racial/ethnic minority patients experienced disproportionately greater gains. We hypothesize that greater insurance stability will be associated with improved processes and outcomes of chronic disease management, resulting in reduced disparities.

We will conduct an innovative study to assess the processes and outcomes of care for six highly prevalent, chronic conditions before and after the implementation of MA Health Insurance Reform. These conditions are diabetes, hypertension, hyperlipidemia, congestive heart failure, asthma, and chronic obstructive pulmonary disease. We will utilize existing electronic medical records on over 110,000 subjects from Boston Medical Center and eight of its affiliated federally qualified Community Health Centers, the largest safety net institution in New England that serves African American and Hispanic communities, and Tufts Medical Center, which serves a large Asian American community in Boston’s Chinatown. When the study is completed, we will provide empiric data on the direct impact of insurance reform and insurance instability on health disparities in multiple populations.

Topics of Interest for Disparities Research:

Hypertension Care
Pediatric oral health care
Medication Adherence
Patient Navigation
Effects of the Massachusetts Health Reform
Health economics

Contact information:

801 Massachusetts Avenue, Crosstown 2nd floor, Boston, MA 02118

Lisa.Marks@bmc.org

Phone: (617)-414-6662
Fax: (617)-638-2736

Related links:

National Institute on Minority Health and Health Disparities

Robert Wood Johnson Finding Answers