Individual Behavior, Biological Individual Behavior, Biological Factors and Communication Factors and Communication

with Clinicianswith Clinicians

Eliseo J. Pérez-Stable, MD

EPI 222: Health Disparities

April 21, 2010

Conceptual Framework: Multi-level Conceptual Framework: Multi-level Determinants of Health DisparitiesDeterminants of Health Disparities

Psychosocial - beliefs, attitudes, adherence, coping, personality

Behavior - exercise, diet, alcohol, smoking, sexual behavior, substance use

Health care system

Demographics - age, gender, race, ethnicity, education, income

Physical environment

Social environment

HealthHealth& health care& health care

disparitiesdisparities

Biological - genetics,stress, allostatic load, opiate receptors, metabolism, telomeres

Contextual Individual-level

Technical aspects of health care

Communication Communication with clinicianswith clinicians

Economic resources

Life Expectancy at BirthLife Expectancy at Birth

Cancer Incidence by Site and Cancer Incidence by Site and Race/Ethnicity in Men, U.S. 2003 - Race/Ethnicity in Men, U.S. 2003 -

2007 2007 (per 100,000 age-adjusted)(per 100,000 age-adjusted)

Af AmAf Am APIAPI WhiteWhite LatinoLatino

ProstateProstate 234.6234.6 9090 150.4150.4 125.8125.8

LungLung 110.2110.2 52.952.9 87.587.5 51.751.7

ColonColon 68.168.1 45.545.5 55.455.4 44.544.5

StomachStomach

LiverLiver16.716.7

7.47.4

17.517.5

12.612.6

9.69.6

4.44.4

14.814.8

9.09.0

Cigarette Smoking in the U.S. – 2009Cigarette Smoking in the U.S. – 2009National Health Interview SurveyNational Health Interview Survey % Men % Women

White African Am Latino Asian Am Ind/AN Multi-racial

24.5 23.9 19.0 16.9 29.7 33.7

19.8 19.2 9.8 7.5 ??? 24.8

8 years or less 9-11 yrs school GED high school dipl College degree

22.2 36.5 53.2 29.0 12.4

11.9 30.5 44.7 21.5 9.9

MMWR 2010;59:1135-1140

What Leads to Differences in Lung What Leads to Differences in Lung Cancer?Cancer?

• Prevalence of smoking–10-20 yr lag • Intensity of smoking – Number of

cigarettes per day• Other environmental exposures –

asbestos, air pollution, radon, combustion products

• Genetic predispositions – family history, specific genes

Multiethnic Cohort Study: Lung Multiethnic Cohort Study: Lung Cancer by Smoking IntensityCancer by Smoking Intensity

• 183,813 Af Ams, Japanese-Am, Latino, Native Hawaiian, Whites; age 45 - 75, in California and Hawaii

• 1979 cases lung cancer, identified through SEER, from 1993-2001; 1135 in men

• African Americans as referent group• Stratify by smoking intensity• Relative risk of Lung Cancer by

race/ethnicity within smoking levelHaiman CA, et al. N Engl J Med. 2006;354(4):333-42

Relative Risk of Lung Cancer by Relative Risk of Lung Cancer by Ethnicity and Smoking IntensityEthnicity and Smoking Intensity

Cigs/dCigs/d Af AmAf Am HawaiiHawaii LatinoLatino JapanJapan WhiteWhite

1-91-9 1.01.0 0.880.88 0.210.21 0.250.25 0.450.45

11-2011-20 1.01.0 0.900.90 0.360.36 0.390.39 0.570.57

21-3021-30 1.01.0 0.930.93 0.610.61 0.610.61 0.730.73

31+31+ 1.01.0 0.950.95 0.790.79 0.750.75 0.820.82

Haiman CA, et al. N Engl J Med. 2006;354(4):333-42

TobaccoTobacco Cancer BiomarkersCancer Biomarkers

• 4-(methylnitrsoamino)-1-(3-pyridyl)-1-butanol (NNAL), a carcinogen itself and metabolite of the tobacco-specific carcinogen (NNK)

• Measured in 5 ml urine, 45 d half-life

• NNAL excretion is highly correlated to nicotine intake per cigarette and with lung cancer development

• Polycyclic aromatic hydrocarbons (PAH): combustion products and smoked and over cooked meats

Nicotine Metabolism and Intake in Nicotine Metabolism and Intake in African AmericansAfrican Americans

• African Americans have 50% more lung cancer and higher cotinine levels per cigarette despite fewer cigarettes/day

• Total and renal clearance of cotinine were 20% lower in African Americans

• Nicotine intake per cigarette was 30% greater in African Americans

JAMA 1999;280:152-56

Nicotine Metabolism in Nicotine Metabolism in Chinese and LatinosChinese and Latinos

• Metabolic clearance of nicotine and cotinine in Latinos was similar to Whites and lower among Chinese

• Intake of nicotine per cigarette:– Chinese: 0.73 mg (0.53 to 0.94)– Latinos: 1.05 mg (0.85 to 1.25)

– Whites 1.10 (0.91 to 1.30)

• Nicotine intake = tobacco smoke

Ethnic Differences in Ethnic Differences in Serum Cotinine Levels: NHANESSerum Cotinine Levels: NHANES 3 3

>15 ng/mlpercent

≤15 ng/mlpercent

African Amssmokernon-smoker

962

498

Whitessmokernon-smoker

942

698

Mexican Amssmokernon-smoker

721

2899

JAMA 1998;280:135-139

Optimal Serum Cotinine for Optimal Serum Cotinine for Distinguishing Smoking StatusDistinguishing Smoking Status

• NHANES: 13,078 nonsmokers and 3,078 NHANES: 13,078 nonsmokers and 3,078 smokers; based on ROC curvessmokers; based on ROC curves

• Whites: 5.92 ng/mlWhites: 5.92 ng/ml• African Americans: 4.85 ng/mlAfrican Americans: 4.85 ng/ml• Mexican Americans: 0.84 ng/mlMexican Americans: 0.84 ng/ml• Overall cut point is 3.08 ng/ml; 96% Overall cut point is 3.08 ng/ml; 96%

sensitivity and 97% specificitysensitivity and 97% specificity• 14 ng/ml underestimates smokers14 ng/ml underestimates smokers

Benowitz N, Am J Epidemiol, November 19, 2008Benowitz N, Am J Epidemiol, November 19, 2008

Personalize Cessation based on Personalize Cessation based on Biological Metrics?Biological Metrics?

• CYP2A6 genotype (main nicotine metabolizing enzyme)

• 3HC/Cot as marker of metabolism• African American light smokers• Persons with slower metabolism had

higher nicotine levels• Slowest 3HC/Cot quartile had higher quit

rates with OR = 1.85 (1.1-3.2)Ho MK, et al, Clin Pharmacol Ther 2009; 85: 635-43.

Genetics of Nicotine DependenceGenetics of Nicotine Dependence

• Cholinergic nicotinic receptor (alpha3/alpha5/beta4 complex (CHRN A3/A5/B4) subunit gene cluster on chromosome 15q24-25

• Association of CHRNA5 SNP rs16969968 with nicotine dependence in both Blacks (OR=2.04; 1.15–3.62) and Whites (OR = 1.40; 1.23 – 1.59

Wei J, et al. Human Genetics 2010; 127: 691-8

Cancer Incidence by Site and Cancer Incidence by Site and Race/Ethnicity, Women, U.S. 2003 Race/Ethnicity, Women, U.S. 2003

- 2007- 2007 (per 100,000 age-adjusted) (per 100,000 age-adjusted)

Af AmAf Am APIAPI White White LatinaLatina

BreastBreast 118.3118.3 9090 126.5126.5 8686

LungLung 53.353.3 52.952.9 27.527.5 26.826.8

ColonColon 68.168.1 45.545.5 55.455.4 44.544.5

UterusUterus 20.620.6 17.317.3 24.424.4 17.617.6

CervixCervix 10.110.1 7.57.5 7.97.9 1212

SEER registries, US

Genetic Ancestry and Breast CAGenetic Ancestry and Breast CA

• 106 ancestry markers genotyped in 106 ancestry markers genotyped in 440 cases and 597 controls440 cases and 597 controls

• Immigrants + less accult protectsImmigrants + less accult protects

• European ancestry associated with European ancestry associated with higher risk of breast CA: OR = 1.79higher risk of breast CA: OR = 1.79

• After adjustment, association was After adjustment, association was attenuated to OR = 1.39 (1.06 – 2.11)attenuated to OR = 1.39 (1.06 – 2.11)

Fejerman L, Cancer Res 2008; 68:9723-28Fejerman L, Cancer Res 2008; 68:9723-28

Acculturation: Unifying DefinitionAcculturation: Unifying Definition

• Change in behaviors, values, and social identities

• Complex process that involves change toward reference group:Dominant group in society (white middle-class)

• Minority sub-culture/group (e.g. ethnic enclave, inner-city ghettos)

• Change varies by context and ethnic group

Segmented AssimilationSegmented Assimilation

• Does not assume linear, one dimensional path

• Classical: mainstream, dominant• Selective: upward social mobility

& preservation of culture• Downward: disadvantage,

poverty, adoption of sub-culture

1ST GENERATIONBehavior: Physical

activity, diet

Conceptual framework for contextual Conceptual framework for contextual influences, acculturation and behaviorinfluences, acculturation and behavior

Socio-economic conditions

COMMUNITY OF ORIGIN

Social cohesion (social capital)

Social norms related to behavior

Built environment

2nd GENERATION+

Behavior: Physical activity, diet

California Health Interview California Health Interview Survey, 2005Survey, 2005

• 18 years old and over, generation, language at home, neighborhood

• Outcome: Non-leisure PA: walking at work most of the day and walking/biking for transportation or errands

• Leisure PA: walking, moderate or vigorous activities in free time

• Merge with US Census 2000

Percent college education by Percent college education by immigrant generation: CHIS 2005immigrant generation: CHIS 2005

Afable-Munsuz A, Ponce N, Perez-Stable E, Rodriguez M. Immigrant generation and physical activity among Mexican, Chinese and Filipino adults in the U.S. Soc Sci Med 2010;70(12):1997-2005.

Percent English only at home by Percent English only at home by immigrant generation: CHIS 2005immigrant generation: CHIS 2005

Afable-Munsuz A, Ponce N, Perez-Stable E, Rodriguez M. Immigrant generation and physical activity among Mexican, Chinese and Filipino adults in the U.S. Soc Sci Med 2010;70(12):1997-2005.

Percentage at Recommended non Percentage at Recommended non leisure-time physical activity by leisure-time physical activity by language at home : CHIS, 2005language at home : CHIS, 2005

Afable-Munsuz A, Ponce N, Perez-Stable E, Rodriguez M. Immigrant generation and physical activity among Mexican, Chinese and Filipino adults in the U.S. Soc Sci Med 2010;70(12):1997-2005.

Recommended non-leisure time physical Recommended non-leisure time physical activity among Mexicans: CHIS, 2005activity among Mexicans: CHIS, 2005

Generation Bivariate OR (95% CI)

Odds Ratio (95% CI)

11stst RefRef RefRef

22ndnd 0.80.8 0.6, 0.90.6, 0.9 0.90.9 0.7, 1.10.7, 1.1

33rdrd 0.80.8 0.6, 0.90.6, 0.9 0.80.8 0.6, 1.10.6, 1.1

.Afable-Munsuz A, Ponce N, Perez-Stable E, Rodriguez M. Immigrant generation and physical activity among Mexican, Chinese and Filipino adults in the U.S. Soc Sci Med 2010;70(12):1997-2005.

Immigrant generation and diabetes risk Immigrant generation and diabetes risk in an aging Mexican-origin populationin an aging Mexican-origin population

• Sacramento Area Latino Study on Aging

• 1998-99: in home visits every 12–15 months for a total of 7 follow-up visits

• 60-101 y at baseline, N=1,789 Generation, acculturation scale

• Diabetes: fasting glucose >125 mg/dl, self-report of MD diagnosis or med Rx

• Only 13% self-report alone

Education by immigrant Education by immigrant generation: SALSA 1998-99generation: SALSA 1998-99

Diabetes prevalence by immigrant Diabetes prevalence by immigrant generation: SALSA 1998-99generation: SALSA 1998-99

Diabetes risk among Mexican-origin Diabetes risk among Mexican-origin older adults: SALSA, 1998-99older adults: SALSA, 1998-99

Generation Unadjusted Odds (95% CI)

Adjusted Odds (95% CI)

1st 1.0 1.0

22ndnd 1.71.7 1.3, 2.31.3, 2.3 1.81.8 1.3, 2.41.3, 2.4

33rdrd 2.02.0 1.4, 3.11.4, 3.1 2.02.0 1.3, 3.11.3, 3.1

*Adjusted for BMI, acculturation, sex, age, lifestyle, education, occupation

Ethnic Disparities in Diabetic Ethnic Disparities in Diabetic Complications at KPMCPComplications at KPMCP

• Observational study: 62 432 patientsObservational study: 62 432 patients

• 10% Lat, 64% W, 14% AA, 12% API10% Lat, 64% W, 14% AA, 12% API

• Latinos had less MI (0.68), CHF (0.61) Latinos had less MI (0.68), CHF (0.61) and stroke (0.72) compared to Whitesand stroke (0.72) compared to Whites

• More ESRD among Latinos–1.46More ESRD among Latinos–1.46

• Setting of uniform accessSetting of uniform access

• Genetics and environment?Genetics and environment?

Kaiser DM cohort: MI outcomeKaiser DM cohort: MI outcome

Age and sex-adjusted onlyAge and sex-adjusted only Fully-adjusted modelFully-adjusted model

0.63

0.68

0.80

0.62

0.60

0.85

1.29

1.15

0.1 1 10

0.73

0.73

0.77

0.56

0.59

0.86

1.53

1.00

0.1 1 10

African American

Latino

All AAPI

Chinese

Japanese

Filipino

Pacific Islander

South Asian

At 10 yrs, Compared to Whites…At 10 yrs, Compared to Whites…

Kaiser DM cohort: ESRD at 10 yKaiser DM cohort: ESRD at 10 yKanaya AM, et al. Diabetes Care, Feb 24, 2011, Online.Kanaya AM, et al. Diabetes Care, Feb 24, 2011, Online.

1.98

1.63

1.81

1.50

2.13

1.96

1.79

1.19

0.1 1 10

African American

Latino

All AAPI

Chinese

Japanese

Filipino

Pacific Islander

South Asian

Latinos and African Americans Live Latinos and African Americans Live Longer than Whites at ADC CentersLonger than Whites at ADC Centers

Race/EthnicityRace/Ethnicity % % MortalityMortality

Hazard Hazard Ratio*Ratio*

95% CI95% CI

African African AmericanAmerican

3030 0.850.85 0.74-0.960.74-0.96

LatinoLatino 2121 0.570.57 0.46-0.690.46-0.69

AsianAsian 1717 1.061.06 0.81-1.390.81-1.39

American American IndianIndian

3838 1.131.13 0.91-1.400.91-1.40

WhiteWhite 4141 1.01.0 refref*Adjusted for Demographics (age as the timescale, gender, educational level, ADC site, current marital status, living situation), MMSE Score, and age at first dementia symptom

U.S. Asthma Mortality 1990-1995U.S. Asthma Mortality 1990-1995Average Annual Rates per Million

11.315

40.75 40.9

0

10

20

30

40

50

Mexican Caucasian African

American

Puerto Rican

Homa et al. 2000Homa et al. 2000

UCS

F

Contribution

45%

52% 24%

61%

15%3.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

MexicanAmerican

Puerto Rican

Percent

Ancestral

Admixture

Native AmericanAfrican

European

Genetic Origins of LatinosGenetic Origins of Latinos

in preparation: Choudhry, Salari & Coyle, et al.

% R

ever

sib

ility

in F

EV 1

aft

er a

lbu

tero

l

0

2

4

6

8

10

12

14

Puerto Ricans Mexicans Puerto Ricans Mexicans

< 16 years old > 16 years old

P=0.0002 p=0.0003

Puerto Ricans Have Lower Drug Response to Albuterol

GALA Study Investigators AJRCCM 2004

Allostatic Load Score in Women: Allostatic Load Score in Women: NHANES, 1999-2005NHANES, 1999-2005

• CV: SBP, DBP, homocysteine, HR; Metabolic: BMI, A1C, HDL, Tchol; Inflammation: albumin, CRP• Higher scores by age, Blacks, less than high school, less income, formerly marries, US born

•Significant interaction by race-ethnicity and age; Blacks at 40-49 14% higher AL than Whites 50-59 and Mex Ams similar

•Foreign born had 11% lower AL JAMA 2001; 286:180-7

CHD Prediction Scores By EthnicityCHD Prediction Scores By EthnicityColor in Framingham?Color in Framingham?

• Applied sex specific CHD functions to 6 ethnically diverse cohorts

• White and Black men and women prediction of CHD events works well

• Japanese & Latino men and American Indian men & women–risk is overestimated

• Adjust for different rates of risk factors and underlying rate of CHD

JAMA 2001; 286:180-7

Chronic Stress, Race, Unhealthy Chronic Stress, Race, Unhealthy Behaviors: HPA AxisBehaviors: HPA Axis

• More depression and suicides in Whites and more substance use/unhealthy eating in Blacks

• Americas’ Changing Lives S: 874 B, 1906 W

• Stressors associated with chronic conditions

•Whites: Unhealthy behaviors strenghthened stressors leading to more depression

•Blacks: Unhealthy behaviors protective for mental health conditions but overall number of chronic conditions increased

Jackson J, AJPH 2010; 100: 933-39

TB Rate Ratio by EthnicityTB Rate Ratio by EthnicityDemographics and SESDemographics and SES

Demographic SES+ Crowding

Afr Amer 9.6 4.4 2.1/2.0

Latino 6.5 2.8 1.6/4.1

Asian 3.8 3.5 3.3/4.5

Am Indian 4.6 2.3 1.9/3.6

Catwell MF, AJRCCM 1997; 157:1016

Communication with CliniciansCommunication with Clinicians

Language

Definition of Limited English Definition of Limited English Proficiency (LEP)Proficiency (LEP)

• 18% of adults LEP in 2000 census; 5% live in linguistically isolated households

• Definitions of LEP by US census question–no routine method

• Response to survey, self assess, fluency scales

• Acculturation, education, legal status

LEP Status and Health OutcomesLEP Status and Health Outcomes

• LEP status not associated with less quality of care in Diabetes (tests, A1c, SBP), immunizations for ≥ 65, psychiatric evaluations, perceived care quality in past 12 mo, cancer screening tests and evaluation of abnormal tests

• LEP is associated with less health info on telephone, harder access, longer waits

Identifying LEP Patients: Two Identifying LEP Patients: Two standard questionsstandard questions

• Need systems to use standard Need systems to use standard questions on all patientsquestions on all patients

• US Census question: How well do US Census question: How well do you speak English? Very well, you speak English? Very well, well, well, not well, not at allnot well, not at all

• What language do you prefer to What language do you prefer to receive your medical care?receive your medical care?

Karliner L, Karliner L, J Gen Intern Med. 2008; 23:1555-60Institute of Medicine Report 2009

Census Question Plus PreferenceCensus Question Plus Preference

• 104 spoke English well; 32 spoke English less than “very well”; and 166 spoke “not well or not at all”

• 52% preferred Spanish for health care• Outcome of effective communication--

discuss or understand• Census: 100/99% sens; 73/67% specific• Census + : 99/97% sens;99/97% sens; 92/84% specific92/84% specific

Constructs in Evaluating Constructs in Evaluating Language AccessLanguage Access

• Patient-clinician encounters

• Communication with staff

• Language concordance is best?

• Interpreters: professional or ad hoc?

• Mode: in person or remote

• Effects on quality of care and disease outcomes: What matters?

Language Concordance MattersLanguage Concordance Matters

• • Understand more MD instructions Understand more MD instructions and ask more questions (NY)and ask more questions (NY)

• Trend to better medication Trend to better medication adherence in asthma (NY)adherence in asthma (NY)

• Ask more questions and receive Ask more questions and receive more patient centered care (UCI)more patient centered care (UCI)

• Patients feel better, have less pain, Patients feel better, have less pain, better health outlook (UCSF)better health outlook (UCSF)

Effect of Clinician Language Effect of Clinician Language Concordance on MOS MeasuresConcordance on MOS Measures

MOS MeasureMOS Measure ConcordantConcordant

(n = 44)(n = 44)

DiscordantDiscordant

(n = 29)(n = 29)

AnxietyAnxiety 72.272.2 55.155.1

DepressionDepression 68.168.1 54.754.7

Current Current healthhealth

47.347.3 31.631.6

Effects of Effects of painpain

34.034.0 54.754.7

LEP is a Risk Factor for Poor LEP is a Risk Factor for Poor Control of DiabetesControl of Diabetes

• Kaiser Diabetes Study, n = 6730, Kaiser Diabetes Study, n = 6730, mean age 60 y, 510 LEP Latinosmean age 60 y, 510 LEP Latinos

• A1c > 9%: 10% Whites, 18% Latinos,A1c > 9%: 10% Whites, 18% Latinos,21% LEP-Lat21% LEP-Lat• • Concordant LEP = 16% vs. 28%Concordant LEP = 16% vs. 28%• • LEP discordant c/w Eng-Lat had OR = LEP discordant c/w Eng-Lat had OR =

1.76 (1.04 - 2.97) of A1c > 9% and OR 1.76 (1.04 - 2.97) of A1c > 9% and OR = 1.98 c/w concordant Latinos= 1.98 c/w concordant Latinos

Fernandez A, JGIM online 29 September 2010Fernandez A, JGIM online 29 September 2010

Pew Hispanic Center/RWJF Latino Pew Hispanic Center/RWJF Latino

Health SurveyHealth Survey • 2921 foreign-born respondents, mean age

41 y, 60% insured, 82% had language concordant care

• English proficiency mean score 2.6• Concordant care: less confusion,

frustration, and perceived bias• Concordance, yrs education, insurance

were associated with higher quality of care ratings in previous 12 mo

Gonzalez HM, J Am Board Fam Med 2010; 23: in press

How Much Fluency is EnoughHow Much Fluency is Enough??

• Language fluency is a gradient and Language fluency is a gradient and patients may avoid discussing patients may avoid discussing complex topics perceiving clinician complex topics perceiving clinician limitations (SFGH)limitations (SFGH)

• Physician self assessment as Physician self assessment as excellent or good verified by excellent or good verified by patients, but “fair” was toss-uppatients, but “fair” was toss-up

• Language certifications for cliniciansLanguage certifications for clinicians

English Language Proficiency and English Language Proficiency and Health LiteracyHealth Literacy

• Study of 771 outpatients, mean age 56 y, 58% women, 51% limited literacy

• 53% Eng, 23% concord, 24% discord• 3 types of communication domains:

receptive, proactive, interactive• Limited HL with poor communication:

35%-35%-62% vs. 24%-20%-50%• LEP discordant with poor communication:

43%-46%-73% vs. 25%-21%-48% (English)Sudore RL , Patient Education and Counseling 2009

Ethnicity in Patient-Doctor Ethnicity in Patient-Doctor RelationshipRelationship

• Refusal: whose issue?

• DNR discussions–Race of clinician is an independent predictor

• Cultural competence

• Language factors

• Racism may affect behavior:– Fewer cardiology referrals in Blacks

Outcomes of Communication Outcomes of Communication on Medical Care at EOLon Medical Care at EOL

• Blacks receive more care• 71 B, 261 W pts with advanced cancer• Outcomes: EOL discussions: awareness,

preferences, DNR; and EOL Care: more, hospice, preferences

• Discussions: 35% vs. 38%, Life-prolonging: 20% vs. 7%

• EOL discussions decreased life-prolonging care in Whites (OR=0.11), but not Blacks.

Mack J, et al. Arch Intern Med 2010; 170:1533-40

Ethnicity and Attitudes toward Patient Ethnicity and Attitudes toward Patient Autonomy among Persons ≥ 65 yrsAutonomy among Persons ≥ 65 yrs

Tell Dx%

Tellprognosis

%

Life support%

European Am 87 69 65

Mexican Am 65 48 41

African Am 89 63 60

Korean Am 47 35 28

JAMA 1995; 274:820

Conceptual Framework: Multi-level Conceptual Framework: Multi-level Determinants of Health DisparitiesDeterminants of Health Disparities

Psychosocial - beliefs, attitudes, adherence, coping, personality

Behavior - exercise, diet, alcohol, smoking, sexual behavior, substance use

Health care system

Demographics - age, gender, race, ethnicity, education, income

Physical environment

Social environment

HealthHealth& health care& health care

disparitiesdisparities

Biological - genetics,stress, allostatic load, opiate receptors, metabolism, telomeres

Contextual Individual-level

Technical aspects of health care

Communication with clinicians

Economic resources