Breaking Down Walls Improving Healthcare for Resilient Populations - - PDF document

2/28/2019 1

Breaking Down Walls

Improving Healthcare for Resilient Populations through Stakeholder Engagement?

Tung Nguyen, MD

Professor of Medicine, UCSF Medical Care of Vulnerable and Underserved Populations February 28, 2019

Disclosures

 Dr. Nguyen’s spouse works for Gilead Sciences, Inc., a pharmaceutical company. No pharmaceutical products will be discussed.  Dr. Nguyen works for UCSF, an academic medical center.

2/28/2019 2

Outline

 The Case for Change  Stakeholder Engagement  Examples of Stakeholder Engagement to Address Health Disparities  Next Steps

We Have The Highest Healthcare Costs

 2017: $3.5 trillion (17.9% of GDP)  Compared to similar countries  Per capita spending ($10,739) is twice as high  Administrative, labor, and drug costs are highest  Outpatient utilization rates are similar  Hospitalization rates and length of stay are lower

2/28/2019 3

Our Healthcare System is Worst Our Health Outcomes Are Worst

Papanicolas et al, JAMA 2018

2/28/2019 4

We Have the Worst Health Disparities

Income Mortality Gap

• Compared to top 1% in income, the poorest 1% live 10.1 years

women) or 14.6 years (men) less.

• The gap has widened from 2001 to 2014.

The Association Between Income and Life Expectancy in the United States, 2001-2014

• JAMA. Published online April 10, 2016. doi:10.1001/jama.2016.4226

Healthcare Access Makes Little Difference among the Poor

Life Expectancy, Bottom Quarter in Income

• Health behaviors and

where they live have a significant impact on the life expectancy of the poor.

• Access to medical care

is not a major determinant of life expectancy among the poor.

The Association Between Income and Life Expectancy in the United States, 2001-2014

• JAMA. Published online April 10, 2016. doi:10.1001/jama.2016.4226

2/28/2019 5

Doing the Same Thing and Expecting Different Results is …

 More health insurance coverage will improve

• utcomes, but by how much and at what cost?

 Are we spending too much on healthcare and not enough on other social services?  Our patients spend most of their lives outside of the healthcare system.  Does “population health management” make sense when it is being managed from within the healthcare system?  Are we doing enough with patients and communities to achieve health outside of clinic and hospital walls?

Outline

 The Case for Change  Stakeholder Engagement  Examples of Stakeholder Engagement to Address Health Disparities  Next Steps

2/28/2019 6

Who Are Stakeholders in the Care of Individual Patients?

 Patients  Caregivers  Healthcare providers  Healthcare staff  Healthcare systems  Health insurers  ???

Who Are Stakeholders in “Population Health”?

 Patients and caregivers  Healthcare providers, staff, and systems  Home health agencies, medical interpreters, etc…  Health insurers  Public health department  Patient advocacy groups  Community-based organizations  Employers  Media  Government  ???

2/28/2019 7

Why Stakeholder Engagement?

 Who should decide:

 What diseases matter or problems that should be prioritized?  What are appropriate processes of care?  What health outcomes matter?  How should these processes and outcomes be achieved?  How are corrective measures determined and applied?  What level of evidence should be used to make decisions and priorities?

Definition and Levels of Stakeholder Engagement for Health

 The involvement of key members and partners of the group(s) affected by the issue that builds on their interests and strengths, and combines knowledge with intervention to improve health.  Level of engagement: Advisory, Steering, Executive  Stages of engagement:  Prioritization  Design  Implementation  Assessment  Dissemination  Sustainability

2/28/2019 8

The Science of Stakeholder Engagement

 Patient-Centered Outcomes Research (PCOR)  Practice-Based Research  Community-Based Participatory Research (CBPR)

Outline

 The Case for Change  Stakeholder Engagement  Examples of Stakeholder Engagement to Address Health Disparities  Next Steps

2/28/2019 9

An Example of Patient-Centered Outcomes Research to Address Health Disparities

Health Within Reach:

Using Mobile Technology to Improve Asian American Health

Patient-Centered Outcomes Research Institute (PCORI) AD-12-11-4615

Overview

• Asian Americans have low screening rates for

hepatitis B and C and high rates of liver cancer.

• Goal: use patient-centered outcomes research to

create tech to address health

• Develop, implement and measure effect of English,

Cantonese, Mandarin, and Vietnamese iPad-based interactive app to increase hepatitis B and C screening among Asian American patients.

2/28/2019 10

Stakeholder Engagement

• Prioritization of topic, identifying intervention, grant writing:

SF Hep B Free (community organization), AANCART (community network), Hep B QIC (systems network, DPH)

• Implementation: SF Hep B Free
• Oversight: Patient Advisory Councils, AANCART, Hep B

QIC

• Focus groups and interviews: community members and

patients, clinic staff, physicians, medical directors.

• Patient Advisory Councils: barriers and responses,

application look and feel (buttons, fonts, colors, flow) video look and feel, languages, control materials, pilot test

• Patients: pilot test of application

Application Look and Feel

2/28/2019 11

Mobile Application: Questions Mobile App and Provider Alert

2/28/2019 12

Pilot Testing Cluster Randomized Trial

• Randomization: Primary Care Physician (PCP)
• Hepatitis: 70 PCPs and patients
• Nutrition & Physical Activity: 52 PCPs and patients
• PCPs in both arms received list of patients not

screened for hepatitis B every 6 months (Provider Panel Notification)

• Prior to PCP visit, both group of patients:
• Used assigned mobile app.
• Received bilingual printout summarizing the assigned

topics and tailored recommendations (Provider Alert) and asked to give to PCP.

2/28/2019 13

Patient Eligibility

• Asian American
• Age 18+
• Speak English, Cantonese, Mandarin, or

Vietnamese

• Clinic patient (visit within 3 years)
• No hepatitis B screening (surface antigen) test in

electronic record.

Hepatitis B Discussion: 3 months

9.3 13.2 16.5 58.9 51.1 70.4

10 20 30 40 50 60 70 80

E ve r aske d doc tor to ge t he patitis B te st Doc tor e ve r r e c omme nde d te sting for he patitis B E ve r disc usse d he patitis B with doc tor He patitis NPA

All p <0.001

2/28/2019 14

Intervention Effects: Multivariate Models

Intervention Odds Ratio 95% Confidence Interval Hepatitis B Test

• rdered within 3

months 7.1 3.5, 14.1 Hepatitis B Test done within 3 months 7.3 3.5, 15.1 Hepatitis C Test done within 3 months (birth cohort) 9.7 5.6, 16.7

Intention to treat

Not Needy But Resilient

2/28/2019 15

An Example of Community-Based Participatory Research to Address Health Disparities

Funder: National Cancer Institute

Lay Health Worker Intervention to Promote Colorectal Cancer Screening Among Chinese Americans

Stakeholder Engagement

 Prioritization of topic, identifying intervention, grant writing: NICOS Chinese Health Coalition, AANCART  Intervention development and pilot: focus groups of community members and leaders  Implementation: NICOS Chinese Health Coalition, lay health workers  Oversight: AANCART  Dissemination: NICOS Chinese Health Coalition

2/28/2019 16

Dual Cluster Randomized Controlled Trial

Randomizes 58 lay health workers (LHWs) into 29 Experimental LHWs 29 Comparison LHWs Recruit 360 experimental participants Recruit 365 comparison participants Pre-educational session survey Pre-educational session survey Two LHW sessions on CRC screening + CRC brochure Two health educator lectures on healthy eating & physical activities + CRC brochure Post-educational session survey Post-educational session survey

Chinese Colorectal Cancer Screening Flipchart

2/28/2019 17

Lay Health Workers

Sociodemographics % Male 19% Married 74% Limited English proficiency 95% Less than high school education 72% Income < $20,000 60% Health and health care access Fair/ Poor 65% Has at least 1 chronic health condition 60% Visited MD in the last 12 months 80% Has regular place of care 90% Uninsured 9%

Characteristics of Chinese American Participants (N=725)

2/28/2019 18

Multivariable Models of Intervention Effects

Ever Had CRC Screening Up-to-date for CRC Screening Intervention Effect 1.94 (1.34, 2.79) 2.02 (1.40, 2.90) US Residence >10 yrs 1.65 (1.11, 2.46) 1.37 (0.94, 2.00) Fair/poor health 1.52 (1.07, 2.15) 1.29 (0.97, 1.73) Had regular place for healthcare 1.81 (1.01, 3.25) 1.81 (0.99, 3.29) Had primary care doctor 2.64 (1.42, 4.92) 2.66 (1.47, 4.83) Have health insurance 2.51 (1.34, 4.68) 2.60 (1.37, 4.94) Model adjusted for LHW cluster, age, gender, education, income, marital status, English fluency, employment

Capacity Building

2/28/2019 19

Outline

 The Case for Change  Stakeholder Engagement  Examples of Stakeholder Engagement to Address Health Disparities  Next Steps

Breaking the Wall

 Food pharmacies with clinical providers, SF DPH, food banks, farmers market.  Housing: population health management for high risk homeless patients, SF DPH and Homeless Outreach Team, shelters, SF Housing  Income and employment: health care systems as ”anchor institutions” through training, hiring, and contracting

 Does any health system have adequate resources to address the diversity of the population in terms of languages, cultures, and

• ther needs?

2/28/2019 20

Next Steps

 Diverse Patient and Family Advisory Councils

 Payment  Input on how systems work, e.g., patient portal, phone lines, educational materials, etc…

 Include Community-Based Organizations in Strategic Planning Activities  Ask if any planned intervention has the right stakeholders involved in the planning  Ask if any planned intervention also build capacity

“T e ll me and I'll for ge t, show me and I may r e me mbe r , involve me and I'll unde r stand.”

Chine se pro ve rb

U CSF Pro file : pro file s.uc sf.e du/ tung .ng uye n T witte r: @ ARCHDrNg uye n E mail: T ung .Ng uye n@ uc sf.e du We b: asianarc h.o rg