Charles R. Drew University of Medicine and Science - College of Medicine Health Care Disparity: The Drew Response May 25, 2005 Charles R. Drew University

Charles R. Drew University of Medicine and Science - College of Medicine

Health Care Disparity:

The Drew Response

May 25, 2005

Charles R. Drew University of Medicine and Science



Mission Statement

To conduct medical education and research in the context of community service in order to train physicians and allied health professionals to provide care with excellence and compassion especially to underserved populations



Lack of accessible health care identified as contributing factor to Watts riots - 1965

McCone Commission recommends general teaching hospital be established - 1966

Charles R. Drew Postgraduate Medical School founded as academic partner of the Martin Luther King, Jr. County Hospital

Drew incorporated as a private, non-profit educational institution - 1966


College of Medicine July 1971: First contract between Los Angeles County

and Drew Postgrad. Med. School for provision of health care and educational services at the King Hospital- MLK-Hospital opens in 1972.

May 1978: Drew/UCLA undergraduate medical student education program for M.D. degree established by California Bd. Of Regents



– 1985: Population: 350,000

– Geographic area: 33 square miles

– Racial Composition: 81% black

– Current: Population: 1.5 million (SW Cluster)

– Poverty Level (31.8%)

– Geographic area: 124.2 square miles

– Racial Composition: 23.3% Black

– 59.7% Latino, 5.4% Asian/Other



A non-profit institution accredited by the Western Association of Schools & Colleges

Individual programs accredited by appropriate accrediting body

Comprised of: The College of Allied Health The College of Medicine Post-graduate Physician Education Educational Pipeline Community programs


The Charles R. Drew University of Medicine and Science

Faculty:

College of Medicine:

250 Academic track

150 Clinical track


College of Medicine

UndergraduateMedical Education

ContinuingMedical Education

GraduateMedical Education

CommunityService

Research

ClinicalService


College of MedicineAccreditation of College of Medicine

and King Drew Medical Center

Liaison Committee onMedical Education

Joint Commission forAccreditation of

Health Care Organizations

Accreditation Councilof Continuing Medical

Education

Accreditation Councilfor Graduate

Medical Education


College of Medicine

Undergraduate Medical Education

Joint MD Program with UCLA 24 Students Each Year (96 Total)

~1800 Applicants Each Year 1st/2nd Year (Basic Sciences) Training at UCLA

3rd/4th Year (Clinical Sciences) at Drew/King Campus Primary Care Curriculum with Primary Care Research

Requirement Learning Resources Center/Medical Informatics


College of Medicine

Graduate Medical Education

Residents Residency Programs

Oral Surgery Orthopedic Surgery Otolaryngology Pediatrics Psychiatry

Anesthesiology Dentistry Dermatology Emergency Medicine Family Medicine Internal Medicine Obstetrics & Gynecology Ophthalmology


College of Medicine

Medical Education Primary Teaching Sites

– King/Drew Medical Center– Ambulatory Care Sites– Hubert H. Humphrey Comprehensive Care Center– T.H.E. clinic– University Muslim Medical Associates Free Clinic


College of MedicineResearch

Changing NIH guidelines now mandate that ethnic minorities comprise a proportion of studies that reflects

their number in the general population

Nationally-recognized for research concerning historically understudied groups

Public policy influence Collaborative research efforts with other

institutions


College of Medicine

Minority Health Initiatives: Alcohol & Drug Abuse Perinatology Cancer Violence/Trauma Hypertension/Cardiovascular

Disease Diabetes HIV/AIDS Aging

Existing Infrastructure: Basic Science Initiative Clinical Research Centers Clinical Trials Unit Research Centers in Minority

Institutions (RCMI) Telemedicine Project

Research

*

*

*

*Funding Priorities*

*

Rank* Organization Awarded Amount 7 University of California Los Angeles $317,017,181 17 University of California San Diego $244,713,718 25 Scripps Research Institution $190,777,342 32 University of Southern California $151,663,710 55 University of California Irvine $95,879,273 122 California Institute of Technology $30,907,904 146 RAND Corporation $21,757,681 153 Charles R. Drew University of Medicine and Science $19,990,406 157 Kaiser Foundation Research Institute $19,093,829 162 Wadsworth Center $17,863,997 164 Harbor-UCLA Research & Education Institute $17,636,764 167 San Diego State University $17,262,472 170 Cedars-Sinai Medical Center $16,895,707 171 Children’s Hospital Los Angeles $16,796,261 182 City of Hope National Medical Center $15,547,534 185 University of California—Los Alamos National Lab $15,050,462 197 University of California Santa Barbara $13,737,95 199 Loma Linda University $13,418,505 207 Veterans Medical Research Foundation/San Diego $12,585,882 237 University of California Riverside $10,088,547

RCMI Impact on Research at Drew NIH Funding: $5,762,903 in 1997 to $19,990,406 in 2002

NIH Awards to Southern California Institutions by Rank in FY 2002

*Rank of institution based on total NIH funding in FY 2002 (last available).Sources: http://grants1.nih.gov/grants/award/awardtr.htm#c; http://grants1.nih.gov/grants/award/trends/rnk02all1to100.htm http://grants1.nih.gov/grants/award/trends/rnk02all101to500.htm

http://grants1.nih.gov/grants/award/trends/rnk02all101to500.htm

HealthRecord

Knowledge Resource

Guidelines

Research

ExpertSystem

Data from the“world outside”

individual patient

James J. Cimino, M.D - NLM source of slide


Volume

348:2681-2683

June 26,

2003

Number 26

Improving the Quality of Care — Can We Practice What We Preach?

Earl P. Steinberg, M.D., M.P.P. It has been 30 years since Wennberg and Gittelsohn published their landmark article demonstrating

substantial variation …….From the perspective of the quality of care, the variation that is the greatest cause for concern is that between actual practice and evidence-based "best practice."

http://grants1.nih.gov/grants/award/awardtr.htm#c


National Report on Health Care Disparity


Non

-Min

orit

y

Min

orit

yDifference

Clinical Appropriateness and Need

Patient Preferences

The Operation of Healthcare Systems and the Legal and Regulatory Climate

Discrimination: Biases andPrejudice, Stereotyping, andUncertainty

Disparity

Qu

a li t

y of

Hea

lth

Car

e

Figure 1: Differences, Disparities, and Discrimination: Populations with Equal Access to Health Care---

(source of slide Institute of Medicine-Unequal treatment)

Populations with Equal Access to Health Care


Recent Health Trends in Los Angeles CountyRecent Health Trends in Los Angeles County

Office of Health Assessment and EpidemiologyLos Angeles County DHS Source of slide

March 6, 2003


Health Indicator Rankings, South and West Health Indicator Rankings, South and West SPA’s: Examples of Geographic Clustering SPA’s: Examples of Geographic Clustering

South SPA West SPA

Indicator Ranking Ranking

Poverty 8 2

Heart disease mortality 8 1

Diabetes mortality 8 1

Lung cancer mortality 8 4

Homicide 8 2

AIDS mortality 7 3

Smoking prevalence 5 6

Obesity prevalence 8 1

% of adults who are sedentary 8 1

% of uninsured adults 8 2

Office of Health Assessment and Epidemiology-County of Los Angeles


Accreditation Council for Graduate Medical Education

Scholarly Activity-Graduate medical education must take place in an environment of inquiry and scholarship in which residents participate in the develop of new knowledge, learn to evaluate research findings and develop habits of inquiry as a continuing professional responsibility.


Practice-Based Learning and Improvement (Source ACGME )

Analyze practice & improve using a systematic methodology

Locate, appraise & apply scientific evidence Apply knowledge of study designs & statistics Obtain & use patient population data Use information technology Facilitate the learning of others


Evaluation by others deficit in delivering bad news

Identify Improvement

Needed

Engage in Learning

Apply Learning

Check for Improvement

Example 1: Use evaluations by others to improve

own skills (slide ACGME website)

Read & appraise studies ; view video;

role play

Perform new skills

Evaluation by others

The Future of Medicine-Drew is a member of INTERNET 2

HEALTH INFORMATION SUPERHIGHWAY

Drug Companies

Medical Manufacturers Databases Hospitals

Patients at homeGovernment

InsurersMedical SchoolsDoctors


Health Workforce

California– Ranks 50th in nation for nurses per 100,000 pop.– Ranks near bottom (40th – 49th ) for mental health,

therapists, technicians, and auxiliary health aids– Ranks 15th in nation for physicians

» 194.5 physicians per 100,000 (US 197.5)


Health Professional “Mal-distribution”

Physician surplus in California– Distribution creates a dichotomy

» 21% of urban zip code clusters – below threshold

» 42% of rural zip code clusters - below threshold

» + association with income Stronger association with African American and Latino communities

» 100% of impoverished AA communities are below threshold *

» 82% of impoverished Latino communities are below threshold *

* Grunbach, et al. 1995. Komaraory, 1996


California Physicians California relies on other states and on foreign schools to train

most of the physicians that practice in the state.– 51% trained in a state outside California

– 22% trained outside of the US

22%

51%27.00%

The Survey•Distributed to three classes

•Demographics

•Specialty choice

•Practice characteristics

•Obligations

•Evaluation of job market


Medical Graduate Evaluation Affiliated programs / sponsoring schools

– UC - Programs (2248)» UC-Davis School of Medicine (443)» UC-Irvine School of Medicine (327)» UC-Los Angeles School of Medicine (549)» UC-San Diego School of Medicine (311)» UC-San Francisco School of Medicine (604)

– Non-UC Programs (930)» University of Southern California Medical Center (466)» Charles King Drew University of Medicine (128)» Loma Linda University Medical Center (237)» Stanford University Hospital (89)

Practice Location

30.8

28.1

14.5

13.8

13.6

10.5

17

14.8

25.2

4.4

0.9

1.8

0

9.4

0.8

1.4

1.4

5.8

Drew

USC

LLU

Stanford

UCD

UCI

UCLA

UCSD

UCSF

Rural

Inner City


Practice Location Demographics Affiliated programs varied widely as to location

demographics of their IMG and USMG residents» Drew (44%), UCLA (35.9%), USC (42.7%), and UCSF

(39.4%) had the highest percentage of IMGs entering rural and inner cities combined (p<0.005)

» UCSF and Drew had the highest percentage of USMGs entering rural and inner city practice locations (30.1% and 28% of USMGs respectively )(p<0.005)


Practice in California There was no significant variation amongst the

USMGs and IMGs of the different affiliations, for plans to practice in or out of the state

» Drew (89.4%), UCSF (84.3%), and USC (85.7%) had the highest percentage of IMG residents planning to stay in California

» UCLA (80%) and UCI (83.3%) had the highest percentage of USMGs planning to stay in California


Practice Type Predilection to practice in an underserved setting

(VA, city / county, state hospitals or public health centers/clinics) was also variable

» LLU (54.5%), UCI (54.5%), UCSD (54.5%), and UCSF (50%) had the highest percentage of IMGs entering these areas

» Drew (48.6%), UCSF (41.6%), LLU (40%) had the highest % of USMGs entering those practice types


Discussion

Association with practice characteristics and program sponsor or affiliated institution was variable.

» Weakened by limitations discussed below

» Some trends seen – Drew and UCSF produce the highest percentage of their own residents that then pursue practice characteristics that will favor alleviating the mal-distribution in California

Figure 2. Do you Plan to Work in an Underserved Area?

DREW

MatriculationQuestionnaire

N=4

N=20

GraduationQuestionnaire

Yes N (%)N = 63(68.5%)

No/ UndecidedN = 29(31.5%)

YesN = 228(28.1%)

No/ UndecidedN = 583(71.9%)

Yes N (%)N = 79(86%)

No/ UndecidedN = 13(14%)

YesN = 160(20%)

No/ UndecidedN = 650(80%)

UCLA

Decision to practice in underserved communities

Documents

Charles R. Drew University of Medicine and Science - College of Medicine Health Care Disparity: The Drew Response May 25, 2005 Charles R. Drew University