Factors that Decrease Inequities in the Healthcare System

Does healthcare inequities exist for minority populations and the poor in the United States?

The family of Thomas Eric Duncan thinks so. They are upset about the “unfair” medical care he received at Texas Health Presbyterian Hospital in Dallas, Texas. Mr. Duncan was from Liberia. He was the first person to die of Ebola in the U.S. after being infected with the Ebola virus.

Mr. Duncan’s nephew, Joe Weeks, told ABC News he felt Duncan had “unfair” medical treatment. Mr. Weeks suggested that Mr. Duncan did not get the same treatment being given to Ebola patient Ashoka Mukpo, in a Nebraska hospital. He did not cite the differences in care.

Although hospital officials told the family they were capable of managing Mr. Duncan’s care, the family questioned why Mr. Duncan was not moved to Emory University Hospital, where two American health workers had been successfully treated following an infection with the Ebola virus while in Liberia. Mr. Weeks said the family was also frustrated that Mr. Duncan was not given donated blood from Ebola survivors to pass on their antibodies of the virus to Mr. Duncan. The hospital officials told the family “that the blood wasn’t a match.”

The jury is still out regarding the facts surrounding Mr. Duncan’s case, and the major snafu that occurred when he initially went to the emergency room for care, but was released and sent home with treatment from antibiotics, thus culminating in his death.

What can we do, in the meantime, as healthcare professionals to ensure that all patients perceive the quality of medical care they receive as being excellent, regardless of their race or economic status?

The racial and ethnic health inequities don’t just reflect income. More African American, Native American, Latino and Pacific Islanders are in poor or less fair health than whites at practically every income level (although recent Latino immigrants report better health).

Ethnic differences highlight the need to further examine social support, socioeconomic status, access to care, and cultural factors to guide future health-related quality of life (HR-QOL). Health includes physical, mental, and social realms.

On the individual level, this includes physical and mental health perceptions pertaining to health risks and conditions, functional status, social support, and socioeconomic status. On the community level, HRQOL includes resources, conditions, policies, and practices that influence a population’s health perceptions and functional status.

HRQOL enables health agencies to legitimately address broader areas of healthy public policy around a common theme in collaboration with a wider circle of health partners, including social service agencies, community planners, and business groups.

The evaluation, diagnosis, treatment, and management of medical conditions will result in significant positive outcomes when there is a clear pathway regarding the objectives to promote healthy behaviors. The implementation of transparent programs and intervention services along with proper allocation of resources is necessary to close health care gaps and decrease priority disparities.

In addition to HRQOL elements, the cultural competency of health care workers is important, and includes five factors that influence health communication.

  1. Behaviors or the manner in which health care workers conduct themselves through their actions and responses with patients from varied demographics. Is the healthcare worker tolerant and attentive or standoffish and impatient?
  2. Language or methods used to ask questions and receive answers for the purpose of exchanging information in a clear and concise manner, which can be understood and recognized by all parties involved. This is extremely important for the purpose of providing medical care and treatment intervention. Does the healthcare facility have a language interpreter for patients that may speak English as a second language so that thoughts and ideas may be conveyed and received properly?
  3. Customs-Is the healthcare worker trained to recognize actions or ways of behaving that are common and traditional among people in a particular group. For example, it is a custom in some religious groups to never leave the woman alone with a male that is not her relative. Does the healthcare organization or facility make concessions for this?
  4. Beliefs or feelings of being sure that someone or something exists or that something is true. Does the healthcare organization have an Imam, priest, and rabbi present for patients and their loved ones who are spiritual believers seeking spiritual guidance and comfort from a ‘Higher Power?’
  5. Perspectives or mental thoughts, feelings, and emotions within and about the environment. Is there a meeting of the minds during the initial contact? Is the communication and explanation process regarding medical treatment between the patient and their family with the hospital staff comprehended? Are next steps going forward understood?

Clearly, these factors are important for achieving accuracy during triage and during the continuum of medical care. The takeaway from the events that transpired in Dallas, Texas is that if healthcare disparities are present, they will often result in suboptimal care, misunderstandings, the potential threat of legal action, and a public relations nightmare.


My vote for Charlie Crist will be Personal

I am a registered Independent African- American voter. I will always remember the prompt response I received from then Governor Charlie Crist’s office in 2007, after I wrote a letter of complaint about the lack of follow- up with the enforcement of a personal matter in the Florida Department of Revenue. The governor’s office intervened and played a pivotal role (I am sure) in the agency’s motivation, to resolve the issue. To this date my daughter benefits from the intervention.

I will do whatever I can in my capacity to garner support for his campaign.

I support his platform to fight for gay marriage because no one should be able to tell anyone who they must love; to make it easier for college students to vote (as the mother of two daughters in college); that he will veto abortion restrictions and protect a woman’s right to choose; that he will attempt to raise the minimum wage; and more importantly, accept federal money for Medicaid expansion- especially on behalf of the poor.

Melissa Bynes- Brooks

Hello Walgreens, Walmart, and CVS Health

Access to affordable and preventive health care is important. Retail clinics are surging and care is transitioning away from the hospital and doctors office to fill a void for many Americans who cannot afford to buy traditional health insurance. Some Americans can’t qualify for coverage under the Affordable Care Act, and others may have fallen between the cracks due to a lack of the Medicaid expansion in their state.

Although, biased about the care they’d prefer to receive and where they’d like to receive it, most consumers are on board with the concept of going to big box stores, grocery stores, and pharmacies for quality healthcare at an affordable price.

In a 2013 Oliver Wyman national consumer survey of more than 2,000 consumers, 77 percent were willing to receive at least one medical or wellness service from a retail establishment. For minor incidents, 36 percent of consumers were interested in receiving care at a drugstore and 20 percent at a grocery store.

Walgreens, Walmart, and CVS Health (formerly CVS Caremark) have each invested in a strategy, which incorporates a business model consisting of different mergers formed with hospitals, physician groups, and nurse practitioners to offer quality affordable healthcare directly to consumers. Health information technology (HIT) has helped to facilitate a smooth transition from traditional visits to the doctor’s office by providing a secure platform for partners to get access to, for the purpose of sharing patient data through electronic health records (EHR).

A new research study from Walgreens found the percentage of visits to Healthcare Clinic locations for preventive services, screening and chronic visit utilization (combined) increased from 4 percent in 2007 to 17 percent in 2013. The study also found the annual percentage of return patient visits to Healthcare Clinic climbed from 15 percent in 2007, to more than 50 percent in both 2012 and 2013. Walgreens has over 400 clinics that offer vaccines, physical exams, and screenings for blood pressure, cholesterol, diabetes, health risk assessment, and influenza.

Walmart has positioned itself to lead the healthcare retail price wars by partnering with hospitals and nurse practitioners from QuadMed to offer primary care services in their walk-in clinics seven days a week, inside Walmart stores. Services include preventive and routine exams such as cholesterol screenings, allergy care, and vaccinations. Employees enrolled in the company’s health insurance plan can pay four dollars for services.

CVS has more than 900 “MinuteClinic” locations, and it plans to expand over the next few years. CVS recorded $126.7 billion in sales during the last fiscal year, and is making headlines now because of the decision to stop selling tobacco products by October 1st. This was a brave proactive decision for preventive care.

Going forward, it will be interesting to see the primary care service line for each of the retail clinic chains. Perhaps, the next frontier could include possible alliances and partnerships with board certified sleep specialists and accredited sleep centers. Perhaps each company could consider offering sleep apnea screenings with portable home sleep study devices to consumers in rural and urban demographics where physician shortages exist, and where there are higher disparities for medical conditions such as diabetes, high blood pressure, heart disease, and cancer.

Has your sleep center team explored this prospect? I’d love to read your feedback, albeit positive or negative.


Commercial Drivers ‘STOP’ Drowsy Driving

Alert commercial drivers are an essential component of a safe transportation system, which includes business logistics strategies for the optimal distribution of goods and services. Yet, they are more likely to drive drowsy according to data from the Centers for Disease Control (CDC). Drowsy drivers are less attentive. They have a slower reaction time, and a decreased ability to make decisions.

Trucking accidents are on the rise because most commercial drivers work long shifts, drive long distances, or suffer from sleep apnea. According to the National Institutes of Health, adults need 7 or 8 hours of sleep a day, while adolescents need 9 or 10 hours.The National Highway Traffic Safety Administration estimates that 2.5% of fatal crashes and 2% of injury crashes involve drowsy driving.

Drivers who drive long distances and work long shifts should try to create a relaxing bedtime routine in an environment that is comfortable and cool, and blocks out all light and noise. They should also know the signs of obstructive sleep apnea (OSA) which occurs due to a blockage in the upper airway that interferes with the ability to breathe normally. OSA may contribute to tiredness, excessive daytime sleepiness, mood swings, memory loss, and problems concentrating while performing various routine activities.

If OSA symptoms are present, the driver may use the STOP questionnaire. It is a concise and easy-to-use screening tool that can identify patients with a high risk for OSA.

Four questions are answered respectively, related to snoring, tiredness during the daytime, observed apnea, and high blood pressure (STOP).

High risk for OSA is determined by answering yes to two or more questions. The driver should consider making an appointment with a board certified sleep specialist who will determine if a sleep study is necessary if there is a high risk for sleep apnea, which can lead to high blood pressure, diabetes, stroke, and cancer.

STOP Questionnaire for Obstructive Sleep Apnea (OSA)

Height: _________ inches Weight: _________ lbs

Age: _______ Male / Female Body Mass Index (BMI): _________

Collar size of shirt: S M L XL or _________ inches

Neck Circumference: _________ cm


The STOP test consists of four questions:

  1. Snoring

Do you snore loudly (louder than talking or loud enough to be heard through closed door)?

Yes No

  1. Tired

Do you often feel tired, fatigued or sleepy during the day?

Yes No

  1. Observed

Has anyone observed you stop breathing during your sleep?

Yes No

  1. Blood Pressure

Do you have or are you being treated for high blood pressure?

Yes No

High risk of OSA: answering yes to two or more questions

Low risk of OSA: answering yes to less than two questions

*Chung, F., Yegneswaran, B., Liao, P., Chung, S., Vairavanathan, S., Islam, S., Khajehdehi, A., Shapiro C. (2008). STOP questionnaire. A tool to screen patients for obstructive sleep apnea. Anesthesiology, 108 (5), 812-21.

Venous Insufficiency and Obstructive Sleep Apnea

For the most part, you’re a healthy person. You get your annual wellness exams and live a reasonably satisfactory lifestyle. You manage a career, along with family matters and extracurricular activities that are important to you.

Lately, you’re experiencing swelling or edema in your legs, feet, or ankles, which is usually caused by an increase in interstitial fluid volume. Being the health conscious person that you are, you follow-up with your physician and the diagnosis is venous insufficiency, a condition in which the veins have problems sending blood from the legs back to the heart.

Your physician proceeds to order a complete workup to rule out cardiovascular disease, peripheral vascular disease (PVD) known to be linked to diabetes, and peripheral arterial disease (PAD). This may include a venous Doppler ultrasound to evaluate blood flow through blood vessels in the legs, to rule out a blood clot in the vein and leaking around the valves of the veins.

Your physician may also order a sleep study to determine if you have sleep apnea. Sleep apnea occurs due to a blockage in the upper airway and can cause pulmonary hypertension, which is a common cause of leg edema. The most likely cause of leg edema in all patients over age 50 is venous insufficiency. It affects up to 30% of the population. Another type of edema, idiopathic edema, occurs in women under age 50, and is usually associated with the menstrual cycle and conditions related to obesity, depression, and diuretic abuse.

The volume of fluid available for movement from the legs increases with sitting and leg edema. Fluid volume that is displaced from the legs overnight is directly proportional to the time spent sitting during the day, not to physical activity.

Patients susceptible to fluid retention, may have fluid movement from the legs while asleep during the night, which may cause or worsen obstructive sleep apnea (OSA). The fluid increases in the neck and limits airflow in the airway during sleep contributing to cardiovascular disease and other medical conditions.

You may be advised to decrease your salt intake, limit sitting or standing for excessive periods of time, and to wear compression stockings to gently improve the circulation of blood in your legs, and reduce swelling. If you are found to be positive for sleep apnea, you may be advised to use Continuous Positive Airway Pressure (CPAP).

The takeaway…Get moving!

The Rx for Reducing Pharmacy Compounding Risks

October 16, 2012

By Melissa Bynes Brooks

According to the International Academy of Compounding Pharmacists (IACP)the compounding industry now makes up an estimated 1 to 3 percent of the U.S. prescription market, which is $300 billion overall.

The Food and Drug Administration (FDA) is aware of a number of product quality problems associated with compounded drugs including contamination, poor compounding processes, and product toxicity. Unlike commercial drug manufacturers, pharmacies aren’t required to report adverse events associated with compounded drugs. Recent deaths from fungal meningitis associated with epidural steroid injections on or outside the outermost membrane covering the spinal cord to relieve back pain have shined a light on the regulation or lack thereof, of pharmacy compounding.

Clinical meningitis is defined as having one or more symptoms (e.g., headache, fever, stiff neck, or photophobia-sensitivity to light) and cerebral spinal fluid (CSF) pleocytosis (more than five white blood cells per µL or microliter), adjusting for the presence of red blood cells, regardless of CSF protein and glucose levels.

On September 18, 2012, the Tennessee Department of Health was alerted by a clinician regarding a patient with culture-confirmed Aspergillus fumigatus meningitis diagnosed 46 days after an epidural steroid injection at a Tennessee ambulatory surgical center. An additional eight patients with clinically diagnosed, culture-negative meningitis were later identified.

Patients had received one or more epidural steroid injections used to treat both peripheral joint and back pain from three lots of single-dose vials (17,676 single vials) with preservative-free methylprednisolone acetate solution (MPA), compounded at New England Compounding Center (NECC) in Framingham, Massachusetts. On October 4, 2012, the Centers for Disease Control (CDC) and FDA recommended that all health care professionals cease use and remove from their pharmaceutical inventory any product produced by NECC.

The states below received injections:

California, Connecticut, Florida, Georgia, Idaho, Illinois, Indiana, Maryland, Michigan, Minnesota, North Carolina, New Hampshire, New Jersey, Nevada, New York, Ohio, Pennsylvania, Rhode Island, South Carolina, Tennessee, Virginia, Texas, and West Virginia.

As of October 16, a multistate investigation led by CDC in collaboration with state and local health departments and the FDA have identified 233 cases and 15 deaths associated with this outbreak in 10 states, with 14,000 persons potentially exposed to medications from NECC.

Four categories of cases in patients who received an injection with MPA produced by NECC have been identified:

1) Fungal meningitis or nonbacterial and non-viral meningitis of subacute (recent) onset following epidural injection on or after May 21.

2) Basilar stroke following epidural injection on or after May 21, in a person from whom no cerebrospinal fluid (CSF) specimen was obtained.

3) Spinal osteomyelitis (inflammation of bone and bone marrow) or epidural abscess (pus-filled cavity) at the site of injection following epidural or sacroiliac injection on or after May 21.

4) Septic (infectious) arthritis or osteomyelitis of a peripheral (near the surface) joint (e.g., knee) diagnosed following injection of that joint on or after May 21.

What is pharmacy compounding?

Pharmacy compounding involves combining, mixing, or altering ingredients to create a customized medication. This is carried out by a state licensed pharmacist. It may involve taking an approved drug substance and making a new medicine when a traditional approved drug is not available to meet the medical needs of a specific patient as prescribed by a physician, veterinarian, or other prescribing practitioner. For these patients, customized medications are the only way to better health. For example, this may involve making a suspension or suppository dosage form for a child or elderly patient who has difficulty swallowing a tablet or a capsule. There is an increased need for pharmacy compounding due to drug shortages and the need to access drugs or dosage forms that have been withdrawn from the market.

Because traditional pharmacy compounding serves an important public health function, the FDA exercises enforcement discretion to allow legitimate forms of pharmacy compounding that is regulated under state laws governing the practice of pharmacy. Therefore, all pharmacies and pharmacists are licensed and strictly regulated at the state level.

How does pharmacy compounding increase safety risks in the public healthcare system?

Although state boards are constantly updating their standards and regulations, the safety and effectiveness of compounded drugs is not proven or established by supporting data which the FDA requires for approving new drugs. Compounded drugs are considered to be unapproved new drugs by the FDA. It is estimated that one fifth of all prescriptions written for FDA-approved drugs are for uses, for which they were not specifically approved.

One caveat is that the risk of obtaining a product of less than desired quality outweighs the benefits of obtaining a compounded drug. Other issues include large-scale drug manufacturing under the deceptive appearance of pharmacy compounding; compounding products containing an active ingredient not approved by the FDA; copying compounded products for economic gains; and selling products removed from the market by the FDA for safety reasons.

Similar circumstances no doubt contributed to the observed fungal contaminated steroid shots made by NECC and confirmed by FDA direct microscopic examination of foreign matter taken from a sealed vial.

More than 200 adverse events involving 71 compounded products since 1990 have occurred resulting in devastating consequences. For example, three patients died of infections stemming from contaminated compounded solutions that are used to paralyze the heart during open-heart surgery. The FDA issued a warning letter in March 2006 to the firm that compounded the solutions.

On October 8, 2012, Senator Richard Blumenthal (D-Conn.) called for stronger federal oversight of pharmacy compounding which manufactures drugs without a patient prescription in a letter to the commissioner of the FDA.

In the meantime, the public healthcare system would be better served if compounding guidelines set forth in the United States Pharmacopeial Convention (USP) were implemented by all pharmacy compounding companies. The USP is a scientific nonprofit organization that sets standards for the identity, strength, quality, and purity of medicines, food ingredients, and dietary supplements manufactured, distributed and consumed worldwide. USP’s drug standards are enforceable in the United States by the Food and Drug Administration, and these standards are developed and relied upon in more than 140 countries.

Validation from the independent Pharmacy Compounding Accreditation Board (PCAB) represents another gold standard benchmark. PCAB offers accreditation to compounding pharmacies that meet nationally accepted quality assurance, quality control, and quality improvement standards. When choosing a compounding pharmacy, PCAB suggests looking for the designation “PCAB Accredited® compounding pharmacy” or the PCAB Seal.

The PCAB evaluation includes:

  • An assessment of the pharmacy’s system for assuring and maintaining staff competency.
  • A review of facilities and equipment.
  • Review of records and procedures required to prepare quality compounded medications.
  • Verification that the pharmacy uses ingredients from FDA registered and or licensed sources.
  • Review of the pharmacy’s program for testing compounded preparations.

The New England Compounding Center (NECC), the company supplying the epidural steroid injections which resulted in the fungal meningitis outbreak, was not accredited by PCAB.

Follow on Twitter @Mlbbrooks

Obamacare + 7.8%: Can Obama Recapture the Race at Debate #2

October 10, 2012

By Melissa Bynes Brooks

A decreased unemployment rate to 7.8 percent in September is the perfect backdrop for underscoring President Obama’s credibility and record during the second presidential debate on October 16, 2012. This will be another opportunity for President Obama to passionately state why his model for governing is the best investment in the long term sustainability in the future of America. The success of his polices may be measured by what they have accomplished in terms of growing the economy, creating jobs, supporting small businesses, providing affordable healthcare, and improving government efficiency.

Before President Obama took office, the economy was losing 800,000 jobs a month. Since then, there have been 31 consecutive months of job growth and 5.2 million new private sector jobs.

Current conditions point to a potential US manufacturing renewal: Industrial output has been slowly rising over the last three years. The US remains one of the world’s largest and most attractive marketplaces: Sales of autos and durable goods are up; factory orders have increased; and the housing market is improving, lifting related construction and retail sectors. The American Auto Industry is thriving again.

The US still boasts the most skilled, highly trained workforce in the world. To maintain that edge, government policies and private initiatives are being implemented. In summer 2011, the Obama administration outlined the expansion of an industry-led worker-training program, Skills for America’s Future, intended to improve partnerships with community colleges and create easier-to-understand, uniform job-training requirement standards for prospective manufacturing employees. They also launched the Advanced Manufacturing Partnership (AMP), an initiative to provide more than $500 million to encourage investments in promising technologies. The plan’s objective was to partner with industry to create high-quality, good-paying jobs for American workers.

On September 16, 2011, President Obama signed into law one of the most significant legislative reforms to the patent system in our Nation’s history. The America Invents Act  was passed with the President’s strong leadership last year, after nearly a decade of effort. A year later, the U.S. Patent and Trademark Office is implementing the legislation in a manner that makes it easier for American entrepreneurs and businesses to bring their inventions to the marketplace sooner, converting their ideas into new products and new jobs while avoiding costly delays and unnecessary litigation, letting them focus instead on innovation and job creation.

Outlays for Social Security and the major federal health care programs are projected to total 12.2 percent of GDP in 2020 under the alternative fiscal scenario, compared with an average of 7.3 percent over the past 40 years, placing increasing pressure on the federal budget. Obamacare reduces costs, manages risks, and improves efficiency in the healthcare delivery system. Contributing factors include a transition from a fee for services payment model to a bundle payment model, incentives for insurance providers and hospitals geared towards pay for performance and quality over quantity, and incentives for the use of health information technology which reduces medical errors. The estimated amount of deficit reduction under Obamacare will be $5 billion. Starting in 2014, insurance companies can no longer reject people with pre-existing conditions.

If Gov. Romney repeals Obamacare, he will add $109 billion to the federal budget deficits over the next 10 years and an estimated 60 million nonelderly people would be uninsured. His current plan would cover pre-existing conditions for people who had health insurance and continue to purchase it, as long as there’s no interruption in coverage of more than 63 days.

The Medicare Program is solvent for a period of 8 more years because President Obama cut $716 billion in wasteful spending from the fee-for-service sector (other than physicians’ services). Payment rates were set up in Medicare Advantage to provide low-income beneficiaries with a sufficient choice of plans without incurring a premium liability. There are reduced Medicare Disproportionate Share Hospital for state DSH payments which are more than the hospital’s eligible uncompensated care costs. Gov. Romney’s promise to restore $716 billion of wasteful spending back into the Medicare program is not congruent with his promise to decrease the federal deficit.

Who should bear the burden of proposed changes in spending cuts and tax increases?

A national survey by the Pew Research Center for the People & the Press, conducted July 12-15 shows the public supports President Obama on the issue of fairness and tax policies.  By two-to-one (44% to 22%), the public says that raising taxes on incomes above $250,000 would help the economy rather than hurt it, while 24% say this would not make a difference. Moreover, an identical percentage (44%) says a tax increase on higher incomes would make the tax system fairer, while just 21% say it would make the system less fair.

SCOTUS is also relevant to the fairness issue. The Supreme Court’s Impact on the 2012 Presidential Election, conducted on behalf of civil rights groups by Hart Research Associates, found that more than half of the 1,007 people surveyed online in late August, 54 percent, believe that the current Court majority “tends to side with corporations” as opposed to individuals. Thirty-six percent said the Court had struck a balance, and just 10 percent believe the Court favors individuals. Between the two candidates, 46 percent swing voters polled said they have “a great deal” or “a fair amount” of confidence that Obama would nominate good federal judges and Supreme Court justices if he wins. Only 35 percent of those swing voters said the same about Romney.

It is the role of government to ensure that organizations observe relevant laws and act ethically. Organizations must be legally, socially, and environmentally responsible. It is illegal to mislead consumers who purchase goods and services.

In February 2012, the Obama Administration oversaw the largest consumer financial protection bipartisan settlement in US history which provides $25 billion in relief to distressed mortgage borrowers. The historic joint state-federal settlement was with the country’s five largest mortgage servicers who routinely signed foreclosure related documents outside the presence of a notary public and without knowing whether the facts they contained were correct.  Both practices violate the law.  The mortgage servicers were Ally/GMAC, Bank of America, Citi, JPMorgan Chase, and Wells Fargo.

On January 29, 2009, President Obama signed the Lilly Ledbetter  Fair Pay Act of 2009 (“Act”).The Equal Pay Act requires that men and women in the same workplace be given equal pay for equal work. Compensation discrimination on the basis of race, color, religion, sex, national origin, age, or disability is illegal.

For the next debate, President Obama must ensure that voters understand and arrive at an implicit understanding of the role of government and public policy which can guide coordinated and measured change towards a stable outcome when the invisible hand fails to restore equilibrium.

There are no quick fixes.


Book Reference

Dixit, A. K. and Nalebuff, B. J. (2008). The Art of Strategy: A Game Theorist’s Guide to Success in Business and Life. New York, NY: W. W. Norton, Inc.