Socioeconomic Status and Health

1. Socioeconomic Status and Health Thom Walsh PhD, MS, MSPT The Dartmouth Center for Health Care Delivery Science & The Dartmouth Institute for Health Policy and Clinical Practice

2. Health & Health Care Clinical training teaches us to link outcomes and exposures • Upper respiratory infection  viruses • Cancer  carcinogens • Obesity  calories in/calories out

3. There Is More to the Story… The Field Model

4. Another Way… C. Monet (1840-1926)

5. The Road Ahead Person Place 3 Perspectives Provider Pathways 4 Pathways Policy 3 Policy Approaches

6. How to put coursework on SES in Perspective Person The Gradient Place Provider Pathways Policy

7. The Whitehall Papers Defined The Gradient Person Place Provider Pathways Policy

8. The Gradient …the gradient is fine grained and appears to have existed in all societies throughout history. KM Cardarelli, JS deMoor, MD Low, BJ Low. Fundamental determinants of population health; in Reinventing Public Health by LA Aday. John Wiley & Sons, Inc. San Fransico. 2005. Person Place Provider Pathways Policy

9. The Gradient is Fine Grained

10. Person Place The Gap Provider Pathways Policy

11. Assumption Based on the known relationship between the gradient and health among people, a wealthier place must also be healthier… . Fact: Only to a point Person Place Provider Pathways Policy

12. The Epidemiologic Transition Person Place Provider Pathways Policy

13. The Epidemiologic Transition Person Place Provider Pathways Policy

14. What is poor? Person Place Provider Pathways Policy

15. Choose You are here A: 3,000sqft home in a neighborhood where the average home is 2,000sqft

16. Choose B: 4,000sqft home in a Neighborhood where the average home is 6,000sqft You are here

18. Measuring the Gap'Gini Coefficient' • A measure of the distribution of a country's residents’ net income • 0 =identical incomes for all • 1 = all income to one person • A wealthy country and a poor country can have the same Ginicoefficient http://www.investopedia.com/terms/g/gini-index.asp#ixzz25jVc5wn4

19. Gini Coefficient

21. Person Place Geographic Variation Provider Pathways Policy

22. How Much Does Health Care Contribute to Population Health? • Some say as little as 10% • J. Michael McGinnis, Pamela Williams-Russo and James R. Knickman. The Case For More Active Policy Attention To Health Promotion. Health Affairs, 21, no.2 (2002):78-93 • Others argue as much as 50% • The Value of Medical Spending in the United States, 1960–2000. David M. Cutler, Allison B. Rosen, & Sandeep Vijan.NEngl J Med 2006; 355:920-927August 31, 2006DOI: 10.1056/NEJMsa054744

23. Ask Yourself… Would you expect to find an equal distribution of all races, incomes, and education-levels among the patients in every region of the US? Person Place Provider Pathways Policy

24. Of Course Not

25. Geographic Variation Some hospitals use effective care at higher rates than others Hospital Quality And Intensity Of Spending: Is There An Association? Laura Yasaitis, Elliott S. Fisher, Jonathan S. Skinner, and Amitabh Chandra. Health Affairs 28, no. 4 (2009): w566–w572 Person Place Provider Pathways Policy

26. Geographic Variation Patient with lower SES tend to reside near and utilize hospitals that deliver lower quality care to ALL of their patients Person Place Provider Pathways Policy

27. Key Insight from Geographic Variation Research #1 Because patients with lower SES are over represented in lower quality hospitals, the poor quality of the hospital will magnify the influence of SES on health status and longevity Person Place Provider Pathways Policy

28. Key Insight from Geographic Variation Research #2 Policies designed to improve the quality of care delivered will have a positive impact on reducing SES disparities Person Place Provider Pathways Policy

29. Further Readings The Original from Baicker, Chandra, and Skinner 2005 More recent Justin Dimick, Joel Ruhter, Mary Vaughan Sarrazin and John D. BirkmeyerIn Segregated Regions Black Patients More Likely Than Whites To Undergo Surgery At Low-Quality Hospitals. Health Affairs, 32, no.6 (2013):1046-1053 Shreya Kangovi, Frances K. Barg, Tamala Carter, Judith A. Long, Richard Shannon, and David Grande. Understanding Why Patients Of Low Socioeconomic Status Prefer Hospitals Over Ambulatory Care. Health Affairs, 32, no.7 (2013):1196-1203

30. Remember This type of analysis does NOT argue that all inequalities in health care are explained by geography. Geography- the quality of the hospital where care is received- plays a role that should be considered Person Place Provider Pathways Policy

31. How to put SES coursework in Perspective Person Place Provider Pathways 4 Pathways Policy

32. Behavioral/Cultural • Lack of self-regulation, poorly developed coping skills, external locus of control, steep discount rates (prioritizing short term gain over future uncertainty)… • Collection of learned behaviors existing within a community Person Place Provider Pathways Policy

33. Materialistic • Higher income affords better shelter, food, clothing • More education affords safer, less physically demanding jobs • Wealthier places have better schools, hospitals, transportation, etc. Person Place Provider Pathways Policy

34. If behavioral or materialistic pathways fully explained inequalities…. But we don’t see this at all There is a fine gradient among people within a place. Person Place Provider Pathways Policy

35. Psychosocial Mechanisms“Stress of trying to keep up” Short-term, Actionable Stress Chronic, In-actionable Stress Increased cardiovascular load Increased clotting factor in circulation Increased blood sugar levels… • Increased HR & BP • Increased Fibrinogen to clot wounds • Increased Cortisol releases fats and sugars into bloodstream for energy “ Under Pressure- The search for a stress vaccine” by Jonah Lehrer Wired. August 2010. Person Place Provider Pathways Policy

36. Life-Course • Early experiences • Key time frames • Chronic exposure • Accumulation Person Place Provider Pathways Policy

37. Adverse Childhood Experience (ACE) Study http://www.cdc.gov/ace/ Person Place Provider Pathways Policy

38. How to put SES coursework in Perspective Person Place Provider Pathways Policy 3 Policy Approaches

39. Education Giving Everyone the Health of the Educated: An Examination of Whether Social Change Would Save More Lives Than Medical Advances. Steven H. Woolf, MD, MPH et al. Am J Public Health. 2007 April; 97(4): 679–683 • Higher education linked to better health • Similar to income – health link • Long time horizon Person Place Provider Pathways Policy

40. Income RedistributionFlattens the Gradient and Closes the Gap 7% “Robin Hood” Tax Source: Chapter 5 Unhealthy Societies; Wilkinson Person Place Provider Pathways Policy

41. Health Care Delivery • Quality Improvement • Shared Decision Making • Accountable Care Organizations • Rational supply of resources to deliver the care an informed population needs & wants • Potentially better care for all • Potentially “doable” • Potentially could work • Health Care Delivery has a relatively minor impact on population health… Person Place Provider Pathways Policy

42. The Road Looked Like… Person Place 3 Perspectives Provider Pathways 4 Pathways Policy 3 Policy Approaches

43. How to put SES coursework in Perspective Person  Gradient Place  Gap 3 Perspectives Provider  Geography Pathways • Behavioral • Materialistic • Psychological • Life Course 4 Pathways Policies • 1. Education Promotion 2. Income redistribution 3. Health Care Delivery 3 Policy Approaches