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Individual Behavior, Biological Factors and Communication with Clinicians

Individual Behavior, Biological Factors and Communication with Clinicians. Eliseo J. P érez-Stable, MD EPI 222: Health Disparities April 21, 2010. Conceptual Framework: Multi-level Determinants of Health Disparities. Contextual. Individual-level. Physical environment.

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Individual Behavior, Biological Factors and Communication with Clinicians

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  1. Individual Behavior, Biological Factors and Communication with Clinicians Eliseo J. Pérez-Stable, MD EPI 222: Health Disparities April 21, 2010

  2. Conceptual Framework: Multi-level Determinants of Health Disparities Contextual Individual-level Physical environment Demographics - age, gender, race, ethnicity, education, income Social environment Psychosocial - beliefs, attitudes, adherence, coping, personality Health & health care disparities Health care system Technical aspects of health care Behavior - exercise, diet, alcohol, smoking, sexual behavior, substance use Communication with clinicians Biological - genetics,stress, allostatic load, opiate receptors, metabolism, telomeres Economic resources

  3. Life Expectancy at Birth

  4. Cancer Incidence by Site and Race/Ethnicity in Men, U.S. 2003 - 2007 (per 100,000 age-adjusted)

  5. Cigarette Smoking in the U.S. – 2009National Health Interview Survey

  6. What Leads to Differences in Lung 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

  7. Multiethnic Cohort Study: Lung Cancer 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 level Haiman CA, et al. N Engl J Med. 2006;354(4):333-42

  8. Relative Risk of Lung Cancer by Ethnicity and Smoking Intensity Haiman CA, et al. N Engl J Med. 2006;354(4):333-42

  9. TobaccoCancer 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

  10. Nicotine Metabolism and Intake in African 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

  11. Nicotine Metabolism in Chinese 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

  12. Ethnic Differences in Serum Cotinine Levels: NHANES 3 > 1 5 ng /ml ≤ 1 5 ng /ml p e r c e n t p e r c e n t A f r ic an A ms s m o k e r 9 6 4 non - s m o k e r 2 9 8 W hi t e s s m o k e r 9 4 6 non - s m o k e r 2 9 8 M e x ic an A ms s m o k e r 7 2 2 8 non - s m o k e r 1 9 9 J A MA 19 9 8;28 0 :13 5 -13 9

  13. Optimal Serum Cotinine for Distinguishing Smoking Status • NHANES: 13,078 nonsmokers and 3,078 smokers; based on ROC curves • Whites: 5.92 ng/ml • African Americans: 4.85 ng/ml • Mexican Americans: 0.84 ng/ml • Overall cut point is 3.08 ng/ml; 96% sensitivity and 97% specificity • 14 ng/ml underestimates smokers Benowitz N, Am J Epidemiol, November 19, 2008

  14. Personalize Cessation based on 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.

  15. Genetics 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

  16. Cancer Incidence by Site and Race/Ethnicity, Women, U.S. 2003 - 2007 (per 100,000 age-adjusted) SEER registries, US

  17. Genetic Ancestry and Breast CA • 106 ancestry markers genotyped in 440 cases and 597 controls • Immigrants + less accult protects • European ancestry associated with higher risk of breast CA: OR = 1.79 • After adjustment, association was attenuated to OR = 1.39 (1.06 – 2.11) Fejerman L, Cancer Res 2008; 68:9723-28

  18. Acculturation: 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

  19. Segmented 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

  20. Conceptual framework for contextual influences, acculturation and behavior 2nd GENERATION+ Behavior: Physical activity, diet COMMUNITY OF ORIGIN RECEIVING COMMUNITY 1ST GENERATION Behavior: Physical activity, diet Socio-economic conditions Co-ethnic concentration Socio-economic conditions Social cohesion (social capital) Social cohesion (social capital) Social norms related to behavior Social norms related to behavior Built environment Built environment

  21. California Health Interview Survey, 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

  22. Percent college education by immigrant 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.

  23. Percent English only at home by immigrant 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.

  24. Percentage at Recommended non leisure-time physical activity by language 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.

  25. Recommended non-leisure time physical activity among Mexicans: 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.

  26. Immigrant generation and diabetes risk in 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

  27. Education by immigrant generation: SALSA 1998-99

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

  29. Diabetes risk among Mexican-origin older adults: SALSA, 1998-99 *Adjusted for BMI, acculturation, sex, age, lifestyle, education, occupation

  30. Ethnic Disparities in Diabetic Complications at KPMCP • Observational study: 62 432 patients • 10% Lat, 64% W, 14% AA, 12% API • Latinos had less MI (0.68), CHF (0.61) and stroke (0.72) compared to Whites • More ESRD among Latinos–1.46 • Setting of uniform access • Genetics and environment?

  31. Kaiser DM cohort: MI outcome Fully-adjusted model African American Latino All AAPI Chinese Japanese Filipino Pacific Islander South Asian At 10 yrs, Compared to Whites… Age and sex-adjusted only

  32. Kaiser DM cohort: ESRD at 10 yKanaya AM, et al. Diabetes Care, Feb 24, 2011, Online. African American Latino All AAPI Chinese Japanese Filipino Pacific Islander South Asian

  33. Latinos and African Americans Live Longer than Whites at ADC Centers *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

  34. Average Annual Rates per Million 50 40.9 40.75 40 30 15 20 11.3 10 0 Mexican Caucasian African Puerto Rican American U.S. Asthma Mortality 1990-1995 Homa et al. 2000

  35. 100% 3.0% 90% 15% 80% 70% 52% 24% African 60% Native American 50% European 40% 30% 61% 45% 20% 10% 0% Mexican Puerto Rican American Genetic Origins of Latinos Percent Ancestral Contribution Admixture UCSF in preparation: Choudhry, Salari & Coyle, et al.

  36. P=0.0002 p=0.0003 14 after albuterol 12 10 1 8 6 4 % Reversibility in FEV 2 0 Puerto Ricans Mexicans Puerto Ricans Mexicans > 16 years old < 16 years old Puerto Ricans Have Lower Drug Response to Albuterol GALA Study Investigators AJRCCM 2004

  37. Allostatic Load Score in Women: NHANES, 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

  38. CHD Prediction Scores By EthnicityColor 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

  39. Chronic Stress, Race, Unhealthy Behaviors: 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

  40. TB Rate Ratio by EthnicityDemographics and SES

  41. Communication with Clinicians Language

  42. Definition of Limited English 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

  43. LEP 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

  44. Identifying LEP Patients: Two standard questions Need systems to use standard questions on all patients US Census question: How well do you speak English? Very well, well, not well, not at all What language do you prefer to receive your medical care? Karliner L, J Gen Intern Med. 2008; 23:1555-60 Institute of Medicine Report 2009

  45. Census 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;92/84% specific

  46. Constructs in Evaluating Language 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?

  47. Language Concordance Matters • Understand more MD instructions and ask more questions (NY) Trend to better medication adherence in asthma (NY) Ask more questions and receive more patient centered care (UCI) Patients feel better, have less pain, better health outlook (UCSF)

  48. Effect of Clinician Language Concordance on MOS Measures

  49. LEP is a Risk Factor for Poor Control of Diabetes Kaiser Diabetes Study, n = 6730, mean age 60 y, 510 LEP Latinos A1c > 9%: 10% Whites, 18% Latinos, 21% LEP-Lat • Concordant LEP = 16% vs. 28% • LEP discordant c/w Eng-Lat had OR = 1.76 (1.04 - 2.97) of A1c > 9% and OR = 1.98 c/w concordant Latinos Fernandez A, JGIM online 29 September 2010

  50. Pew Hispanic Center/RWJF Latino Health 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

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