>> OKAY, GOOD AFTERNOON,
EVERYONE.
AND WELCOME TO THE NIMHD
DIRECTOR'S SEMINAR SERIES.
MY NAME IS ELISEO PEREZ-STABLE,
AND THANK YOU FOR JOINING US
TODAY.
THIS IS THE SECOND LECTURE OF
2024, AND WE ARE EXCITED TO
CONTINUE THIS SERIES WITH
TODAY'S ESTEEMED SPEAKERS.
I'M DELIGHTED TO INTRODUCE
MIGUEL MARINO AND JOHN HEINTZMAN
FROM OREGON HEALTH AND SCIENCE
UNIVERSITY.
WHO WILL PRESENT ON THE ROLE OF
PRIMARY CARE IN LATINO HEALTH
EQUITY.
GIVEN TODAY'S ANNOUNCEMENT ABOUT
THE PROPOSED NEW NIH -- FOR
HEALTH NETWORK THIS TOPIC IS
MOST APPROPRIATE FOR US TO HEAR
ABOUT.
BACHELOR OF MATHEMATICS, MASTERS
IN BIOSTATISTICS, I A WARDED A
PH.D. IN BIOSTATISTICS FROM
HARVARD IN 2011.
DR. HEINTZMAN ATTENDED THE
UNIVERSITY OF MICHIGAN FOR HIS
UNDERGRADUATE DEGREE IN
PSYCHOLOGY AND GRADUATED FROM
TEMPLE UNIVERSITY SCHOOL OF
MEDICINE IN 2002.
HE COMPLETED A RESIDENCY IN
FAMILY MEDICINE AND MASTERS IN
PUBLIC HEALTH AND IN CLINICAL
RESEARCH AT OREGON HEALTH
SCIENCES UNIVERSITY.
AS HE JOINED THE FACULTY IN
DEPARTMENT OF FAMILY MEDICINE.
MIGUEL AND JOHN ARE RENOWNED
EXPERTS IN THEIR FIELDS AND THEY
BRING A WEALTH OF KNOWLEDGE AND
EXPERIENCE TO TODAY'S
DISCUSSION.
MIGUEL IS CURRENTLY AN ASSOCIATE
PROFESSOR OF BIOSTATISTICS IN
THE DEPARTMENT OF FAMILY
MEDICINE AT OHSU, AND ALONGSIDE
WITH JOHN, HE CO-DIRECTS THE
PRIMARY CARE LATINO HEALTH
EQUITY RESEARCH CENTER, OR
PRIMER, WHICH IS DEDICATED TO
UNDERSTANDING DISPARITIES IN
EQUITY AND PRIMARY CARE FOR
HISPANIC LATINO COMMUNITIES.
MIGUEL IS FIRST GENERATION
MEXICAN-AMERICAN WHO ESTABLISHED
HIS CAREER IN PRIMARY CARE AND
HEALTH SERVICES RESEARCH, PUBLIC
HEALTH AND BIOSTATISTICS.
HIS RESEARCH FOCUSES ON
DEVELOPING AND IMPLEMENTING
STATISTICAL METHODOLOGIES TO
ADDRESS THE COMPLEXITIES
ASSOCIATED WITH USING ELECTRONIC
HEALTH RECORDS TO STUDY HEALTH
EQUITY AND CHANGES IN HEALTH
POLICY AMONG LOW INCOME AND
DISADVANTAGED POPULATIONS,
SEEKING CARE IN PRIMARY CARE
CLINICS.
MIGUEL SERVES AS EDITOR FOR JAMA
HEALTH FORUM, CO-CHAIR OF THE
COMMUNITY ALLIANCE OR SEAL AND
NEEDS ASSESSMENT EVALUATION WORK
GROUP.
AND A MEMBER OF THE NATIONAL
ADVISORY COMMITTEE ON RACIAL,
ETHNIC AND OTHER POPULATIONS FOR
THE U.S. CENSUS BUREAU.
HE'S ALSO AN E ELECTED MEMBER OF
THE NATIONAL ACADEMIES OF
SCIENCES ENGINEERING AND
MEDICINE.
IN RECOGNITION OF HIS
SIGNIFICANT CONTRIBUTIONS TO THE
FIELD, MIGUEL HAS PUBLISHED OVER
200 PAPERS AND RECEIVED SEVERAL
AWARDS, INCLUDING THE NORTH
AMERICAN PRIMARY CARE RESEARCH
GROUP NEW INVESTIGATOR RESEARCH
AWARD.
JOHN IS AN ASSOCIATE PROFESSOR
OF FAMILY MEDICINE AT OREGON
HEALTH SCIENCES UNIVERSITY.
AND HE IS A BOARD CERTIFIED
FAMILY PHYSICIAN, HEALTH EQUITY
RESEARCHER AND PRACTICING
COMMUNITY HEALTH CENTER
CLINICIAN.
JOHN'S RESEARCH CAREER FORMALLY
BEGAN WITH A CAREER DEVELOPMENT
AWARD FROM AHRQ, THE AGENCY FOR
HEALTH RESEARCH AND QUALITY IN
2012, FOCUSED ON PREVENTIVE
SERVICES FOR LATINO IMMIGRANTS.
HE IS FUNDED THROUGH MULTIPLE
NIH PROJECTS AND COLLABORATES
CLOSELY WITH MIGUEL, THUS WE
HAVE A TWO FOR ONE TODAY, FIRST
TIME EVER IN AND NIMHD
DIRECTOR'S SEMINAR.
JOHN HAS ALSO RECEIVED AWARDS
FROM A NON-PROFIT EQUITY SERVING
COMMUNITY HEALTH CENTERS IN
LATINO PATIENTS NATIONWIDE
AMONGST OTHER POPULATION GROUPS.
CURRENTLY HE'S DUAL PI FOR THE
ADVANCED CLINICAL RESEARCH
NETWORK AND CO-CHAIR OF THE
PATIENT-CENTERED OUTCOMES
RESEARCH NETWORK RESEARCH
COMMITTEE.
HE HAS PUBLISHED OVER 80 PEER
REVIEWED PAPERS, RECEIVED
SEVERAL AWARDS, INCLUDING THE
OHSU'S ALUMNI ASSOCIATION EARLY
CAREER ACHIEVEMENT AWARD.
TODAY'S TALK WILL EXPLORE THE
PERSISTENT HEALTH AND HEALTHCARE
INEQUITIES FACED BY LATINO
POPULATIONS ACROSS NUMEROUS
HEALTH CONDITIONS.
MIGUEL AND JOHN WILL DISCUSS HOW
UNDERSTANDING AND IMPROVING
THESE INEQUITIES REQUIRE A
COMPREHENSIVE AND MULTI-LEVEL
APPROACH.
SO WE ARE THRILLED TO HAVE YOU,
AND PLEASE GIVE THEM A VIRTUAL
WELCOME TO MIGUEL MARINO AND
JOHN HEINTZMAN .
MIGUEL AND JOHN.
>> YEAH, THANK YOU, THANK YOU,
ELISEO, FOR THE INTRODUCTION,
AND FOR THE INVITATION TO
PRESENT OUR WORK IN PRIMARY CARE
AND LATINO HEALTH.
IT REALLY IS AN HONOR TO BE PART
OF THIS SERIES, AND WE HOPE TO
INSPIRE CONVERSATION THAT
CONTINUES TO BUILD ON THE
IMPORTANCE OF IMPROVING HEALTH
AND HEALTHCARE FOR LATINOS IN
THE UNITED STATES.
SO I'M A BIOSTATISTICIAN WITH
DEEP ROOTS IN PRIMARY CARE, AND
THAT LED -- THAT WAS A PATH THAT
TOOK A WHILE, I THINK, YOU KNOW,
WHEN I GRADUATED WITH MY PH.D.
IN BIOSTATISTICS 13 YEARS AGO,
THERE COULD HAVE BEEN MANY AREAS
I COULD HAVE APPLIED MY TRADE
IN, AND I DID FOR A WHILE, SO I
WORKED ON MANY TOPICS FROM AIDS
RESEARCH TO CANCER RESEARCH,
GENETICS WORK, AND SO MANY
OTHERS, BUT THROUGH IT ALL, AT
THE END OF THE DAY, THERE WAS
THIS INTEREST IN REALLY TRYING
TO UNDERSTAND HOW TO IMPROVE
COMMUNITY-BASED HEALTH, AND SO
LONG STORY SHORT, I DECIDED TO
DEDICATE MY WORK IN
UNDERSTANDING THE ROLE OF
PRIMARY CARE IN IMPROVING
COMMUNITY HEALTH AND IN
PARTICULAR, LATINO HEALTH.
>> THANK YOU AGAIN, ELISEO, FOR
THAT INTRODUCTION, AND FOR
HAVING US TODAY.
I'M JOHN HEINTZMAN, CO-DIRECTOR
OF THE CENTER WITH MIGUEL AND AS
HE SAID, I'M A FAMILY PHYSICIAN
BY TRAINING AND MY FIRST JOB OUT
OF RESIDENCY WAS AT A COMMUNITY
HEALTH CENTER HERE IN OREGON AND
I FELT LIKE MANY OF MY PATIENTS,
I DIDN'T UNDERSTAND THE FULL
BARRIERS THAT THEY FACED IN
OBTAINING CARE, AND SO SET ABOUT
KIND OF A JOURNEY TO GET
RESEARCH SKILLS, A LOT OF
CONTENT KNOWLEDGE BUT ALSO A LOT
OF RELATIONSHIPS AND
QUESTION-ASKING AND DIDN'T
REALLY KNOW WHAT I WAS DOING BUT
BY SOME KIND OF SET OF SMALL
MIRACLES, I GOT A CAREER
DEVELOPMENT AWARD AND THAT'S
WHERE I MET MIGUEL AND WE
STARTED HATCHING IDEAS FOR THAT
PROJECT AS WELL AS OTHERS IN THE
LAST 12 YEARS HAVE BEEN SUPER
FORTUNATE TO BUILD A TEAM AND
VISION UNDERSTANDING HOW EQUITY
WITH LATINO PATIENTS IN PRIMARY
CARE.
>> WE WANT TO THANK OUR FUNDERS,
SEVERAL NIH INSTITUTES, FAMILY
FOUNDATION FOR SUPPORTING ALL
THE WORK THAT THEY HAVE, IT'S
SOMETHING WE'RE GOING TO TALK
ABOUT TODAY AS WELL AS OUR
PARTNERS, CHAIRED BY DR
DR. JENNIFER -- FELLOW TRAVELER
ON THIS JOURNEY AND ADVANCE THE
CLINICAL RESEARCH NETWORK FOR
THE INSTITUTION.
PREMIER IS ABOUT TEAM SCIENCE
AND ALL OF THESE PEOPLE, I WISH
WE COULD TALK ABOUT EACH ONE OF
THEM TODAY, THEIR CONTRIBUTIONS
AND UNIQUENESS, AND WE DON'T
HAVE TIME, BUT THEY HAVE ALL
MESH CONTRIBUTED TO THE WORK YOE
GOING TO HEAR ABOUT AND MAKE
MIGUEL AND I FEEL HONORED AND
GRATEFUL TO BE ON THIS JOURNEY
WITH ALL OF THEM.
>> BRF BEFORE I FORGET, JOHN ANI
DON'T HAVE ANY CONFLICTS OF
INTEREST TO DECLARE.
WE WANT TO START OFF TODAY'S
TALK WITH SOME GENERAL HIGH
LEVEL TOPICS ABOUT LATINOS AND
PRIMARY CARE, AND THEN REALLY
FOCUS DOWN ON THEIR
INTERSECTION.
SO FIRST I WILL PROVIDE SOME
INFORMATION ABOUT LATINOS IN THE
U.S.
HERE AS YOU CAN SEE IN THESE TWO
FIGURES, IN 2021, LATINOS
ACCOUNTED FOR ABOUT 19% OF THE
U.S. POPULATION MAKING IT THE
LARGEST RACIAL OR ETHNIC
MINORITY GROUP.
THE CENSUS PROJECTS BY 2045, THE
LATINO POPULATION WILL CONSIST
OF 1 OUT OF EVERY 4 PEOPLE IN
THE U.S.
SO WITH THIS CONTINUING AS FAR
AS 2060.
IT'S ALSO IMPORTANT TO NOTE THAT
LATINOS ARE NOT A HOMOGENEOUS
GROUP.
I THINK MANY OF US KNOW THAT
HERE.
THE LATINO POP RANG POPULATION E
U.S. HAS NOTABLE VARIATION BY
COUNTRY OF ORIGIN, IMMIGRATION
STATUS,
[PLEASE STAND BY]
AND SO BY LUMPING INTO A BROAD
LATINO CATEGORY, IT IGNORES
SIGNIFICANT VARIATION THAT
EXISTS WITHIN THAT BROAD
CATEGORY, SO THINGS LIKE
IMMIGRATION PATTERNS, LIVED
EXPERIENCE, ACCULTURATION,
VARIATION IN SOCIAL DETERMINANTS
OF HEALTH AND MANY OTHER THINGS
THAT MAY PLAY AN IMPORTANT ROLE
IN HEALTH OUTCOMES.
SO WE'LL TALK A LITTLE BIT ABOUT
THE POTENTIAL FOR UNDERSTANDING
THIS HETEROGENEITY LATER IN THE
PRESENTATION.
IT'S ALSO WELL ESTABLISHED THAT
BROADLY, LOWER SOCIOECONOMIC
STATUS, SO FOR EXAMPLE THINGS
LIKE LOW LEVELS OF INCOME AND
EDUCATION IS ASSOCIATED WITH
GREATER MORTALITY AND MORBIDITY.
AND WHAT THE LITERATURE HAS
CITED OVER AND OVER AGAIN IS
THAT RELATIVE TO NON-LATINO
WHITES, LATINOS HAVE A LOWER
SOCIOECONOMIC STATUS PROFILE.
SO RESEARCH HAS CONSISTENTLY
DOCUMENTED THAT LATINOS HAVE
SOME OF THE LOWEST HOUSEHOLD
INCOMES, SOME OF THE LOWEST
RATES OF HEALTH INSURANCE
COVERAGE, HIGH FOOD INSECURITY,
AMONG MANY OTHER FACTORS THAT
ARE IMPORTANT THAT ARE DRIVERS
OF HEALTH.
SO SURVEY-BASED STUDIES
CONSISTENTLY DOCUMENT THAT
LATINOS TEND TO HAVE WORSE
ACCESS TO HEALTHCARE, THEY
EXPERIENCE WORSE MORBIDITY AS A
RESULT OF LACK OF CARE OR
TREATMENT AND THEY RECEIVE
POORER QUALITY OF CARE WHEN
COMPARED TO NON-LATINO WHITE
AMERICANS.
AND YET, EVEN THOUGH I SORT OF
MENTIONED ALL THOSE THINGS, EVEN
THOUGH LATINOS HAVE AN OVERALL
LOWER SOCIOECONOMIC STATUS
COMPARED TO NON-LATINO WHITES,
OVER THE PAST FEW DECADES,
RESEARCH HAS CONSISTENTLY SHOWN
THE LIFE EXPECTANCY IS HIGHER
AMONG LATINOS THAN NON-LATINO
WHITE AMERICANS.
SO THIS FINDING IS NO -- LATINO
MORTALITY PARADOX AND THERE'S
STILL A LOT TO UNPACK HERE THAT
COULD PROVIDE INSIGHTS INTO WHAT
ARE THE POSITIVE THINGS THAT
CONTRIBUTE TO HEALTH.
IT IS IMPORTANT TO NOTE THAT THE
MORE RECENT DATA SUGGESTED THAT
THE COVID-19 PANDEMIC MAY HAVE
BEEN PARTICULARLY IMPACTFUL ON
LATINO MORTALITY IN THE U.S., SO
DURING THE PANDEMIC, THE LATINOS
HAD HIGHER SPECIFIC DEATH RATES
FROM COVID, AND MORTALITY IN
GENERAL.
SO THIS HERE SHOWS WHILE LATINOS
HAVE A LIFE EXPECTANCY OF ABOUT
82 YEARS IN 2019, WHICH WAS
GREATER THAN ALL OTHER
RACE/ETHNICITY GROUPS OTHER THAN
ASIAN AMERICANS, THAT DROPPED IN
2020 AND 2021 AND WAS MORE
SIMILAR TO NON-LATINO WHITE.
SO THIS OBSERVATION LED TO SOME
RESEARCHERS DISCUSSING THE
PANDEMIC AS THE END OF THE
LATINO PARADOX.
OR MAYBE NOT.
SO THE LIFE EXPECTANCY ESTIMATES
PUBLISHED A FEW MONTHS AGO
SUGGEST THAT THE PARADOX MIGHT
NOT BE OVER.
SO THE 2022 ESTIMATES OF LIFE
EXPECTANCY WENT UP FOR LATINOS
TO ABOUT 80 YEARS, WHICH IS
CONSISTENTLY HIGHER AGAIN THAN
ALL GROUPS EXCEPT FOR ASIANS,
AND SO AGAIN, THE SET OF SERIES
OF THESE LAST SLIDES REALLY
HIGHLIGHTS THAT THERE'S A LOT TO
UNPACK HERE THAT COULD PROVIDE
INSIGHTS INTO WHAT ARE THE
POSITIVE THINGS THAT CONTRIBUTE
TO HEALTH, NOT ONLY AMONG
LATINOS BUT FOR ALL AMERICANS.
SO THIS RELATIVE MORTALITY
ADVANTAGE HAS BEEN NOTED MOST
PROMINENTLY IN MAJOR DRIVERS OF
SOCIETAL MORTALITY.
SO FOR EXAMPLE WHEN WE LOOK AT
CANCER INCIDENCE AND MORTALITY,
LATINOS CONSISTENTLY OVER TIME
HAVE HAD LOWER OVERALL CANCER
INCIDENCE AND MORTALITY COMPARED
TO NON-LATINO WHITE AMERICANS.
WHEN WE LOOK AT ANOTHER MAJOR
DRIVER OF MORTALITY AT HEART
DISEASE, LATINOS HAVE HAD A
SLIGHT DECREASE IN AGE-ADJUSTED
DEATH RATES FOR HEART DISEASE
AND CONSISTENTLY LOWER COMPARED
TO NON-LATINO WHITES.
AND THIS IS TRUE EVEN THOUGH
LATINOS DISPROPORTIONATELY HAVE
HIGHER RATES OF CARDIOVASCULAR
RISK FACTORS COMPARED TO
NON-LATINOS, SO FOR EXAMPLE
ILLUSTRATED HERE ON THE LEFT,
LATINOS ARE 20% MORE LIKELY TO
BE OBESE AND HAVE HIGHER RATES
OF DIABETES COMPARED TO
NON-LATINO WHITES.
SO JUST PUTTING EVERYTHING
TOGETHER, LATINOS ARE A DIVERSE
AND GROWING POPULATION AND THEIR
OVERALL LOWER SOCIOECONOMIC
STATUS DOES NOT ALWAYS TRANSLATE
TO WORSE OUTCOMES.
AND AS I MENTIONED EARLIER,
THERE'S A LOT TO LEARN ABOUT THE
RESILIENCE AND STRUGGLES OF
LATINO POPULATION SPACE AS THEY
ENCOUNTER THE U.S. HEALTHCARE
SYSTEM.
SO WHEN WE THINK OF THE
HEALTHCARE SYSTEM, FOR
UNDERSTANDING AND ADDRESSING
HEALTHCARE INEQUITIES MAY BE TO
MORE DIRECTLY OBSERVE HOW LATINO
POPULATIONS INTERACT WITH THE
U.S. HEALTHCARE SYSTEM.
SO I'LL PASS THIS ON TO JOHN TO
TALK A LITTLE MORE ABOUT PRIMARY
CARE IN THE U.S. AS A WINDOW TO
THAT SYSTEM.
>> AS MIGUEL SAID, WE ARE
INTERESTED IN UNDERSTANDING SOME
OF THOSE FACTORS THAT PLAY INTO
THAT COMPLEX PROCESS WHEN IT
COMES TO LATINO PATIENTS.
THIS IS DATA THAT SHOWS THAT
85 TO 90% OF FOLKS IN THE UNITED
STATES HAVE A USUAL SOURCE OF
CARE THAT DOES NOT INCLUDE THE
EMERGENCY DEPARTMENT.
BUT AMONG THOSE THAT USUAL
SOURCE OF CAROL, THERE ARE
500 MILLION PRIMARY CARE VISITS
IN THE UNITED STATES EVERY YEAR.
HALF A BILLION.
PRIMARY CARE, AS MANY OF YOU
KNOW, IS DEFINED BY THE WORLD
HEALTH ORGANIZATION AS FIRST
CONTACT MEDICAL CARE THAT'S
COMPREHENSIVE, IT'S CONTINUOUS,
AND IT'S COORDINATED.
THERE'S A RELATIVELY ROBUST
EVIDENCE BASE, ESPECIALLY FROM
THE EARLY 2000s, BARBARA
STARRFIELD AND MANY OF HER
COLLEAGUES DEMONSTRATE THAT
PRIMARY CARE RESOURCES IN A
GIVEN COMMUNITY ARE ASSOCIATED
WITH FAVORABLE OUTCOMES,
MORTALITY, MAJOR ISSUES OF
MORBIDITY, EVEN WHEN YOU ADJUST
FOR OTHER HEALTHCARE RESOURCES
AND NUMEROUS OTHER THINGS
FACTORS IN THAT COMMUNITY, AND
THERE ARE 1.6 PRIME RYE CARE PRS
PER PERSON IN THE UNITED STATES.
WE KNOW THOSE AREN'T DISTRIBUTED
EQUITABLY, BUT A SPECIFIC REASON
WE ARE INTERESTED IN PRIMARY
CARE, MIGUEL'S LAST COUPLE
SLIDES WHERE HE TALKED ABOUT THE
MAJOR DRIVERS OF HEALTH
OUTCOMES, THE MAJOR CONDITIONS,
WHEN YOU LOOK AT THE GUIDELINE
AND EVIDENCE BASE SERVICES THAT
ARE GEARED TO ADDRESS THOSE
THINGS, TO DRIVE DOWN MORTALITY,
TO DRIVE DOWN MORBIDITY AND
DRIVE UP QUALITY OF LIFE, THOSE
ARE PLACED SOLELY -- SQUARELY IN
THE LAP OF PRIMARY CARE.
THAT IS WHERE THEY'RE OFTEN
AIMED AND IT'S OUR CENTER'S
INTEREST TO BEST UNDERSTAND HOW
OUR COUNTRY'S PRIMARY CARE
SYSTEM, CLINICS AND PROVIDERS
SERVE PATIENTS AND WE'RE
INTERESTED IN -- THIS HALF A
BILLION PRIMARY CARE VISITS,
WHAT HAPPENS TO LATINO PATIENTS
IN THOSE VISITS?
BUT OUR INTEREST ACTUALLY GETS A
LITTLE MORE FOCUSED.
WE ARE SPECIFICALLY INTERESTED
IN THE CARE DELIVERED THROUGH
OUR NATION'S NETWORK OF
COMMUNITY HEALTH CENTERS.
THEY'RE OUR PRIMARY CARE CLINICS
THAT HAVE SPECIFIC MANDATES,
GUIDELINES AND FEDERALLY
SUPPORTED FUNDING STRUCTURES TO
PROVIDE CARE REGARDLESS OF
PATIENTS' ABILITY TO PAY.
THEY'RE OFTEN TARGETED AND
PLACED IN LOW INCOME
COMMUNITIES, WHILE THERE'S GREAT
VARIATION IN WHO GETS SEEN AT A
COMMUNITY HEALTH CENTER.
MY MIDDLE CLASS FAMILY GETS SEEN
IN A COMMUNITY HEALTH CENTER.
THERE'S VARIATIONS NATIONWIDE.
COMMUNITY HEALTH CENTERS CARE
FOR 10% OF THE UNITED STATES
POPULATION.
AND WE ARE SPECIFICALLY
INTERESTED IN SETTING PRIMARY
CARE DELIVERED AT COMMUNITY
HEALTH CENTERS OR CHCs
BECAUSE -- FOR TWO REASONS
REALLY.
NUMBER ONE, THE SETTING TAKES
DISPROPORTIONATE CARE OF LATINO
PATIENTS AND COMMUNITIES.
1 IN 6 LATINOS IN THE UNITED
STATES GETS THEIR CARE AT A
COMMUNITY HEALTH CENTER.
THEY'RE ALSO IN GENERAL -- THEY
DO SERVE FOLKS WHO EXPERIENCE
BARRIERS TO HEALTHCARE AND
HEALTH -- POSITIVE HEALTH
OUTCOMES, SO IF YOU'RE CONCERNED
ABOUT FOLKS EXPERIENCING THOSE
BARRIERS, IT IS A NATIONAL
SETTING TO STUDY SAYING THAT WE
HAVE TO BE CONCERNED ABOUT, AND
THAT'S WHERE WE KIND OF PUT OUR
FOCUS.
WE WORK WITH A NON-PROFIT
COOPERATIVE OF COMMUNITY HEALTH
CENTERS, 35-PLUS STATES IT'S
MORE THAN THAT NOW, SERVING
HUNDREDS OF SYSTEMS, THOUSANDS
OF CLINICS, THAT'S ABOUT
6 MILLION PLUS, I THINK IT'S
PROBABLY MORE FOR -- GREATER TO
LATINO.
THIS IS -- THESE ARE CLINICS,
EACH ONE OF THESE POINTS
REPRESENTS MULTIPLE CLINICS.
AND THERE ARE DATA PARTNERS BUT
OUR PARTNER OVERALL.
>> SO NOW THAT WE PROVIDED SOME
CONTEXT, WE WANT TO SHARE THE
OBJECTIVES OF TODAY'S
PRESENTATION.
SO FIRST WE'RE GOING TO TALK
ABOUT THAT INTERSECTION BETWEEN
PRIMARY CARE AND LATINO HEALTH.
WE'LL THEN TOUCH A LITTLE BIT ON
THEN WHAT'S THE FURTHER -- THE
ROLE OR THE INTERSECTION THEN
WITH SOCIAL DETERMINANTS OF
HEALTH.
WE'LL THEN TALK ABOUT LATINO,
HOW DO WE UNDERSTAND THAT LATINO
VARIATION.
AND LATINO SUBIMREUPS, SUBGROUPY
TALK ABOUT INTERVENTIONS GOING
ON, PRIMARY CARE, U.S.
HEALTHCARE SYSTEM IS DYNAMIC AND
CHANGING OVER TIME, SO HOW CAN
WE LEVERAGE PRIMARY CARE TO
UNDERSTAND REAL WORLD
INTERVENTIONS.
SO WE'LL START OFF BY TALKING
ABOUT THE UNIQUE AND STRATEGIC
SETTING OF PRIMARY CARE IN WHICH
TO STUDY LATINO HEALTH EQUITY.
SO TO START OFF, BECAUSE OF
PRIMARY CARE'S COMPREHENSIVENESS
AND COMPLEXITY, WE BELIEVE THAT
STUDYING THE LATINO HEALTH
EQUITY IN THE CONTEXT OF PRIMARY
CARE REQUIRES THE USE OF
MULTIPLE METHODS AND APPROACHES
TO MORE FULLY CONNECT THE SET OF
COMPREHENSIVE HEALTH OUTCOMES,
SOCIAL CHALLENGES, AND
MULTILEVEL FACTORS THAT MAY
CONTRIBUTE TO HEALTH OUTCOMES IN
LATINO POPULATIONS.
AND SO WE'VE FOUND THAT THE
NIMHD RESEARCH FRAMEWORK TO BE A
HELPFUL PARADIGM IN HOW WE THINK
ABOUT THAT MULTILEVEL WORK
NEEDED TO UNDERSTAND LATINO
HEALTH EQUITY, AND SO AS MANY OF
YOU KNOW, THIS FRAMEWORK COVERS
DIFFERENT LEVELS OF INFLUENCE
AND DOMAINS OF INFLUENCE AND WE
WANT TO HIGHLIGHT HERE THAT THE
HEALTH SYSTEM IS SPECIFICALLY
INCLUDED IN THIS FRAMEWORK AS IT
PLAYS AN IMPORTANT ROLE IN
HEALTH DISPARITIES THROUGH
PREVENTION, CARE, AND MANAGEMENT
OF DISEASES ACROSS THE LIFESPAN.
>> BUT OUR FOCUS IN PRIMARY
CARE, WE CAN TRY TO TAKE THAT
FRAMEWORK AND APPLY TO THE CARE
ENVIRONMENT.
THIS IS IMPORTANT BECAUSE AS
MANY OF YOU KNOW IF YOU'RE A
CLINICIAN OR EVEN IF YOU'RE NOT,
CARE IS A MULTI-STEP PROCESS.
IT'S NOT A SINGLE-STEP PROCESS.
SO FROM PRESENTATION, GETTING
THE DOOR, DIAGNOSIS, TREATMENT,
COMPLICATIONS, FOLLOW-UP, HOME
MANAGEMENT, PREVENTION, ALL OF
THESE THINGS, THE STRUCTURAL
FACTORS THAT CAN CONTRIBUTE TO
ANY ONE OF THOSE POINTS, THEY
MIGHT ACT DIFFERENTLY, BUT
EQUITY OR INEQUITY ISN'T A
MONOLITH IN EVERY INSTANCE.
UNDERSTANDING POINTS OF
STRENGTH, VULNERABILITY,
GOOD/BAD ARE, WE CAN BE REALLY
BEST POISED TO CREATE A
HEALTHCARE SYSTEM THAT WORKS.
THIS IS A WORKING MODEL THAT WE
USE AS WE FORMULATE MANY OF OUR
RESEARCH QUESTIONS AND WE'LL
SHOW TO YOU AGAIN.
>> AND WHILE EARLIER WE TALKED
ABOUT LATINOS IN THE U.S.
OVERALL, I DO WANT TO SPEND A
MINUTE TALKING ABOUT LATINOS AND
THEIR INTERACTION WITH COMMUNITY
HEALTH CENTERS.
SO AS JOHN MENTIONED EARLIER,
COMMUNITY HEALTH CENTERS ACROSS
THE U.S. SEE ABOUT 32 MILLION
PATIENTS A YEAR, AND OF THESE
32 MILLION, ABOUT 32%
SELF-IDENTIFY AS LATINOS OR TO
PUT IT IN OTHER WORDS AS JOHN
MENTIONED THIS, ABOUT 1 IN
6 LATINOS IN THE U.S. SEEK CARE
A COMMUNITY HEALTH CENTERS.
IN FACT IN MANY STATES, LATINOS
ARE THE MAJORITY USERS OF
COMMUNITY HEALTH CENTERS.
AND WHILE THERE HAVE BEEN SOME
STUDIES SHOWING THAT LATINOS
TRUST IN THE HEALTHCARE SYSTEM
AND CLINICIANS IN PARTICULAR ARE
NOT AS HIGH AS OTHER GROUPS,
THERE ARE SOME FINDINGS THAT
SUGGEST THAT THIS MAY NOT BE THE
CASE FOR COMMUNITY HEALTH
CENTERS.
SO CHCs ARE MISSION-DRIVEN
ORGANIZATIONS THAT ARE WIDELY
VIEWED AS PROVIDERS OF
CULTURALLY COMPETENT CARE.
SO THIS INCLUDES SERVICES LIKE
MULTILINGUAL SERVICES, THE
INCLUSION OF BILINGUAL STAFF,
AND CULTURALLY TAILORED OUTREACH
PROGRAMS.
SO BECAUSE OF THEIR SPECIALIZED
KNOWLEDGE ABOUT TREATING
UNDERSERVED POPULATIONINGS
INCLUDING LATINOS, THEY ARE
ABOUT TO PLAY AN IMPORTANT ROLE
IN ELIMINATING RACIAL AND ETHNIC
DISPARITIES IN CARE, QUALITY AND
HEALTH OUTCOMES.
>> BUT DO THEY INDEED?
SO WE LOOK AT SPECIFICS, DO WE
SEE EMPIRIC EVIDENCE THAT
COMMUNITY HEALTH CENTERS
CONTRIBUTE TO MORE POSITIVE
OUTCOMES IN LATINO PATIENTS AND
LATINO COMMUNITIES?
SO LET'S TAKE A COUPLE REAL
WORLD EXAMPLES.
WE'RE COMING -- WE'RE EMERGING
FROM, STILL IN AN AREA WHERE
VACCINATION IS A CRUCIAL TOPIC,
AND AS MANY OF US COULD ATTEST
TO, AROUND THE IDEA OF VACCINE
HESITANCY.
THIS CONCEPT WAS OFTENTIMES
PEOPLE OF COLOR, LATINO
INDIVIDUALS.
NOW THE PAPER THAT YOU SEE
BEFORE YOU JUST KIND OF
DEMONSTRATES THAT, THAT IT'S NOT
CRITIQUE IN ANY WAY OF THIS
COLLEGE AND INDEED THESE PIECES
ALL HAD VERY DIFFERENT THINGS TO
SAY ABOUT PIECES OF THAT TOPIC,
BUT THE POINT IS -- IN THE
SCIENTIFIC LITERATURE THAT
LINKED VACCINE HESITANCY TO
LATINO PEOPLES.
COMMUNITY HEALTH CENTERS, WE SAW
EVIDENCE OF A DIFFERENT STORY.
WE WANT TO TALK ABOUT THAT.
THESE TWO FIGURES ARE -- DEAL
WITH CHILDREN AND ADOLESCENTS
AND VACCINATIONS IN RELATIVELY
LARGE SAMPLES OF PATIENTS.
SO THE LEFT, THERE IS 155,000
CHILDREN, THERE'S A
SUBPOPULATION HERE OF ABOUT
20,000 CHILDREN WITH ASTHMA,
WITH VERY SIMILAR FINDINGS.
INFLUENZA VACCINATION RATES.
THE SPECIFIC ANALYSIS WAS
FOCUSING ON -- WHY THESE
CATEGORIES WERE USED, BUT LATINO
CHILDREN HAD A HIGHER RATE OF
INFLUENZA VACCINATION AND THAT
WHITE CHILDREN AND THE ABSOLUTE
RATE AREN'T SHOWN,
APPROPRIATENESS, APPROACHING ONE
PER YEAR.
ON THE RIGHT IS A ANALYSIS OF
HPV, HUMAN PAPILLOMAVIRUS,
VACCINE INITIATION, BROKEN DOWN
BY NUMEROUS LATINO SUBGROUPS AND
THAT WOULD BE PLACE OF BIRTH,
AND WHEN THAT WASN'T AVAILABLE,
PREFERRED LANGUAGE.
THIS SHOWED THAT LATINO
ADOLESCENTS HAD A MUCH HIGHER
ADJUSTED PREVALENCE OF
INITIATING VACCINE THAN WHITE
CHILDREN, REPRESENTED BY BLUE
BARS ON THE WAY ON THE FAR LEFT.
AND IN ADULTS, WE SEE SOME
SIMILAR, SOME SLIGHTLY DIFFERENT
FINDINGS OF VACCINATIONS.
ON THE LEFT, YOU SEE AN ANALYSIS
OF INFLUENZA AND PNEUMOCOCCAL
VACCINATION, PNEUMONIA VACCINE
FOR OLDER ADULTS, AND THOSE BLUE
BARS ARE SPANISH REFERRING
LATINO PATIENTS WHO IN ALL
OUTCOMES, SOME ARE -- EVER
HAVING A VACCINE, LATER
VACCINATION, COMPLETION OF TWO
VACCINES AND WHETHER THE PATIENT
WAS 50 TO 65 WITH CERTAIN
CONDITIONS THAT REQUIRED
VACCINATION OR OVER 65 -- HAD
MORE VACCINE.
YOU SEE A SEPARATION BETWEEN THE
RED AND BLUE THERE, AND THAT'S
IMPORTANT AND WE'RE GOING TO M
COME BACK TO THAT.
BUT THEN ON THE RIGHT, A IN
PROCESS, NOT PEER REVIEWED YET
ANALYSIS OF COVID VACCINATION IN
LATINO PATIENTS VERSUS
NON-HISPANIC WHITE PATIENTS THAT
SHOWS A CLEAR SIGNIFICANT
DIFFERENCE IN VACCINE PREVALENCE
IN LATINO PATIENTS.
SO HERE'S WHAT'S IMPORTANT FOR
ALL THESE FIGURES.
YOU KNOW, GENERIC VACCINE
HESITANCY NARRATIVE IN LATINO
COMMUNITIES IS INSUFFICIENT.
POSSIBLE STRENGTHS OF THE
COMMUNITY, POSSIBLE STRENGTHS OF
THE DELIVERY SYSTEM AND THE
POSSIBLE SYNERGIES BETWEEN THE
TWO, AND YOU SEE PART OF THE
CULTURAL CONVERSATION.
BUT ALSO PEOPLE SAY WE'RE
MISSING SOMETHING BY JUST
LOOKING AT COMMUNITY HEALTH
CENTERS.
I THINK WE MAY BE MISSING
SOMETHING IF WE DON'T.
HOWEVER, THE SECOND POINT HERE I
THINK AS WELL, WE'RE PRACTICALLY
CONCERNED WITH HOW TO ACHIEVE
THE EQUITABLE DELIVERY OF
HEALTHCARE SERVICES.
WE NEED TO KNOW THE SETTINGS IN
WHICH IT IS DELIVERED TO
UNDERSTAND PATTERNS OF SERVICE
UTILIZATION.
AS THAT FIGURE SHOWS ON THE
LEFT, NOT ALL LATINO PATIENTS
WERE GETTING THE SAME THING IN
THE SAME SITUATION, AND THAT
THEME, THAT NUANCE OF THE NEED
TO DISSECT THINGS BY STEP AND
WHILE SOME GROUPS CONTINUE TO
SHOW UP AS WE CONSIDER OTHER
SERVICES.
WE'LL COME BACK TO OUR WORKING
MODEL, AND IMMUNIZATION IS ONE
OF THOSE THINGS THAT YOU COULD
IMAGINE IS A SINGLE STEP IN
HEALTHCARE BUT WHAT ABOUT
SOMETHING A LITTLE MORE COMPLEX,
A CONDITION THAT REARS MORE REQE
STEPS?
ASTHMA AS A COMMON DISCUSSED
CONDITION IN LATINO COMMUNITIES,
IT'S A PROBLEM, MUCH OF
SCHOLARSHIP IN THE LAST 30 OR 40
YEARS HAS FOCUSED ON PREVALENCE
AND PREVALENCE DIFFERENCE FOR
PUERTO RICAN INDIVIDUALS HAVE A
HIGH PREVALENCE OF ASTHMA,
MEXICAN ORIGIN FOLKS HAVE MUCH
LOWER.
BUT THE EVIDENCE WOULD GENERALLY
SUGGEST THAT REGARDLESS OF
SUBGROUPS, ASTHMA OUTCOMES CAN
BE WORSE IN LATINO PATIENTS AND
COMMUNITIES, THIS IS CDC DATA
THAT DOUBLES FOR LATINO PATIENTS
COMPARED TO NON-HISPANIC WHITE
PATIENTS.
IN OUR WORK, WE'VE SEEN SLIGHTLY
DIFFERENT DYNAMICS AT PLAY.
THAT ARE I THINK WORTH EXPLOR
EXPLORING.
THIS IS BY KAUFMANN, LATINO
CHILDREN DID ACTUALLY HAVE MORE
ASTHMA EXACERBATIONS CODED AS
SUCH IN THE MEDICAL RECORD,
ASTHMA, FLARE OF THEIR SYMPTOMS.
THEY ACTUALLY WENT TO THE
CLINIC, THE COMMUNITY HEALTH 16
TE PRIMARY HEALTH CLINIC AND NOT
THE EMERGENCY DEPARTMENT.
THOSE FAMILIAR WITH THE
MANAGEMENT OF ASTHMA, MOST
ASTHMA FLARES CAN BE HANDLED IN
PRIMARY CARE, THEY HAVE THE
EXPERTISE NECESSARY TO DO THAT,
MINORITY ACTUALLY NEED TO GO TO
THE EMERGENCY DEPARTMENT.
SO WHILE THERE WAS A DISPARITY,
THEY ACTUALLY WENT TO THE BETTER
PLACE TO HAVE THAT DEALT WITH
THAT'S CHEAPER AND FASTER AND
PROBABLY MORE CONVENIENT FOR
THEM.
AND THE SAME LATINO CHILDREN IN
THIS ANALYSIS WHO WILL GO INTO
THE HEALTH CLINIC FOR THEIR
EXACERBATIONS WERE GIVEN
PREVENTIVE MEDICATIONS, MORE
APPROPRIATE IMMUNIZATIONS AND
MORE REGULAR VISITS.
AND INDEED WE -- WITH THAT
ANALYSIS HAD MANUSCRIPTS ON
ASTHMA PRESCRIBING, SO
PRESCRIBING MEDICATIONS AND
INHALERS IS A BIG PART OF ASTHMA
MANAGEMENT, NOT THE ONLY PART
BUT IT IS A BIG PART.
AND THIS ANALYSIS LOOKED AT
SPANISH -- ENGLISH --
COMPARATIVE GROUP IN THE
VERTICAL LINE.
GENERALLY, NOT COMPLETELY BUT
GENERALLY, THE PATTERN WITH
SPANISH LATINO CHILDREN HAD
HIGHER ODDS OF HAVING A
PRESCRIPTION WRITTEN FOR THEM,
WHEN IN ASTHMA -- THIS ANALYSIS
KIND OF GOES ACROSS ALL THOSE
ROWS ARE DIFFERENT MEDICATION
CLASSES OR DIFFERENT SEVERITIES
OF ASTHMA, AND ESPECIALLY
CORTICOSTEROID INHALERS, THOSE
ARE PREVENTIVE MEDICINES,
CONTROLLER MEDICINES THAT ARE
MEANT TO REDUCE THE NUMBER OF
FLARES AND EXACERBATIONS.
SO AGAIN, A COUPLE IDEAS HERE.
NUMBER ONE, YOU ACTUALLY SEE IN
A COMMUNITY HEALTH CENTER SOME
GROUPS OF LATINOS, SOME GROUPS
GETTING SEEMINGLY WHAT THEY NEED
OR SOME STEPS IN THE CARE
PROCESS BEING POSITIVE.
THERE'S -- WE STILL HEAR THAT
WITH THE PREVIOUS SLIDE WHERE
THERE'S MORE EXACERBATIONS, AND
AGAIN, THAT CONCEPT THAT
CONTEXT, SPECIFIC CONTEXT,
SPECIFIC STEP IN CARE MATTERS
AND MAKE IT A SPECIFIC WINDOW
INTO THE DRIVERS OF INEQUITY.
SO IN THIS SETTING, PROVIDERS
ARE INDEED WRITING THAT BUT
THAT'S NOT ENTIRE STORY, THERE'S
DEFICIT IN COMMUNICATION,
THERE'S PROBLEMS FILLING,
PROBLEMS USING IT, THERE'S
ENVIRONMENTAL EXPOSURE,
OVERWHELMS THE USE OF THE
MEDICATION TO BEGIN WITH, BUT
THAT GRANULARITY, THAT
SPECIFICITY IS HELPFUL FOR, I
THINK, INCLUDING THE SYSTEM
OVERALL AND SHOWS UP I THINK IN
OTHER CONDITIONS AS WELL.
>> SO OTHER CONDITIONS LIKE
DIABETES, SO WE TURN OUR
ATTENTION TO ANOTHER CHRONIC
CONDITION HIGHLY REF PLANT IN
LATINOS, WE KNOW U.S. LATINOS
DISPROPORTIONATELY FACE
DIABETES-RELATED DISPARITIES
COMPARED TO LCOMPARE NON-LATINOO
THEY'VE BEEN CONSISTENTLY LINKED
TO THESE DISPARITIES.
SO WE WANTED TO SEE IF THIS WAS
ALSO TRUE IN COMMUNITY HEALTH
CENTERS.
SO A COMMON APPROACH FOR
MONITORING DIABETES IS TO HAVE
CONSISTENT H1AC TESTING SO IN
THIS STUDY WE AIM TO CAROL HBA1C
TESTING RATES AND LEVELS AMONG
THOSE WITH ENGLISH AND SPANISH
PREFERENCE IN COMMUNITY HEALTH
CENTERS.
HERE THERE ARE ALSO TWO KEY
TAKEAWAYS.
SO FIRST, LOOKING AT THIS HERE,
SPANISH PREFERRING LATINOS HAD
HIGHER HBA1C TESTING RATES
COMPARED TO NON-LATINO WHITES AS
EVIDENCED BY THESE GREEN LINES
ON THE WHITE.
ALTERNATIVELY, SPANISH --
COMPARED TO NON-LATINO WHITES
SEEN BY THESE YELLOW LINES HERE.
THE SECOND TAKE AWAY BY THE TOP
RIGHT PORTION OF THE SLIDE,
SPANISH PREFERRING LATINOS
DISPROPORTIONATELY FACED A
HIGHER PREVALENCE OF HAVING
HBA1C ABOVE 9%, WHICH AS
RECOMMENDED BY THE AMERICAN
DIABETES ASSOCIATION SHOULD LEAD
THE PATIENT TO RECEIVE HBA1C
TESTING AT LEAST THREE TIMES PER
YEAR IN ORDER TO CONTINUOUSLY
ASSESS PROGRESS.
AND SO THE TESTING OF THOSE WITH
HBA1C GREATER THAN 9% IS
REPORTED HERE IN THE BOTTOM
RIGHT PORTION OF THE SLIDE.
SO OVERALL, ALL GROUPS ARE
RECEIVING LESS THAN THE
RECOMMENDED ADA TESTING RATE.
WITH A SLIGHT LEHIGHER LY HIGHEY
AMONG SPANISH PREFERRING LATI
LATINOS.
SO THEY ARE GETTING APPROPRIATE
CARE MORE OFTEN.
THAT DOESN'T NECESSARILY EQUAL
DIABETES CONTROL.
>> WE'VE SEEN A SIMILAR PATTERN
WITH SOME OF THE WORK WE'VE DONE
WITH HYPERTENSION.
THIS IS AN ANALYSIS OF PATIENTS
IN 23 STATES THAT LOOKED AT
DIFFERENT ASPECTS OF THE CARE
CASCADE FOR HYPERTENSION.
SO FIRST HYPERTENSION
ACKNOWLEDGMENT.
THAT WAS DEFINED AS IF THERE ARE
ELEVATED BLOOD PRESSURES TO
DIAGNOSTIC CRITERIA ON THE
CHART.
THERE'S TIERP TENSION, HIGH
BLOOD PRESSURE GET ON TO THE
ELECTRONIC HEALTH RECORD PROBLEM
LIST, OFFICIAL DOCUMENTATION.
LATINO PATIENTS IT HAPPENED MORE
OFTEN, ESPECIALLY SPANISH
PREFERRING LATINO PATIENTS, BUT
THOSE GROUPS ACTUALLY HAD THEIR
HYPERTENSION ACKNOWLEDGED ON THE
CHART.
ONCE THAT WAS ACKNOWLEDGED,
SPANISH PREFERRING LATINO
PATIENTS WERE MORE LIKELY TO
HAVE PRESCRIPTION PRESCRIBED.
THAT'S GOOD GENERALLY SPEAKING
HOWEVER THIS DID NOT NECESSARILY
EQUATE TO HIGHER RATE OF CONTROL
AND HULL GROUPS ALL GROUPS HAD E
AMOUNT OF CONTROL, ABOUT 60% OF
OVERALL BLOOD PRESSURE VALUES
AFTER TREATMENT WAS INITIATED,
SO FOR LATINO PATIENTS, SOME
GOOD CARE STEPS DID, IN FACT,
HAPPEN, BUT DIDN'T NECESSARILY
RESPOND TO MORE -- TO BETTER
OUTCOMES.
THIS IS AN IMPORTANT KIND OF
CUTOFF TO THEM.
>> IF WE TURN OUR ATTENTION TO
CANCER, COLORECTAL CANCER, WHAT
WE KNOW IS IMPROVEMENTS IN
COLORECTAL CANCER MORTALITY HAVE
NOT BEEN EQUITABLE IN THE LAST
20 YEARS.
THERE HAS BEEN SOME SURVEY-BASED
CROSS-SECTIONAL RESEARCH THAT
HAS SHOWN THAT THERE IS A
REDUCED COLORECTAL CANCER
SCREENING IN LATINOS.
WHAT'S LESSER KNOWN IS WHAT'S
GOING ON IN PRIMARY CARE.
SO WE SOUGHT OUT TO TRY TO
EMPLPROVIDE A WINDOW INTO THE
COLORECTAL SCREENING PRACTICES
IN COMMUNITY HEALTH CENTERS
AMONG LATINOS, SO WHAT WE FOUND
AS SHOWN HERE ON THE FIGURE ON
THE LEFT WAS THAT LATINO
PATIENTS -- AND THIS WAS A
SAMPLE OF OLDER PATIENTS, 50
YEARS AND OLDER.
SO LATINO PATIENTS AND IN
PARTICULAR SPANISH PREFERRING
LATINOS WERE MORE LIKELY TO
RECEIVE STOOL-BASED SCREENING
TESTS FOR COLORECTAL CANCER
SCREENING THAN NON-HISPANIC
WHITES.
BUT IF YOU LOOK AT THE FIGURE ON
THE RIGHT, THIS SHOWS THAT
LATINOS WERE LESS LIKELY TO
RECEIVE ENDOSCOPY REFERRALS THAN
NON-HISPANIC WHITE.
SO EVEN WHEN EXPERIENCING A
POSITIVE STOOL-BASED SCREENING
TEST, WHICH SHOULD TRIGGER A
FOLLOW-UP REFERRAL OR AN ORDER
FOR COLONOSCOPY, SO THIS LEADS
US TO THINK OF WAYS TO EXTEND
THIS WORK TO UNDERSTAND THIS
BREAKDOWN MORE FULLY.
SO IN PARTICULAR IT HIGHLIGHTS
POE TEPTION AREAS OF
INTERVENTIONS IN COMMUNITY
HEALTH CENTERS AND PERHAPS
BEYOND THAT COULD ENCOURAGE
REFERRALS FOR LOWER GI ENDOSCOPY
TO IMPROVE COLORECTAL CANCER
OUTCOMES.
AND IF WE TURN OUR ATTENTION TO
BREAST CANCER SCREENING, IN A
RECENT STUDY, WE CONDUCTED AN
ANALYSIS OF MAMMOGRAPHY ORDER
RATES IN LATINAS, SO BY LANGUAGE
PREFERENCE OVER A 10-YEAR
PERIOD.
SO WE EVALUATE TWO OUTCOMES.
SO THE FIRST WAS DID ELIGIBLE
PATIENTS EVER HAVE A MAMMOGRAM
ORDERED DURING THE STUDY PERIOD,
AND THOSE RESULTS ARE DISPLAYED
ON THE X AXIS.
HERE WE ALSO LOOKED AT ANNUAL
RATES, SO HOW MANY TIMES OVER
TIME OF MAMMOGRAPHY ORDERS, AND
THOSE RESULTS ARE DISPLAYED ON
THE Y AXIS.
AND SO I'LL WALK THROUGH THESE
RESULTS SINCE THERE'S A LOT
GOING ON HERE.
SO WE FOCUS ON LATINAS WHO
PREFER ENGLISH, SO THIS RED
SYMBOL HERE.
THEY ESSENTIALLY HAVE SIMILAR
ODDS OF RECEIVING AT LEAST ONE
MAMMOGRAM ORDER COMPARED TO
NON-LATINO WHITE PATIENTS.
HOWEVER, AMONG THOSE RECEIVING
MAMMOGRAM ORDERS, ENGLISH
PREFERRING LATINAS HAD LOWER
MAMMOGRAM ORDER RATES THAN
NON-LATINO WHITE WOMEN, SO ABOUT
8% LESS ORDER.
SO ENGLISH PREFERRING LATINAS
HAD SIMILAR ODDS OF GETTING AT
LEAST ONE ORDER, BUT COMPARED TO
NOP LATINO WHITE PATIENTS, THEY
HAD OVERALL LOWER RATES OF
MAMMOGRAM ORDERS OVER TIME.
SO IF WE TURN OUR ATTENTION TO
LATINOS WHO PREFER SPANISH, THEY
SEEM TO BE AN OUTLIER IN A WAY.
THIS SUGGESTS THAT SPANISH
PREFERRING LATINAS HAD HIGHER
ODDS OF EVER HAVING A MAMMOGRAM
ORDERED THAN NON-LATINO WHITES
SO MORE THAN DOUBLE, SO IF THEY
EVER HAD A HIGHER RATE OF ANNUAL
MAMMOGRAM ORDERS, A LITTLE OVER
50% MORE ORDERS OVER TIME.
SO THESE FINDINGS SUGGEST THAT
BREAST CANCER DETECTION VARIES
IN LOW INCOME LATINOS MAY NOT
STEM FROM A LACK OF ORDERS IN
PRIMARY CARE, BUT IN SUBSEQUENT
ACCESSIBILITY OF RECEIVING
ORDERED SERVICES.
SO EVEN IN CANCER SCREENING,
SOME STEPS WORK WELL FOR SOME
LATINOS AND LATINAS ACROSS THE
CONTINUUM AND SOME NOT.
BUT RIGOROUSLY EVALUATING THESE
STUDIES IN COMMUNITY HEALTH
CENTERS CAN PROVIDE A WINDOW
INTO WHAT'S WORKING IN PRIMARY
CARE SETTINGS, SOMEWHERE IT
BREAKING DOWN IN THE CANCER CARE
CONTINUUM, AND WHERE CAN WE
INTERVENE TO IMPROVE PREVENTIVE
SERVICES TO IMPROVE CANCER CARE
AND MORE BROADLY TO IMPROVE
CHRONIC CONDITION CARE AMONG
LATINOS.
SO I KNOW WE THREW A LOT OUT
THERE, WE PRESENTED A LOT, BUT I
THINK WHAT WE SEE IS THE BROAD
RANGE OF POTENTIAL INSIGHTS INTO
LATINO EQUITY AND LATINO
HEALTHCARE DELIVERY THROUGH
STUDIES IN PRIMARY CARE FROM
MULTIPLE DISEASES TO MULTIPLE
LATINO GROUPS, OVER TIME, AND
WENT NUANCE OF WHEN HEALTH
SYSTEMS WORK AND WHEN IT BREAKS
DOWN AND WHERE WE CAN INTERVENE.
SO THESE DISPARATE FINDINGS
STILL UNDERLIE THE IMPORTANCE OF
PRIMARY CARE, BUT WE HAVE A
FOUNDATION FOR NEXT STEPS AND
THAT IS THEN TO NOW THINK ABOUT
THESE CLINICS, THEY'RE PART OF
NEIGHBORHOODS, THESE PATIENTS
ARE PART OF NEIGHBORHOODS, HOW
DO WE THINK ABOUT THE SOCIAL
DETERMINANTS OF HEALTH WHEN WE
STUDY PRIMARY CARE AND LATINO
COMMUNITIES.
SO WE'LL SPEND A COUPLE MINUTES
TALKING ABOUT SOCIAL
DETERMINANTS OF HEALTH.
>> WE'RE GOING TO TALK ABOUT A
VERY SMALL SLICE OF THAT PIE
TODAY.
THAT PIE, SOCIAL DETERMINANTS IS
BIG, THOSE OF US IN HEALTH --
SPEND TIME ARGUING ABOUT WHAT
PIECE OF THAT PIE IS IMPORTANT,
HOW BEST TO STUDY THAT PIE, WHAT
THAT PIE SHOULD BE CALLED.
WE'RE NOT GOING TO DO THAT
TODAY.
WE'RE GOING TO SHOW YOU A REAL
SMALL SLICE ABOUT HOW SOME OF
THE ISSUES THAT WE CAN COME
ACROSS, TACKLE, AS WE TRY TO
UNDERSTAND HOW COMMUNITY
ENVIRONMENT, CONTEXT IMPACTS THE
PRIMARY CARE PROCESS, HOW THOSE
THINGS INTERRELATE, INTERACT IN
LATINO PATIENTS.
>> JUST SO WE'RE ALL ON THE SAME
PAGE, I DID WANT TO PUT THE
DEFINITION, AT LEAST THE ONE
THAT WE USE ABOUT WHAT IS A
SOCIAL DETERMINANT OF HEALTH AND
I'LL READ IT OUT LOUD AS WELL.
SOCIAL DETERMINANTS OF HEALTH
ARE THE CONDITIONS IN THE
ENVIRONMENTS WHERE PEOPLE ARE
BORN, LIVE, LEARN, WORK, PLAY,
WORSHIP, AND AGE THAT AFFECT A
WIDE RANGE OF HEALTH,
FUNCTIONING, AND QUALITY OF LIFE
OUTCOMES AND RISKS.
SO THERE HAVE BEEN A LOT OF
EFFORT TO FIGURE OUT HOW TO
COLLECT SOCIAL DETERMINANTS OF
HEALTH DATA.
INCLUDING A REALLY VALUABLE
SOURCE IN THE PHOENIX TOOLKIT.
SO THESE ECONOMIC ENVIRONMENTAL
AND SOCIAL INFLUENCES AT AN
INDIVIDUAL LEVEL ARE IMPORTANT.
BUT THERE STILL NEEDS TO BE A
BIGGER DISCUSSION AS HOW DO WE
INCORPORATE THIS INTO THE
CLINICAL WORKFLOW SINCE PRIMARY
CARE CLINICS ARE EXTREMELY BUSY
AND TO THINK OF ADDING EVEN
FIVE, SIX, SEVEN, 20 QUESTIONS,
IT MAY BE HARD AND THERE'S
DEFINITELY A LOT OF COMPLEXITY
THERE.
BUT IN THE MEANTIME, ARE THERE
WAYS TO LEVERAGE PRIMARY CARE
SETTINGS AND AGAIN SPECIFICALLY
COMMUNITY HEALTH SETTINGS TO
UNDERSTAND THE INFLUENCE OF
SOCIAL DETERMINANTS OF HEALTH ON
LATINO HEALTH?
>> SO WE THINK THERE IS,
SPECIFICALLY IN THE COLLECTION
OF ADDRESS DATA, COLLECTING OR
VERIFYING ADDRESSES AT EVERY
VISIT AND THE POTENTIAL OF
UNDERSTANDING THE CONNECTION
BETWEEN ENVIRONMENT NEIGHBORHOOD
AND CARE PROVIDED IS ACTUALLY
POWERFUL, BUT A COUPLE OF THINGS
HAVE COME UP WHEN YOU TRY TO DO
THAT.
NUMBER ONE, WE LIVE IN A --
SOCIETY, PEOPLE MOVE.
LOW INCOME FOLKS, MAYBE EVEN
MORE.
SO THIS SLIDE TALKS A LITTLE BIT
ABOUT OUR KIND OF EXPLORATIONS
INTO THAT IDEA.
THE GRAPH ON THE LEFT, WE'RE
LOOKING AT ALL OF THE ADDRESSES
ADDED TO THE DATASET OVER EACH
YEAR, AND WHAT YOU SEE THOSE RED
LINE BOXES ARE BASICALLY THE
ADDRESS IS NOT A FIRST ADDRESS.
SO IT ESSENTIALLY IS THE DATASET
OF ADDRESSES INCREASES, YOU GET
MORE AND MORE SECOND, THIRD AND
FOURTH ADDRESSES.
ON THE RIGHT, IT'S A TABLE THAT
SHOWS SOME BASIC ASSOCIATIONS
BETWEEN THIS IDEA OF ADDRESS
CHANGE AND CARE RECEIPTS.
SO THESE ARE CHILDREN WITH
ASTHMA, AND IT SHOWS A COUPLE
THINGS.
ON THE BOTTOM, MANY OF US MIGHT
NOT BE SURPRISED AT, THE MORE
MOVES THAT A CHILD HAD IN THEIR
CHART, MORE ADDRESS CHANGES,
EXCUSE ME, THE LESS REGULAR --
THIS IS A CHILD WITH A CHRONIC
DISEASE, ASTHMA, THE LESS
REGULAR VISITS THEY HAD, AND
THEIR INFLUENZA VACCINATION RATE
DROPPED.
AGAIN, NOT SURPRISING BUT
IMPORTANT TO KNOW.
ABOVE, WE'VE ALSO DONE
EXPLORATIONS OF THE TYPE OF
NEIGHBORHOOD OR FEATURES OF THE
NEIGHBORHOOD WHERE PEOPLE MOVE
TO, IN GENERAL WHAT WE FOUND
HEHERE, OTHER PLACES TO, WHEN A
NEIGHBORHOOD HAS MORE
DEPRIVATION, AS MEASURED IN
SEVERAL VALIDATED INDICES THAT
MEASURE ADVERSITY IN A
NEIGHBORHOOD, SOCIAL, ECONOMIC
DIVERSITY, THAT CARE IS --
UTILIZATION GOES UP, AND SO
THAT'S ANOTHER JUST A PEACE OF
THIS PICTURE.
THOSE FINDINGS, THOSE ARE PRETTY
MODEST CHANGES, AND I THINK IN
SOME WAYS DIFFICULT TO
INTERPRET, BUT I THINK A
TAKE-HOME IS THAT A NEIGHBORHOOD
AFFECT SOMEONE'S HEALTH AND
HEALTHCARE OVER TIME, AND YOUR
CARE CHANGES OVER TIME.
BOTH OF THESE THINGS ARE
LONGITUDAL PHENOMENA.
YOU DON'T GET A SENSE OF THIS IN
ONE TIME POINT, TWO TIME POINTS
OR THREE TIME POINTS.
WE TAKE A PRIMARY CARE
PERSPECTIVE BECAUSE PRIMARY CARE
VALUES CONTINUITY AND WE WANT TO
KNOW WHAT IS HAPPENING OVER TIME
TO THE FUTURE, IN THE
ENVIRONMENT, IN THE CARE SYSTEM,
AND WHILE THESE -- IN OUR
ABILITY TO GIVE UNDERSTANDING,
THIS KIND OF APPROACH IS
NECESSARY TO FULLY UNDERSTAND
THESE MULTILEVEL INFLUENCES OVER
TIME.
BUT THIS LEADS US TO A MOBILITY
ISSUE THAT WE'VE BEEN THINKING
ABOUT THAT IS DISPROPORTIONATELY
PRESENT IN SOME LOW INCOME
FAMILIES, ESPECIALLY ON THE WEST
COAST, OTHER PLACES AS WELL, AND
THAT'S OF BEING A SEASONAL
FARMWORKER.
SOME OF YOU MAY KNOW, THAT'S AN
OFFICIAL BUREAU OF LABOR
DESIGNATION FOR FOLKS IN
AGRICULTURE THAT MOVE BASED
ON -- SEASONS AND COMMUNITY
HEALTH 16 CENTERS COLLECT THAT A
ON TENS OF THOUSANDS OF
PATIENTS.
AND THIS IS AN ANALYSIS THAT
LOOKED AT THE PREVIOUS ANALYSIS
OF ASTHMA EXACERBATIONS, AND IT
SHOWED THAT LATINO CHILDREN IN
FARMWORKER FAMILIES HAVE MORE
EXACERBATIONS BUT THEY SHOULD GO
TO THE CLINIC FOR THOSE AND HAD
A LOWER RATE OF EMERGENCY
DEPARTMENT USE.
I THINK THE PROGRESS HERE IN
THESE FINDINGS, CLINICS COLLECT
MATCHING THIS KIND OF SOCIAL
DETERMINANTS DATA THAT IS
SPECIFICALLY -- INTO LATINO
FAMILIES IS POTENTIALLY VERY
POWERFUL.
ALSO THERE'S THE INKLING, KIND
OF A FOUNDATION HERE THAT A
HEALTH SYSTEM THAT MIGHT BE
ACTUALLY AWARE OF DIFFERENT
SOCIAL DETERMINANTS MIGHT
ACTUALLY HAVE A BENEFICIAL
IMPACT, SOME THINGS CAN BE
MITIGATED.
THAT'S -- WE'RE JUST GETTING
INTO THAT, WHAT THIS MIGHT MEAN
AND A LOT MORE TO COME THERE.
>> SO WE KNOW WE PRESENTED JUST
A SMALL SLIVER AS JOHN MENTIONED
AND WE THINK THERE'S A LOT OF
POTENTIAL AND WE'D BE HAPPY TO
DISCUSS THAT SOME MORE.
BUT WE DO WANT TO TURN THE TOPIC
NOW TO OPPORTUNITIES FOR
STUDYING DATA DISAGGREGATION IN
LATINO COMMUNITIES.
SO AS I MENTIONED EARLIER,
LATINOS ARE A HETEROGENEOUS
GROUP SO WHAT WE SEE IN A
MAJORITY OF RESEARCH AS I
MENTIONED EARLIER IS THAT
LATINOS ARE AGGREGATED INTO ONE
LARGE GROUP, AND IT IGNORES THE
SIGNIFICANT VARIATION THAT
EXISTS WITHIN THOSE BROAD
CATEGORIES.
THIS REALLY LIMITS OUR ABILITY
TO TARGET RESOURCES WHERE
THEY'RE NEEDED MOST,
SPECIFICALLY THOSE GROUPS THAT
ARE EXPERIENCING DISPARITIES.
SO THIS TOPIC OF DATA
DISAGGREGATION, THIS IDEA OF
BREAKING OUT DATA BY MORE
GRANULAR KEY CHARACTERISTICS IS
NOT A NEW TOPIC.
THIS GOES BACK AS FAR AT 1985
WITH THE HECKLER REPORT.
SINCE THEN, MULTIPLE
ORGANIZATIONS LIKE THE AMERICAN
MEDICAL ASSOCIATION AND POLICIES
LIKE THE AFFORDABLE CARE ACT
HAVE HIGHLIGHTED THE IMPORTANCE
OF DATA DISAGGREGATION OF
GREATER UNDERSTANDING OF HEALTH
INEQUITIES.
THIS LED US TO THINK, HOW CAN
COMMUNITY HEALTH CENTERS PROVIDE
AN OPPORTUNITY TO LOOK INTO THIS
IDEA OF DATA DISAGGREGATION TO
PRODUCE MORE NUANCED HEALTH
EQUITY RESEARCH IN LATINOS?
THE FIRST QUESTION WE ASKED IS
DO WE EVEN COLLECT THIS DATA.
SO WE ENDEAVOR TO DESCRIBE THE
EXTENT TO WHICH COUNTRY OF BIRTH
IS RECORDED IN COMMUNITY HEALTH
CENTERS, IN THEIR EHRs ACROSS
COMMUNITY HEALTH CENTERS.
>> THIS IS A BRIEF DESCRIPTION
OF THAT.
ONE POSSIBLE AXES FOR
DISAGGREGATION, BUT THIS IS WHAT
WE EXPLORED HERE.
IT SHOWED COMMUNITY HEALTH
CENTERS DID INDEED COLLECT -- IN
22 DIFFERENT STATES HOWEVER,
THAT WAS HIGHLY CLUSTERED IN
ABOUT EIGHT OR NINE STATES.
NOW THIS IS A COUPLE YEARS OLD,
THIS GRAPH IS KIND OF FILLED --
FILLED UP MORE WITH DATA BUT
THAT WAS STILL GETTING COLLECTED
OVER 782 CLINICS SERVING
782 PATIENTS TOTAL, THERE'S
ABOUT -- OVER THAT DENOMINATOR
IN CLINICS ABOUT THAT SIZE,
984 PATIENTS.
WHAT ABOUT WHEN THIS DATA IS
COLLECTED, IS IT ASSOCIATED WITH
ANYTHING MEANINGFUL CLINICALLY?
WE LOOKED AT THE PREVALENCE OF
CARDIOVASCULAR DISEASE, HEART
DISEASE, AND ITS RISK FACTORS,
HIGH CHOLESTEROL, HIGH BLOOD
PRESSURE, DIABETES, OBESITY, IN
GROUPS BY NATIVITY.
FIRST WHAT WE DID HERE IS, WE
LOOKED AT IT BY BIG GROUPS.
NON-U.S. BORN LATINO OR LATINOS
WITHOUT PLACE OF BIRTH COLLECTED
IN THE DATASET, AND YOU CAN SEE
THESE THINGS ARE -- THE
DIAGNOSIS PREVALENCE IS
CLUSTERED, REALLY PRETTY CLOSE
TOGETHER.
WHEN WE TOOK THE FOREIGN BOARD
LATINO GROUP AND SPLIT THEM OUT
BY THE COUNTRIES THAT WERE MOST
PREVALENT, ALL OF A SUDDEN --
SOME NOT SO MUCH, 10 TO 15,
ALMOST 20% DIFFERENCES.
HYPERLIP TELIPIDEMIA, 28% FOR MN
INDIVIDUALS.
SO YOU SEE ALL OF A SUDDEN THIS
DISAGGREGATION STARTS TO BECOME
A LITTLE MORE CLINICALLY
RELEVANT.
LOOKED AT STATIN ELIGIBILITY IN
PRESCRIBING, SO A STATIN IS A
MEDICATION USED TO LOWER
CHOLESTEROL AND LOWER HEART
DISEASE RISK.
THIS TABLE JUST LOOKED AT THE
CRITERIA FOR PRESCRIBING THESE
HAVE SEVERAL DIFFERENT POSSIBLE
ELEMENTS THAT CAN QUALIFY
SOMEONE FOR ELIGIBILITY.
AND THIS ANALYSIS, IT JUST BROKE
OUT THE FOREIGN LATINO PATIENTS
BY COUNTRY OF BIRTH TO SEE WHICH
CHARACTERISTIC OF THE CRITERIA
WAS RESPONSIBLE FOR THEM BEING
ELIGIBLE.
AND YOU SEE DIFFERENCES, YOU SEE
DIFFERENCES.
SO FOR INSTANCE, ASCVD HEART
DISEASE, PRESENCE OF A HEART
DISEASE DIAGNOSIS, 6.5% OF CUBAN
BORN INDIVIDUALS, THAT WAS THEIR
REASON FOR BEING E ELIGIBLE FORA
STATIN, WHEREAS IT WAS ABOUT
HALF, 3.7% FOR MEXICANS.
DIABETES, 41% OF CUBANS, WHERE
74% OF MEXICAN INDIVIDUALS DID.
AND SO THE IDEA HERE, THIS
DISAGGREGATED DATA IS BECOMING
MORE AND MORE RELEVANT TO
FACTORS THAT ARE CLINICALLY
RELEVANT FOR THE POINT OF CARE
FOR DECISION-MAKING.
BUT AS WE KIND OF MENTIONED,
THIS IS 180,000 PEOPLE IN A
DENOMINATOR OF A MILLION
LATINOS, SO IT'S PROPORTIONATELY
A MINORITY, AND THAT'S A
PROBLEM.
AND MIGUEL IS GOING TO TALK A
LITTLE BIT ABOUT HOW WE'VE
APPROACHED THAT TO A DEGREE.
>> SO A BIG LIMITATION OF THOSE
STUDIES IS OF THE 1 MILLION
LATINO PATIENTS IN THIS
COMMUNITY NETWORK, COUNTRY OF
BIRTH WAS ONLY COLLECTED IN
ABOUT 14% OF THOSE PATIENTS.
SO THERE ARE A LOT OF LATINO
PATIENTS THAT ARE GOING TO BE
LEFT OUT OF ANY FURTHER
ANALYSES, AND SO ONE OF THE
GOALS OF OUR CENTER IS TO
IMPROVE APPROACHES TO STUDYING
LATINO DISPARITIES BY DEVELOPING
AND VALIDATING NOVEL METHODS TO
DO LATINO SUBGROUP DATA
DISAGGREGATION AGAIN FOR THE
PURPOSES OF PRODUCING MORE
NUANCED HEALTH EQUITY RESEARCH
AMONG ALL LATINOS.
SO WHAT WE -- AL ILLUSTRATED IN
THE TOP RIGHT IS TO BREAK UP
THIS LARGE LATINO CATEGORY TO
MORE GRANULAR IS UP GROUPS TO
REALLY FULLY APPRECIATE THE
HETEROGENEITY OF LATINO
POPULATIONS BY UTILIZING ALL
LATINO DATA AND NOT JUST IGNORE
OR THROW AWAY THOUSANDS OF ROWS
OF VALUABLE INFORMATION THAT
INCLUDES LATINOS FROM ACROSS THE
U.S.
AT THIS MOMENT MOMENT BEFORE WE
GO INTO SPECIFICS WHAT WE DID IN
THIS WORK, I DO WANT TO
HIGHLIGHT THAT OUR PROPOSED
METHODOLOGY IS NOT INTENDED AT
THE PATIENT LEVEL TO PROVIDE
CARE, TO AN INDIVIDUAL APART
FROM THEIR OWN SELF
IDENTIFICATION.
SO IN THE ABSENCE OF WIDESPREAD
SELF-REPORTED DATA LINKED TO
RICH OBJECTIVE HEALTHCARE DATA,
THIS APPROACH IF IT WORKS REALLY
STARTS TO IDENTIFY IN WHAT
CIRCUMSTANCES AND IN WHAT HEALTH
CONDITIONS COUNTRY OF BIRTH DATA
MIGHT BE BENEFICIAL TO COLLECT
IN THE FEWER TOUR.
FUTURE.
SO TO START OFF OUR THINKING, WE
THOUGHT WELL, COULD A MACHINE
LEARNING APPROACH IN THIS
SETTING BE USEFUL?
SO IN THIS STUDY, WHICH IS A
SMALL PILOT STUDY OF ASTHMA
CHILDREN, SO ABOUT 20,000 LATINO
CHILDREN WITH ASTHMA, WE USE
MACHINE LEARNING METHODS WITH
UTILIZING SURNAME, CLINICAL AND
NEIGHBORHOOD LABEL DATA.
AND -- SPECIFIC COUNTRY OF
BIRTH, LIMITED TO MEXICO,
GUATEMALA AND CUBA DUE TO THE
SAMPLE SIZE RESTRICTION.
SO ALL MODELS SHOW OUTSTANDING
DISCRIMINATION BETWEEN
FOREIGN-BORN STATUS AND SPECIFIC
COUNTRY OF BIRTH.
>> ABOUT 20,000 CHILDREN, WE
WANTED TO SEE IF WE WERE ABLE TO
EXTEND TH THESE PREDICTIONS TO
ADULTS, WE UTILIZED 1.5 MILLION
LATINO ADULT PATIENTS IN THE C
NETWORK, SIMILARLY AS TO THE
PREVIOUS PILOT STUDY, COUNTRY OF
BIRTH WAS RECORDED IN ABOUT 12%
OF LATINO ADULT PATIENTS.
SO SIMILAR TO THE PREVIOUS STUDY
WE DID DEVELOP A MACHINE
LEARNING ALGORITHM TO REFER
FOREIGN BORN STATUS AND SPECIFIC
COUNTRY OF BIRTH USING SURNAME
AND NEIGHBORHOOD COMPOSITION AND
WE SAW OUTSTANDING TO EXCELLENT
PREDICTION OF FOREIGN BORN
STATUS AND SPECIFIC COUNTRIES
AMONG LATINOS.
AND AGAIN BECAUSE OUR GOAL --
OUR OVERALL GOAL FOR THIS WORK
IS TO USE THOSE PREDICTIONS IN
SUBSEQUENT DISPARITIES RESEARCH,
WE STARTED OUT WORKING ON
UTILITY ON THAT END.
SO AS A TEST CASE, AND THIS IS
ALSO A WORK IN PROGRESS, WE USE
THOSE MODEL -- OF LATINO
SUBGROUPS TO EVALUATE COLORECTAL
CANCER SCREENING -- BY FOREIGN
BORN STATUS, SO COMPARING
LATINOS FOREIGN-BORN VERSUS U.S.
BORN.
SO IN OUR CASE EXAMPLE, USING
THE ACTUAL KNOWN FOREIGN-BORN
STATUS THAT'S COLLECTED AT THE
CLINIC, WE OBSERVED THAT U.S.
U.S.-BORN LATINOS HAD LOWER ODDS
OF SCREENING, ABOUT HALF AS
MUCH, AND THAT'S DENOTED HERE ON
THAT BLUE LINE.
AND SO THE -- IS 0.5.
SO THAT'S USING THE KNOWN
INFORMATION.
SO WHEN WE REPLACE THE KNOWN
STATUS WITH THE PREDICTED --
FROM THESE MACHINE LEARNING
MODELS, WE SEE AN ASSOCIATION
HERE IN GREEN THAT IS IN A
SIMILAR DIRECTION BUT IS
SLIGHTLY BIASED.
THEN WHEN WE EXTEND THESE
PREDICTIONS TO THE FULL SAMPLE,
SO EVEN THOSE THAT DID NOT HAVE
COUNTRY OF BIRTH, WE ACTUALLY
SEE AN ASSOCIATION, AGAIN, IN A
SIMILAR DIRECTION BUT, AGAIN,
SLIGHTLY BIASED.
SO THIS IS A SIMPLE USE CASE AND
WE'RE ACTIVELY WORKING ON
METHODS TO ADDRESS THIS BIAS AND
TO REALLY FULLY UNDERSTAND HOW
TO INCORPORATE -- GENERALLY IN
THE WORK WE DO.
SO AT PRESENT, THIS APPROACH IS
NOT SUITABLE FOR CLINICAL AND
HEALTHCARE USE, USE IN POLICY
DESIXES, AND ALTHOUGH PREDICTION
ALGORITHMS ARE IMPERFECT AND
CANNOT REPLACE SELF-REPORTED --
IN COUNTRY OF ORIGIN, THIS
HOPEFULLY PROVIDES A STARTING
POINT ABOUT WHEN AND WHERE THIS
DATA SHOULD BE COLLECTED,
ESPECIALLY WHEN WE THINK ABOUT
JUST THE SETTING OF BUSY PRIMARY
CARE CLINICS.
SO I WANT TO END, WE ONLY HAVE A
FEW MINUTE LEFT SO WE WANT TO
TAKE THIS OPPORTUNITY TO LOOK AT
REAL WORLD INTERVENTIONS IN
HEALTH EQUITY AND PRIMARY CARE
AMONG LATINOS.
>> SO WHILE THIS IS
OBSERVATIONAL, IT DOESN'T
MEAN -- EVALUATE INTERVENTIONS.
THIS WORK ISN'T ACTUAL WILL
FUNDAMENTALLY OURS, THIS IS SOME
OF OUR TEAM MEMBERS ON THIS
TEAM, SO SHOUT OUT TO OUR
COLLEAGUES, THE WONDERFUL FOLKS
AT UCSF, DR. LAURA GOTTLIEB,
THEY HAVE FOR SEVEN YEARS DONE
-- IN COMMUNITY HEALTH CENTERS
NATIONWIDE, SO LITERALLY ONE OF
THE PAPER QUESTIONNAIRES ABOUT
SOCIAL CONTEXT, SOCIAL
ADVERSITY, TO TRY TO CONNECT
PATIENTS WITH RESOURCES AND
INTERVENE.
THIS IS THE RESULT OF AN
INCREDIBLE AMOUNT OF INFORMATION
AVAILABLE, CONNECTED, CONNECT
TODAY CLINICAL INFORMATION.
BUT THERE ARE -- THERE'S A LOT
TO BE STUDIED, FOR EXAMPLE, IN
THIS FOLLOW-UP ANALYSIS THAT
THEY DID SEVERAL YEARS AFTER THE
INITIATION OF SCREENING IS
LOOKING AT WHO WAS SCREENED.
FOR INSTANCE, BLACK LATINOS AND
BLACK NON-HISPANIC PATIENTS WERE
TWICE AS LAKELY T LIKELY TO BE ,
AND LATINO PATIENT, ONLY 20%
LESS LIKELY TO BE SCREENED THAN
NON-HISPANIC WHITE PATIENTS.
SO THE FULL UNDERSTANDING OF HOW
THESE ONGOING EVOLVING
INNOVATIONS IN CARE, PRIMARY
CARE IS STILL LACKING ABOUT HOW
WE CAN BEST USE THINGS THAT ARE
ONGOING TO UNDERSTAND HOW BEST
TO SERVE LATINO PATIENTS.
IT'S GOING TO LOOK AT THIS
LATINO PATIENTS AND CONNECTIONS
TO CANCER CARE, BUT THE POINT OF
THIS OPPORTUNITY TO STUDY IN
REALTIME INNOVATIONS IN HOW IT
AFFECTS LATINO PATIENTS.
>> WE'LL TALK ABOUT ANOTHER
INNOVATION I THINK MANY OF YOU
ARE FAMILIAR WITH, IT'S TELEHEL.
TELEELT.
PRIOR TO THE COVID-19 PANDEMIC,
MOST PRIMARY CARE SERVICES,
ESPECIALLY CHRONIC CARE
MANAGEMENT, WAS DELIVERED DURING
IN-PERSON VISITS.
SO RESTRICTIONS TO KEEP PATIENTS
SAFE AND REDUCE THE SPREAD OF
THE VIRUS SHIFTED.
MOST OF THAT IN-PERSON VISITS TO
TELEHEALTH.
AND CHC, THEY ROSE TO THIS
CHALLENGE.
SO THIS FIGURE HERE SHOWS THE
TOTAL NUMBER OF TELEHEALTH
ENCOUNTERS IN THE MILLIONS THAT
COMMUNITY HEALTH CENTERS
PROVIDED EACH YEAR IN THE OCHA
NETWORK.
THERE WAS VERY LITTLE TELEHEALTH
UTILIZATION AND IT STEADILY
INCREASED OVER 2020 TO 2022
DURING THE THICK OF THE
PANDEMIC.
THERE WERE SEVERAL QUESTIONS
ABOUT WHETHER CURRENT TELEHEALTH
USE HAS DECREASED AS THE
EMERGENCY FOR COVID-19 HAS
EXPIRED AND WHETHER THESE TRENDS
DIFFER BY ETHNICITY IN LANGUAGE
GROUPS WHO MAY EXPERIENCE
DIFFERENT BARRIERS TO
TELEHEALTH.
SO WHAT WE CAN SEE HERE FROM
WORK THAT IS EXPLORATORY AND IN
PROGRESS, WE SEE UTILIZATION AT
LEAST AT COMMUNITY HEALTH
CENTERS, THEY'RE NOT GOING DOWN.
SO IN 2023, IT INCREASED TO
ABOUT 1.75 MILLION ENCOUNTERS
AND PROJECTIONS SHOW BASED OFF
OF 2024 DATA THAT THIS COULD
ACTUALLY HIT 2 MILLION
ENCOUNTERS THIS YEAR.
SO WE ALSO OBSERVED THAT THE
PROPORTION OF TELEHEALTH VISITS,
SO TELEVISITS DIVIDED BY PLUS
IN-PERSON VISITS SO THE
PROPORTION OF TELEVISIT AMONG
LATINO ENGLISH PREFERRING
PATIENTS ARE HERE IN BLUE, IT
INCREASED FROM 16.7% IN 2020 TO
ABOUT 29% IN 2022 AND THEN IT
HAS DECREASED SLIGHTLY IN MORE
RECENT DATA IN 2024.
NON-HISPANIC WHITE PATIENTS SAW
SIMILAR TREND TO NON-ENGLISH --
ACTUALLY SAW SIMILAR INCREASE
THROUGHOUT THE PANDEMIC BUT MOST
RECENT PROPORTION OF
TELEMEDICINE VISITS ARE LOWER
COMPARED TO OTHER GROUPS, SO THE
KEY TAKEAWAY FROM THIS INITIAL
WORK IS THAT AT LEAST IN THE
U.S., COMMUNITY HEALTH CENTERS
CONTINUE TO DELIVER A LARGE
VOLUME OF TELEHEALTHCARE, UNDER
UNDERSCORING THEIR ROLE IN SER
SERVING THOSE POPULATIONS.
-- FUTURE WORK SHOULD STUDY HOW
THAT MAY IMPACT THE TYPE OF CARE
RECEIVED AND ITS IMPACT IF ANY
ON THEIR HEALTH.
>SO WANT TO JUST SHARE SOME
CONCLUDING THOUGHTS.
COMMUNITY HEALTH CENTERS CARE
FOR ABOUT 1 IS IN 6 LATINOS IN
THE U.S. AND THEY DO THIS
CONTINUOUSLY OVER TIME.
SO THEY SEE PATIENTS,
SPECIFICALLY LATINO PATIENTS OF
ALL BACKGROUNDS FROM LOW AND
HIGH INCOMES, TO SEASONAL MY
GRANT WORKERS TO UNINSURED, SO
COMMUNITY HEALTH CENTERS AND THE
CARE THEY PROVIDE ALLOWS US TO
PUT ANOTHER PIECE IN THE PUZZLE
IN REALLY UNDERSTANDING LATINO
HEALTH IN THE U.S.
>> IN SECOND -- FINDINGS THAT
UNDERSTANDING HEALTHCARE
HEALTHCARE EQUITY AND INEQUITY
IN LATINO PATIENTS THAT DEMANDS
PRIMARY CARE -- ESPECIALLY
COMMUNITY HEALTH CENTERS,
BECAUSE THERE ARE TRENDS,
NUANCES, PATTERNS THAT MORE
SPECIFICALLY PAIFNT THE
DISPAPAINT THEDISPARITIES PICTUO
ABOUT COMMUNITIES AND CLINICS,
AGAIN, EQUITY OR INEQUITY IS IN
THIS SORT OF VAGUE GENERAL
MONOLITH, BUT SPECIFIC FORCES
AND FACTORS THAT ACT MORE OR
LESS AT SPECIFIC POINTS.
AND AS WE TRY AND CREATE A
SYSTEM THAT SERVES PATIENTS
BETTER, METHODS AND EVALUATION
THAT HAS THIS AS THE MINDSET, WE
THINK IS NECESSARY.
>> THE THIRD BULLET THERE IS
GENERALLY TRYING TO CAPTURE THAT
JUST BECAUSE OF THE RELATIONSHIP
WITH COMMUNITY HEALTH CENTERS
AND LATINO PATIENTS, THERE IS
THIS CRUCIAL DATA THAT IS
SELECTED IN SOCIAL DETERMINANTS
OF HEALTH DATA, DATA THAT
INFORMS DATA DISAGGREGATION, SO
REALLY THIS IS CRUCIAL IN
UNDERSTANDING THE HEALTH OF
LATINO COMMUNITIES, AND THIS IS
BEING COLLECTED AND THERE'S
STILL A LOT TO THINK ABOUT HOW
DO WE EVEN FURTHER DATA
COLLECTION TO TRY TO GET AT MANY
MO ARE ESSENTMORE SOCIAL DETERM-
HOPEFULLY THESE INITIAL
EXPLORATIONS SHOW THERE'S
PROMISE HERE.
>> LASTLY, PRIMARY CARE IS
EVOLVING, RAPIDLY CHANGING, IT'S
NOT WAITING FOR THE RFP --
METHODS THAT OBSERVE CHANGES ON
THE GROUND, YOU KNOW, ON THE
GROUND INNOVATIONS IN REALTIME
AS MUCH AS POSSIBLE AND IT CAN
EXAMINE HOW THESE LARGE CHANGES
AFFECT GROUPS -- LATINO
COMMUNITIES.
THAT WILL CONTINUE TO BE OUR
PRIORITY AND HOPE IT'S A BROADER
PRIORITY AS WELL.
>> AND BEFORE WE END FOR THE Q &
A PART OF THIS TALK, WE DO WANT
TO SHARE THAT OUR CENTER HOSTS,
LATINO HEALTH SERVICES RESEARCH
SEMINAR SERIES, NATIONAL THOUGHT
LEADERS DELIVER VIRTUAL
PRESENTATIONS WITH A QUESTION
AND ANSWER SESSION ON LATEST
FINDINGS, CURRENT CHALLENGES,
FUTURE DIRECTIONS FOR THE FIELD.
SO IT HAPPENS EVERY TWO MONTHS.
IF YOU'RE INTERESTED, DO LET US
KNOW, SEND US AN EMAIL, WE'D BE
HAPPY TO ADD YOU TO THE
LISTSERV.
SO WITH THAT SAID, JUST THANK
YOU SO MUCH FOR YOUR ATTENTION,
AND HAPPY TO START THE
DISCUSSION.
>> THANK YOU.
>> THANK YOU SO MUCH, MIGUEL AND
JOHN, THAT WAS GREAT, AND YOU
PULLED OFF A DUO HERE LIKE I
HAVE NOT SEEN, REALLY, EVER.
SO IT'S CLEAR THE TWO OF YOU
CONNECT WELL AND WORK WELL WITH
EACH OTHER, AND REALLY ARE
SYNERGISTIC IN YOUR APPROACHES.
I'M JUST GOING TO ASK A COUPLE
OF GLOBAL QUESTIONS BECAUSE
AUDIENCE QUESTIONS ARE ROLLING
IN.
IN YOUR SORT OF PRESENTATION
ABOUT THE LATINO PARADOX, YOU
DIDN'T REALLY QUESTION ITS
EXISTENCE, WHICH SOME PEOPLE
STILL HAVE OR PEOPLE HAVE
POSTULATED, OH, IT'S GOING TO GO
AWAY WITH THE -- AS MORE PEOPLE
ARE MORE ACU ACCULTURATED AND
U.S.-BORN, AND YET WE HAVE YET
TO SEE THAT HAPPEN.
YOU DID SHOW THAT THOSE WHO
PREFER SPANISH, YOU DIDN'T HAVE
THIS DISAGGREGATION FOR WHICH I
DO HAVE A QUESTION ON, BUT I
DIDN'T HEAR MUCH MENTION ABOUT
SOCIOECONOMIC STATUS.
SO GENERALLY PEOPLE THINK YOU'RE
GOING TO FQAC OR COMMUNITY
HEALTH CLINIC, YOU'RE NOT OF THE
HIGHER SOCIOECONOMIC STATUS OR
YOU IMPLY THAT THAT'S NOT ALWAYS
THE CASE.
DO YOU HAVE A SENSE OF THIS
SAMPLE OF A -- MAJORITY MEDICAID
COVERED, ARE THEY UNINSURED, ARE
THEY PRIVATE INSURANCE?
GIVE US A SENSE BECAUSE CLEARLY
ROBUST STUDIES, TREMENDOUS DATA,
ANAND A REALLY IMPORTANT GROUP O
STUDY.
SO JUST WONDER WHETHER YOU HAD
THAT AND HOW YOU THINK THAT
INFLUENCES SOME OF THOSE
FINDINGS.
>> SO EVERY ANALYSIS WE DO DOES
INCORPORATE SORT OF THE
INFORMATION ON HOUSEHOLD INCOME.
WE DO HAVE ACCESS TO THAT.
WE HAVE ACCESS TO INSURANCE,
CONTINUOUSLY OVER TIME.
WE ALSO ADJUST FOR CERTAIN
COMORBIDITIES.
WE DON'T HAVE THINGS LIKE
EDUCATION, BUT BASICALLY INCOME,
INSURANCE, IS DEFINITELY
ADJUSTED FOR.
NOW THAT DOESN'T NECESSARILY
TALK ABOUT HIGH VERSUS LOW
INCOME, BUT GENERALLY SPEAKING,
OUR WORK DOES ACCOUNT FOR THAT.
>> YEAH, ALSO TO YOUR POINT, IT
IS -- THERE'S VARIATION IN THIS
SAMPLE.
IT IS A HEAVIER SLICE OF A LOWER
INCOME PIECE.
SO FOR INSTANCE, WHEN WE WILL
BREAK FOLKS UP INTO, YOU KNOW,
LEVEL 100, 200, 300, ONCE YOU
GET ABOVE 300, THE NUMBERS FALL
OFF DRAMATICALLY.
SO YOU DEFINITELY -- WHICH
AFFECTS OUR ABILITY TO REALLY --
YOU CAN'T REALLY LOOK AT THE
ENTIRE RANGE OF INCOME LEVELS SO
THAT'S A FACTOR THAT IS A
LIMITATION IN A LOT OF OUR WORK.
OBVIOUSLY WE THINK IT'S
IMPORTANT TO FOCUS ON WHAT'S
LARGELY A LOW INCOME SYSTEM, WE
DON'T GET THAT ENTIRE RANGE AND
CAN'T EVALUATE THAT SPECIFIC
DYNAMIC.
>> AND SO JUST TO GIVE YOU
SPECIFIC NUMBERS, SO EACH STUDY
HAS DIFFERENT
INCLUSION/EXCLUSION CRITERIA, SO
CHILDREN IS DIFFERENT INSURANCE
RATES, BUT GENERALLY, ESPECIALLY
WHEN WE'RE LOOKING AT LATINOS,
IF WE'RE LOOKING AT UNINSURED
RATES, WE KNOW COMMUNITY HEALTH
CENTERS DO SERVE PEOPLE WHO ARE
UNDERINSURED AND UNINSURED, AND
SO I THINK THAT'S SOMEWHERE IN
THE 10 TO 20% RANGE.
PUBLIC INSURANCE, PROBABLY IN
THE 60% RANGE AND THEN PRIVATE
IN SORT OF THE LAST WHATEVER
THAT IS, LIKE 10, 20% AS WELL.
SO THE MAJORITY IS PUBLIC
INSURANCE.
AND BECAUSE THERE'S A LOT OF
PEOPLE WHO ARE SEEN REGARDLESS
OF THEIR INSURANCE STATUS, WE DO
SEE SOME -- A SIZABLE, 10 TO 20%
OF UNINSURED PATIENTS.
>> ALL RIGHT.
THANK YOU.
AND IT IS 20% OF LATINOS BETWEEN
18 AND 64 WHO ARE UNINSURED
ACROSS THE COUNTRY, SO THAT
WOULD SEEM APPROPRIATE.
IN OTHER WORK THAT I'VE BEEN
INVOLVED WITH, WE'VE SEEN A
TREND THAT IF YOU BECOME MORE
ACCULTURATED BUT REMAIN OF LOWER
SOCIOECONOMIC STATUS, THAT'S
WHERE YOU HAVE THE WORST HEALTH
OUTCOMES.
AND THE LESS ACU ACCULTURATED WO
MOVE UP THE SOCIAL ECONOMIC
LADDER ACTUALLY DO PRETTY WELL.
SO THERE IS THIS DYNAMIC THAT IS
NOT FULLY CAPTURED BY LANGUAGE
PREFERENCE, BUT I THINK WE NEED
TO STRATIFY AND LOOK AT SOME
MEASURE OF SOASH Y SOCIOECONOMIA
TIS, ZOTSTATUS.DIVIDING UP BY WE
BORN IN THE U.S. OR NOT IS
GREAT, AND THEN THE COUNTRY
WHERE YOU WERE BORN, HOWEVER,
70% OF LATINOS ARE BORN IN THE
U.S.
SO THE HERITAGE QUESTION IS THE
ONE THAT I WOULD BE CURIOUS
ABOUT, SO WHAT'S GOING ON WITH
THE SECOND -- AND IS THAT IN THE
DATA, IN THE DATA INFRASTRUCTURE
THAT YOU HAVE -- THAT YOU WORK
WITH?
>> THAT IS A GREAT QUESTION.
AND UNFORTUNATELY, WE ARE LIMIT
TODAY WHAT DATA IS COLLECTED IN
COMMUNITY HEALTH CENTERS, SO
COUNTRY OF BIRTH IS A DISCRETE
FIELD EMBEDDED IN THE EHR.
SO THAT IS INCLUDED, SO THAT'S
TYPICALLY WHAT WE USE, AND WE
UNDERSTAND THAT THE BACKGROUND
THAT IS IMPORTANT -- HERITAGE IS
IMPORTANT.
UNFORTUNATELY WE CAN'T DO THAT
NOW IN EHR BASED APPROACHES, BUT
THERE IS A THOUGHT THAT IF
MACHINE LEARNING APPROACHES --
AT LEAST WITH EHRs, IF THIS IS
SUITABLE, WE CAN FIGURE OUT HOW
TO DEBIAS THIS A BIT, THERE MAY
BE OPPORTUNITIES TO EXTEND THAT
WORK IN SURVEY-BASED RESEARCH.
SO I THINK OF THE SEOUL STUDY
WHERE THEY DO COLLECT SOME OF
THIS INFORMATION, PARTNERING,
THICKINTHINKING OF CREATIVE WAYS
LEVERAGING CURRENT LATINO
COHORTS TO SEE AND COMPARE IF
IT'S A SUITABLE APPROACH IN
OTHER SETTINGS.
>> IT IS A CRUCIAL ISSUE, THIS
IS KIND OF THE LOW HANGING FRUIT
FOR LACK OF A BETTER TERM
BECAUSE WE HAVE THAT DATA, IT --
FEELS LIKE A MAJOR THING WE'RE
MISSING, EXPLORED USING -- SOME
OF THE WORK WE'VE WORKED ON HAS
BEEN LINKS OR LINKING MOMS AND
KIDS, LINKING THEIR RECORDS, AND
SO THAT YOU HAVE MOM'S PLACE OF
BIRTH, SO YOU BUILD UP A LITTLE
BIT OF FIRST GENERATION FOLKS,
YOU CAN HAVE THAT BUT YET STILL,
IT'S -- THAT STILL MAY NOT GET
EVERYTHING YOU WON'T, PROBABLY
LOW, SO THAT'S KIND OF THAT NEXT
PIECE THAT YOU HAVE TO FIND WAYS
TO LINK DATA, TO UNDERSTAND THE
HERITAGE PIECE, WHICH IS JUST --
YEAH, IT'S CRUCIAL TO PUT ALL
THESE QUESTIONS.
>> THANK YOU FOR THAT.
AS YOU PROBABLY ARE AWARE, ON
THE DIRECTIVE 15 WAS REVISED IN
MARCH, AND IT NOW -- ONE OF THE
REQUIREMENTS, IT'S NOT JUST TO
COLLECT "AMERI IDENTITY, BIG CA,
BUT ALSO THE SECOND LEVEL THAT I
ASKED ABOUT, MOSTLY GEOGRAPHIC
ORIGIN OF HERITAGE.
OR HERITAGE.
FOR ALL RACIAL AND ETHNIC
GROUPS.
SO FOR WHITES, BLACKS, LATINOS
AND ALL THE OTHER RACE AND
ETHNIC GROUPS AS WELL, INCLUDING
A NEW CATEGORY OF MIDDLE EASTERN
AND NORTH AFRICAN.
SO LET ME -- MAYBE WE CAN CHANGE
THE SYSTEM.
WE CAN TURN TO THE QUESTIONS.
I HAVE ONE HERE AND I'LL READ
IT.
IN THE CASE OF THE HIGHER
MAMMOGRAM SCREENING RATIOS IN
SPANISH SPEAKING LATINAS VERSUS
ENGLISH SPEAKING LAHTI
NEAS/NON-HISPANIC WOMEN, COULD
THE CAUSE OF THE INCREASE IN
SCREENINGS DUAL TO CULTURAL
FACTORS?
I'M A SECOND-YEAR MEDICAL
STUDENT AND I VOLUNTEER AT A
FREE CLINIC IN NEW ORLEANS.
I NOTICED THAT LATINA WOMEN TEND
TO REQUEST PAP SMEARS YEARLY,
WHICH GOES AGAINST THE STANDARD
TIME FRAMES USED IN
GYNECOLOGICAL GUIDELINES.
I WAS JUST WONDERING IF CULTURAL
BACKGROUND COULD BE A REASON FOR
THIS OUTLIER IN SCREENINGS.
>> IT'S A GREAT QUESTION.
I THINK THE GENERAL ANSWER IS
YES.
I THINK THAT'S POSSIBLE.
YOU KNOW, THOSE FINDINGS THAT WE
FIRST PRESENTED AT A MEETING IN
SAN ANTONIO AND SAT BASICALLY
THE SCIENCE OF CANCER AND
LATINOS, WE HAD SPOKEN WITH ONE
OF OUR MENTORS ABOUT THOSE
FINDINGS AND SHE HAD POSITED
THIS SPECIFICALLY ABOUT
MAMMOGRAPHY THAT ESPECIALLY --
FORGIVE ME I'M GOING TO BUTCHER
HER ANSWER, BUT HER INPUT WAS
THAT IN CERTAIN LATINA
COMMUNITIES, ESPECIALLY IN
BORDER STATE, THERE JUST
WASN'T -- THERE WAS A SPECIFIC
CULTURAL DIALOGUE ABOUT
MAMMOGRAPHY.
AND SHE THOUGHT WOULD CONTRIBUTE
WOULD MAKE SENSE TO HER, SO I
THINK THERE ARE THOSE -- JUST
THOSE DIALOGUES THAT TAKE HOLD
IN NOT JUST LATINO CULTURES BUT
ANY CULTURE.
BASED ON THAT SPECIFIC SERVICE
COULD BE THE CASE.
IT INTERESTING, THERE'S SOME
WORK UNDER REVIEW THAT WE HAVE
THAT ACTUALLY SHOWS THAT NOT
ONLY IS IT ORDERS BUT ACTUAL
ACTUALLY -- LATINOS ARE ACTUALLY
MORE UP TO DATE WITH COMPLETION,
THAT'S STILL EARLY, WE'RE STILL
WORKING THROUGH SOME OF THAT
DATA, BURY THINK THE ANSWER TO
THAT QUESTION IS YES.
>> AND I JUST WANT TO HIGHLIGHT
THAT, AGAIN, THERE ARE THESE
POSITIVES, AND FOR US TO SORT OF
SHOWCASE OR HIGHLIGHT THOSE AND
THEN DO TRY TO FIGURE OUT WAYS
TO DO SUBSEQUENT WORK, WE TRY
AND UNDERSTAND WHAT ARE THE
DRIVERS THAT ARE LEADING TO
THESE IMPROVED RATES OF
SCREENING, SO I THINK THERE'S A
LOT OF WORK TO BE DONE AND THE
HOPE IS THAT WE CAN TRY TO
IDENTIFY WHAT ARE THE SPECIFIC
COMPONENTS HERE TO TRY TO LEARN
FROM THAT TO THEN LEARN HOW TO
INCORPORATE THAT INTO
INTERVENTIONS.
>> MAMMOGRAPHY, IF YOU LOOKED AT
JUST THE ABSOLUTE RATES, THEY
WERE NOT OVERRECOMMENDATION,
THEY WERE ACTUAL RECOMMENDED
LEVELS, BETWEEN EVERY YEAR OR
TWO KIND OF A THING, SO IN THAT
CASE, THEY WERE -- THAT SEEMED
TO BE A APPROPRIATE
PRESCRIBING -- OR EXCUSE ME --
ORDER RANGE FOR LATINOS.
IT'S A GREAT QUESTION.
>> THE DATA YOU SHOWED FOR MY
OWN CLARIFICATION WAS AN ANNUAL
RECOMMENDATION OR EVERY TWO-YEAR
RECOMMENDATION?
BECAUSE WITH THE STANDARD
RECOMMENDATION IT'S EVERY TWO
YEARS, RIGHT?
>> YES.
THAT WAS -- LIKE THESE ARE EVERY
TWO YEARS FOR SOMEONE WHO'S HAD
NORMALS, SO FORTH.
WE DIDN'T ACTUALLY SHOW THE
ABSOLUTE RATES IN OUR FIGURE,
BUT -- THEY WERE ABOUT WHAT YOU
WOULD EXPECT, LIKE I THINK IT'S
.5 A YEAR OR SOMETHING LOO IK
THAT.
>> AND YOU EMPHASIZED THAT IT
WAS ORDERS BULL M BUT ARE MOST M
DONE, DO YOU THINK?
>> SO WE ACTUALLY PULLED THAT
SLIDE OUT, BUT WE DO HAVE A
STUDY THAT IS CURRENTLY UNDER
REVIEW THAT IS LOOKING AT SH DID
THEY ACTUALLY RECEIVE IT AND
LOOKING AT TIME FROM 50TH
BIRTHDAY TO THE RECEIPT, AND
SIMILAR TREND SHOWS THAT SPANISH
SPEAKING LATINAS, IN THIS CASE
ACTUALLY IT WAS FOREIGN-BORN
WHICH WAS A LITTLE BIT OF AN
OVERLAP, BUT LATINAS DO HAVE
MORE UP TO DATE AND GENERALLY
THEY'RE MORE UP TO DATE.
>> OKAY.
>> IT'S AN INTERESTING -- WHEN
WE FIRST -- YOU HAVE RESULTED
BECAUSE OF THE WAY EHR IS
STRUCTURED WHEN YOU GO OUT AND
IN TIME HAS GONE ON, IT EVOLVES,
IS MORE INTERCONNECTED THEN
WE'RE ABLE TO DO THIS MORE FULL
ANALYSIS THAT'S UNDER REVIEW.
>> EXCELLENT.
SO ANOTHER QUESTION, THIS IS
FROM ONE OF OUR PROGRAM STAFF,
CAN YOU SPEAK TO WHAT YOU'VE
LEARNED IN YOUR RESEARCH ABOUT
SPECIFIC PROTECTIVE FACTORS THAT
COUNTRY OF BIRTH AND RELEVANT
SOCIAL DETERMINANTS OF HEALTH
FACTORS IN LATINO POPULATIONS
MAY HAVE ON PRE-CLINICAL
PRESENTATION OF DISEASE AND IN
PREFERRED SPANISH SPEAKING
POPULATIONS OR POPULATIONS THAT
PREFER SPANISH, COMPARED TO
THOSE WHO PREFER ENGLISH, AND
LEADING TO SPECIFIC HEALTH
OUTCOMES, SECONDARY/TERTIARY
PREVENTION AND MANAGEMENT?
DID YOU GET ALL THAT?
>> YEAH, YEAH, YEAH.
>> IT'S IN THE CHAT, BUT --
>> I THINK I WOULD SAY TWO
THINGS.
GREAT QUESTION.
LOTS TO SAY ABOUT IT.
I THINK -- BECAUSE WHEN I
DON'T -- WHAT WE -- IN THIS
REALLY BROAD CATEGORY WORK, WE
DON'T -- WE'RE CAREFUL ABOUT
EXTRAPOLATING TOO MUCH OF THIS
SPECIFIC THING THAT WE THINK IS
RESPONSIBLE FOR IT, BUT IN
GENERAL -- GENERALLY, THERE IS
THAT SUGGESTION THAT THE
MAMMOGRAPHY THING IS A GOOD
EXAMPLE, WHEN YOU START TO GET
OTHER EXPERTS, TRIANGULATE WITH
OTHER WORK THAT IS AWARE OF
THOSE DIALOGS AND -- YOU START
TO UNDERSTAND THAT THERE ARE
THOSE CONDITIONS, THOSE -- THOSE
CULTURAL DIALOGUES THAT CAN BE
REALLY POSITIVE, PROTECTIVE.
AND THE OTHER THING, I THINK, IS
THAT IS THIS KIND OF IDEA THAT
AS WE LEARNED THIS DISRUPTION
OF -- IMMUNIZATION IS A GOOD
EXAMPLE, JUST KIND OF WHAT WE'VE
HEARD A LOT, VACCINE HESITANT,
THAT'S AN OVERGENERALIZATION BUT
THAT'S ACTUALLY NOT THE CASE.
AND SO JUST TO BE VERY PRACTICAL
AND PRAGMATIC ABOUT IT, -- THAT
ARE BEING RECEIVED REGARDLESS OF
THE EXPLANATION THAT SOMETHING
IS WORKING THERE.
AND SO IT REQUIRED THAT TO GO VR
BY VR TO UNDERSTAND, WHAT'S
BEING DELIVERED AND WHAT'S NOT.
IT HARD TO EXTRAPOLATE ON EXACT
POTENTIAL FACTORS FOR THESE
FINDINGS, BUT IT STARTS TO
UNCOVER THAT.
>> AND THEN I'LL ADD ANOTHER
LAYER, I THINK ANOTHER WAY TO
THINK ABOUT IT IS WHAT SHOULD
PRIMARY CARE CLINICIANS BE
LOOKING AT WHEN THEY CARE FOR
LATINO COMMUNITIES, RIGHT?
SO WHEN YOU SEE THAT ENGLISH
PREFERRING LATINOS HAVE SIMILAR
OR WORSE ODDS OF ANY OF THESE
SERVICES, IS THAT SOMETHING
PRIMARY CARE CLINICIANS SHOULD
TRY TO UNDERSTAND WITHIN THEIR
OWN CLINIC, SO MAYBE LATINO
COMES IN, HAVING SOME
INFORMATION ABOUT TYPICALLY YOU
GET LESS SERVICES, SO THEN
SHOULD THEN THAT BE AN
OPPORTUNITY FOR A PRIMARY CARE
CLINICIAN TO START THAT DIALOGUE
TO UNDERSTAND WHY.
SO I THINK PART OF THIS IS
CAPTURING -- IN WHAT INSTANCES
DOES THIS INFORMATION HELP, SO
THE BROADER AUDIENCE, SCIENTIFIC
AUDIENCE, BUT HOW DOES THIS
IMPACT PRIMARY CARE?
I THINK THAT'S ALSO AN IMPORTANT
DISCUSSION THAT WE'RE TRYING TO
FIGURE OUT WHAT'S THE RIGHT
BALANCE.
DO YOU NEED TO KNOW THE COUNTRY
THEY COME FROM, DO YOU NEED TO
KNOW -- SO IT'S ALMOST AS THEY
DO -- WHEN DOES THAT HAPPEN.
I THINK THAT'S ANOTHER BIGGER
PICTURE DISCUSSION WE NEED TO
HAVE.
>> AND JUST TO PIGGY BACK ON
THAT, IN THIS CASE, THE DIALOGUE
STARTED -- IT'S NOT LIKE THIS
IS -- IF WE CAN GET -- AND -- TO
HAVE A DIALOGUE WITH COMMUNITY
HEALTH SERVICE CLINICIANS, THIS
IDEA IS PEOPLE'S HEADS, NOT IN A
DETERMINISTIC WAY, BUT TO GET
THOSE KIND OF IDEAS AND THOSE
KIND OF DYNAMICS IN PEOPLE'S
HEADS CAN BE A BIG SPRINGBOARD,
AND BETTER PREVENTION AND BETTER
CARE OVERALL.
>> EXCELLENT.
YOU KNOW, I WOULD SAY
UNEQUIVOCALLY THAT IT'S
IMPORTANT TO KNOW WHO YOUR
PATIENT IS IN TERMS OF THE
SOCIAL CONTEXT, REGARDLESS OF
THEIR RACE AND ETHNICITY.
YOU START WITH LANGUAGE, THEY
DON'T SPEAK ENGLISH, YOU NEED
SOMEONE WHO SPEAKS SPANISH WITH
THEM.
AND THEN KNOWING THEIR CONTEXT,
YOU KNOW, I THINK IF YOU'RE
GOING TO PRACTICE MEDICINE, IT
WAS ALWAYS IMPORTANT TO THE
PEOPLE, WHERE THEY CAME FROM,
HOW LONG THEY'VE BEEN HERE, WHAT
WAS THEIR FAMILY AND PERSONAL --
SO A COUPLE MORE QUESTIONS FOR
YOU.
THIS IS FROM AN ACADEMIC
PEDIATRICIAN THANKING YOU FOR
YOUR PRESENTATION.
THIS PERSON WORKS IN MARYLAND
WITH LATINO CHILDREN AND
IMMIGRANT FAMILIES.
ANY INTERVENTIONS IN PRIMARY
CARE OR BY REFERRAL FROM PRIMARY
CARE THAT SHOW PROMISE IN
ADDRESSING HEALTH DISCARROTS
REGARDING SUSTAINABILITY AND
SCALABILITY, ESPECIALLY FOR
MENTAL HEALTH OR OBESITY?
BIG PROBLEMS.
>> LET ME THINK ABOUT THAT.
>> SO I'LL -- THIS MAY NOT BE A
SATISFYING ANSWER.
NOT THAT I KNOW.
IT'S A GREAT QUESTION, AND IT'S
ACTUALLY CLOSE TO OUR MINDS
RIGHT NOW.
WE HAD A MEETING WITH A PARTN
PARTNER -- IMMUNIZATIONS WERE
JUST STARTING TO CHARACTERIZE
APPROPRIATELY, ABOUT WHETHER WE
COULD HELP WITH SOME OF OUR DATA
NEEDS, AND WHAT THEY WANTED TO
TRY TO UNDERSTAND IS
SPECIFICALLY MENTAL BEHAVIORAL
HEALTH FOR LATINO PATIENTS AND
WHAT RESOURCES ARE BEING
ACCESSED AND UTILIZED AND HOW
THERE'S SUS A PAUCITY OF DATA
ABOUT HOW THAT WORKS WELL.
I THINK WE'RE OPTIMISTIC JUST
BECAUSE IN MOST COMMUNITY HEALTH
CENTERS, IT IS MORE COMMON TO
HAVE RESOURCES CO-LOCATED IN
THOSE CASES, AND INDEED, I THINK
WE HAVE A FIRST ANALYSIS THAT
DID SHOW THAT LATINO PATIENTS
ROW W -- USEDTHOSE AT SOME LEVE.
BUT IT'S STILL VERY GENERAL.
I DON'T THINK -- THERE'S NOT
GREAT DATA, THAT DOESN'T MEAN
THERE HAVEN'T BEEN SUCCESSFUL
INTERVENTIONS IN CERTAIN
LOCATIONS.
I'M JUST NOT AWARE.
>> SO I THINK YOU'VE HIT ON AN
IMPORTANT LIMITATION WITH THIS
WORK, SO TZ LARGE SCALE
MULTISTATE MULTIYEAR, SO IT IS
REALLY HARD TO IDENTIFY SPECIFIC
INTERVENTION OF THAT FROM
SPECIFIC STUDIES OR -- THE WORK
WE DO IS THE SORT OF MORE BROAD
OBSERVATIONAL WORK.
NOW WHAT WE COULD DO IS LOOK AT
POLICY INTERVENTIONS.
SO WE KNOW THAT THE AFFORDABLE
CARE ACT AIMED TO INCREASE
INSURANCE COVERAGE FOR LOWER
INCOME FOLKS R, SO THINGS LIKE
THAT, WE HAVE DONE THESE
INTERVENTIONS, THE AFFORDABLE
CARE ACT DID INCREASE INSURANCE
RATES IN SOME PEOPLE THAT LED TO
MORE SERVICES, SO FROM THE WORK
WE DO, THE CENTER DOES, IT'S
MORE LOOKING AT THOSE KIND OF
INNOVATIONS AND INTERVENTIONS,
SO WE'RE NOW LOOKING INTO -- WE
HAVE A GRANT WHERE WE'RE GOING
TO LOOK AT HOW DOES THE IMPACT
OF INTRODUCING THIS NEW
TECHNOLOGY IMPACT DELIVERY OF
CARE, CHANGES IN HEALTH OUT
COME, SO WE HAVE A LOT MORE TO
BE DONE, BUT I THINK WE'RE
TALKING ABOUT SPECIFIC
INTERVENTIONS, KIND OF HARD TO
TELL, BUT THE MORE SORT OF BROAD
POLICY AND JUST GENERAL
INNOVATIONS, THAT'S SOMETHING
IT'S EASIER TO CAPTURE WITH A
PRE/POST DESIGN OF SOME SORT.
>> THE THING IS, I THINK IT ALSO
GETS THE IDEA OF -- AND WE
STRUGGLE -- ALL THOAL WE'RE
TRYING TO -- ESPECIALLY THE TWO
CONDITIONS YOU LISTED OFTEN
INVOLVE OTHER MEMBERS OF THE
TEAM, HEALTHCARE TEAM, SO
WHETHER THAT'S IN LATINO
COMMUNITIES, COMMUNITY HEALTH
WORKERS OR OBVIOUSLY MENTAL
BEHAVIORAL HEALTH STAFF OR
NUTRITIONISTS, SOME OF THOSE ARE
AVAILABLE IN THE RECORDS THAT WE
STUDY, TRYING TO FIGURE OUT DO
YOU DO THAT, HOW DO YOU ME SURE
THAT TEAM -- AND WHETHER THOSE
TEAMS, A LOT OF THOSE OTHER
TYPES OF CLINICIANS ARE KIND OF
EFFECTIVELY INCORPORATED IS A
PIECE OF THAT THAT WE'RE TRYING
TO FIGURE OUT HOW TO STUDY AT
SCALE, OR VERY, VERY SLIGHTLY,
BUT I THINK IT'S AN IMPORTANT
ELEMENT TO -- WHEN YOU THINK
ABOUT -- WHEN YOU THINK ABOUT
REAL WORLD INTERVENTIONS, THE
LAST 15 YEARS HAS BEEN
TEAM-BASED CARE SO HOW DO YOU
REALLY UNDERSTAND HOW THAT HAS
BEEN BENEFICIAL OR NOT TO LOOK
FOR LATINO PATIENTS.
>> RIGHT, LET ME ADD THERE ARE
OTHER STUDIES THAT SORT OF FOCUS
ON INTERVENTIONS RELATED TO
MANAGEMENT OF OBESITY AND
ADOLESCENTS OR CHILDREN, AS WELL
AS MENTAL HEALTH ISSUES IN
FAMILIES THAT ARE OBVIOUSLY NOT
THIS SCALE, THIS SIZE, WITH
HUNDREDS OF THOUSANDS THAT SHOW
EFFICACY OF APPROACHES.
I'M THINKING PARTICULARLY WILLIE
P RA. ADO WHO WE HOSTED AT A
DIRECTOR'S SEMINAR OVER A YEAR
AGO AND HIS STUDIES FOCUSING ON
ISSUES AROUND MENTAL HEALTH AND
BEHAVIOR RELATED TO SEXUAL RISK
FACTORS AND SUBSTANCE USE WITH
FAMILIES IS VERY MUCH EMBEDDED
IN THE FAMILY APPROACH, AND I
THINK LATINOS IN GENERAL ARE, A,
JUST GENERALIZING WITHOUT --
OBVIOUSLY EVERYONE IS DIFFERENT,
ARE ACCEPTING OF A MENTAL HEALTH
PROBLEM AND APPROACH, THINKING
OF THE MIND-BODY CONNECTION, SO
THE CHALLENGE IS ACCESS TO
PEOPLE WHO CAN SEE THEM.
PARTICULARLY IF THEY DON'T SPEAK
ENGLISH.
THAT'S A HUGE CHALLENGE.
SO I HAVE A COUPLE MORE WE CAN
GET IN, MAYBE AT LEAST ONE.
THANK YOU FOR SUCH A WONDERFUL
PRESENTATION.
HOWEVER, I HAVE A CONCERN.
THE ENTIRE RESULTS COMPARE
LATINOS AND WHITE NON-LATINOS.
ARE WE ASSUMING THAT THE STUDY
LATINOS ARE WHITE?
WHERE DO BLACK LATINOS FALL IN
THESE RESULTS?
DID YOU HAVE A WAY TO EXCLUDE
THEM SO THAT YOU COULD ONLY
COMPARE WHITE LATINOS WITH WHITE
NON-LATINOS, OR ARE THEY PART OF
THE LATINO GROUPS?
IF YES, I MIGHT INCLUDE BLACKS
AS WELL IN THE COMPARISON
BECAUSE OF SKIN COLOR FACTORS DO
A LOT IN HEALTH DISPARITIES.
PLEASE CLARIFY.
>> YEAH, NO, THAT IS A GREAT
QUESTION.
AND SO IN THE MAJORITY OF OUR
WORK, WE DO ONLY LOOK AT
ETHNICITY, SO THE WAY THE OMB
CATEGORY, LATINO OR NON-LATINO,
AND THEN WE THEN FURTHER FOR THE
NON-LATINO DO LOOK AT WHITES.
SO FOR -- WE DID THIS FOR A FEW
REASONS.
SO ONE IS, OUR EXPERIENCE, OUR
SORT OF -- AT LEAST WITH MY
LIVED EXPOSURE, IS IN A LATINO
COMMUNITY.
AND WE BELIEVE TO REALLY DO
JUSTICE TO UNDERSTAND JUST
LATINOS BROADLY, IT DOES REQUIRE
LOOKING AT A LATINO GROUP IN
COMPARISON TO OTHER GROUPS AS
WELL, SO IN OUR WORK, WE TRY TO
FOCUS -- HAVE THE FOCUS ON THE
LATINO GROUP.
THIS ARE -- MANY OF OUR STUDIES
INCLUDE LATINO BLACK AND
NON-HISPANIC BLACK PATIENTS AS
WELL.
BUT WE TRY TO LET OUR CO-AUTHORS
WHO HAVE EXPERTISE IN THAT LEAD
THE WAY THERE.
SO THERE'S THIS REALLY NICE
PAPER FROM ELLE THAT TALKED
ABOUT HEALTH EQUITY TOURISM.
AND IT REALLY HELPED US SORT OF
THINK ABOUT WHAT ARE THE RIGHT
TIMES FOR US TO THINK ABOUT
INCLUDING NON-LATINO GROUPS IN
OUR WORK, AND SO I THINK
GENERALLY SPEAKING, WHEN WE HAVE
THE RIGHT EXPERTISE IN THE TEAM,
BECAUSE THE TEAM IS BIG AND SOME
PEOPLE HAVE EXPERTISE AND SOME
HAVE -- IT WAS IN CARDIOVASCULAR
DISEASE, SO WHEN THE EXPERTISE
IS THERE, WE DO TRY TO THINK
ABOUT INCLUSION OF OTHER GROUPS
AS WELL BUT OUR PRIMARY FOCUS IS
ON LATINO AND WE DO INCLUDE IN
THE LATINO GROUP BLACK LATINOS.
SO THE OTHER THING IS AS WE NOW
SORT OF ENTERED A SCENARIO WHERE
WE DO HAVE MORE DATA, IN OUR
INITIAL STUDIES WE WERE ALWAYS
LIMITED BY DATA SAMPLE SIZE.
IN OUR MOST RECENT DATA POLLS,
WE HAVE NOW SUFFICIENT SAMPLE
SIZE AND WE ARE LOOKING TO THINK
ABOUT WAYS TO INCORPORATE AFRO
LATINOS, AFRO LATINAS INTO THIS
WORK BY SAMPLE SIZE
CONSIDERATIONS AND ALSO TEAM
EXPERTISE AND IN GENERAL, WE
WANT TO DO IT JUSTICE AND DO IT
RIGHT.
>> YEAH, WE DON'T ASSUME.
IT REALLY WAS -- THERE'S --
BECAUSE IT'S REALLY JUST A WAY
THAT THE NETWORK HAD DEVELOPED
THAT MOST OF THE NUMBERS OF
PATIENT WHO IDENTIFIED AS BLACK
ANDLY TA AND LATINO WERE VERY ST
LED TO A LOT MORE -- A DIFFERENT
CATEGORY OR BEING VERY CAREFUL
ABOUT THE ANALYSIS AND
IMPLICATIONS FROM THAT, BUT WE
DON'T ASSUME ALL OF THOSE
PATIENTS ARE WHITE LATINOS.
>> AGAIN, I WOULD ADD THAT
NATIONAL DATA DO HELP HERE, AND
BASED ON CONSISTENCY OVER THE
LAST THREE CENSUSES, AT LEAST,
YOU KNOW, ABOUT HALF OF LATINOS
IDENTIFIED AS WHITE AS WELL IN
THE CENSUS, SOMEWHERE AROUND 40%
PUT OTHER OR I ALREADY TOLD YOU
WHY ARE YOU ASKING ME AGAIN, AND
THESE ARE MOSTLY THE LATINOS WHO
ARE CLEARLY MIXED USUALLY WITH
INDIGENOUS AMERICANS, AND THERE
ARE SOMEWHERE IN THAT 5 TO 10%
RANGE OF LATINOS WHO WOULD
SELECT BEING AFRO LATINO OR
BLACK LATINOS, BUT THEIR FIRST
IDENTITY IS STILL LATINO.
THAT IS THE CHALLENGE HERE.
SO I DO THINK THAT YOU ARE
CAPTURING THEIR DATA, YOU JUST
TONIGHT HAVE THE ABILITY TO
SEPARATE THEM OUT TO SEE HOW
DIFFERENT THEY ARE.
YOU CITED ELIZABETH ARIAS
EARLIER FROM NATIONAL CENTER FOR
HEALTH STATISTICS, AND SHE'S
PUBLISHED A PAPER LOOKING AT
MORTALITY BY WHITE LATINO VERSUS
BLACK LATINO, AND THE MAIN
MESSAGE IS THEY'RE BOTH LOWER
FOR WHITE NON-LATINOS, BUT
BLACK -- HIGHER THAN WHITE
LATINOS I THINK AS I RECALL
PARTICULARLY FOR FEMALES, BUT SO
THERE IS BEGINNING TO ARE
MORE -- THE SEOUL STUDY YOU
MENTIONED ALSO HAS RACE DATA,
BUT AGAIN, THE OVERWHELMING
MAJORITY EITHER PUT OTHER OR
WHITE.
SO -- BUT THERE ARE -- THERE IS
A SUBSET OF LATINOS IN SEOUL WHO
SAY THEY IDENTIFIED AS BLACK,
AND THERE'S DATA FROM THE PEW
FOUNDATION THAT HAS DONE MORE
WORK ON THIS THAN THE U.S.
CENSUS, THAT LATINOS WHO ARE
BLACK PREFER TO IDENTIFY AS AFRO
LATINO OR AFRO CARIBBEAN IN MANY
CASES, MANY OF THEM ARE FROM THE
CARE PCARIBBEAN COUNTRIES, BUT E
ARE BLACK MEXICANS AS WELL.
AND IN LATIN AMERICA, THE
QUESTION OF RACE FOR PEOPLE OF
AFRICAN HERITAGE, BLACK, HAS
BEEN ADDED TO AT LEAST NOT ONLY
BRAZIL BUT ALSO THE COUPLE OF
CARIBBEAN ISLANDS, CUBA, MEXICO,
AND SO WE'RE GOING TO SEAL MORE
DATA COMING FROM LATIN AMERICA
ON THIS AS WELL.
ALL RIGHT.
SO WE'VE HIT 5:00.
THE LAST QUESTION I DIDN'T ASK
YOU WAS, WHAT IS THE BEST WAY
FOR US TO COLLECT DATA FROM
LATINOS, AND I THINK WE ALREADY
TALKED ABOUT THAT TO SOME EXTENT
FROM THE LATINO COMMUNITY.
SO AGAIN, I WANT TO REALLY THANK
YOU FOR BEING -- SETTING THE
CONTEXT, AND THEN REALLY DOING
THE PRESENTATION BASED ON YOUR
OWN WORK, WHICH IS REALLY WHAT I
WANT THESE SEMINARS TO BE.
WHERE IS THE SCIENCE THAT YOU'VE
DONE WITH ALL THE GRANULARITY OF
THE GOOD THINGS AND THE BUMPS,
THAT'S WHAT WE WANT TO SEE,
BECAUSE THAT'S WHAT I WANT OUR
AUDIENCE TO HEAR.
AND THE FOCUS AGAIN ON PRIMARY
CARE IS VERY TIMELY, AND OF
COURSE IN MY OWN INDIVIDUAL
INTEREST, FOCUSED ON LATINO
HEALTH IS ALWAYS ALSO OF GREAT
INTEREST.
SO THANKS AGAIN, JOHN AND
MIGUEL, FOR A WONDERFUL
PRESENTATION.
>> THANK YOU SO MUCH.
>> THANK YOU FOR THE INVITE AND
THANKS EVERYBODY FOR LISTENING.
>> ALL RIGHT.
THANK YOU.
, EVERYONE, FOR SUPPORTING THE
PRESENTATION TOO.