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Alita Alee Mid-term Progress Report - BHC

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					        The Health Implications of Discrimination:

Understanding Socioeconomic and Racial/Ethnic Health

               Disparities in the City of Berkeley




                  San Francisco State University
HED 892 Community Needs Assessment – Berkeley Health Center for Women and Men


                           Alita Alee

                      MPH Candidate 2005



Gwen Roe-Lee Sykes, DrPH, Executive Director Bay Area Consortium for Quality
Health Care
Victoria Quijano, MPH, San Francisco State University




                           August 13, 2004




                                                                               1
Table of Contents


Acknowledgements…………………………………………………………………….….3

Agency Introduction and Capability………………………………………………………4

Purpose of Internship……………………………………………………………………...7

Goals and Objectives……………………………………………………………………...8

Methods and Activities……………………………………………………………………9

Timeline………………………………………………………………………………….11

Background and Significance……………………………………………………………12

Literature Search Results………..……….………………………………………………13

Limitations…………………………………………………………………………….…22

References………………………………………………………………………………..23

Appendix A: Bay Area Consortium for Quality Health Care Annual Report 2001..…....25

Appendix B: Bay Area Consortium for Quality Health Care Organizational Chart….…25

Appendix C: Map of MUA Designated Areas for Service Recipients………………..…25

Appendix D: Secondary Data Analysis - ICD9 Codes - January to June 2004...……….25




                                                                                  2
                               Acknowledgements



       I would like to thank the following organizations and individuals who helped to

make this project a success. Most importantly, I wish to thank my site supervisor, and

course instructor for their valuable insight and support.



        Bay Area Consortium for Quality Health Care-Gwen Roe-Lee Sykes, DrPH

         Site Supervisor – Executive Director

        San Francisco State University- Victoria Quijano, MPH

         Course Instructor

        Berkeley Health Center for Women and Men-Helga Cooper

        Administrative Clinic Manager

        Berkeley Health Center for Women and Men-Carolyn Rowe-Carter

         Clinical Nurse Manager

        City of Berkeley Health and Human Services- Vicki Alexander, MD, MPH

         Director Maternal, Child, Adolescent Health




                                                                                         3
Agency Introduction and Capability


       The Bay Area Consortium for Quality Health Care was founded in 1975, and

incorporated as a California Nonprofit Public Benefit Corporation 501(C) (3) in 1979. A

Board of Directors, consisting of twenty -one social, health, and legal professionals,

governs it. They are an affiliate of the California Black Health Network, a broad based

federation of health professionals, community organizations and individuals, with six

chapters in California. The Network advocates and sponsors programs to improve the

health status of people of color. Their mission is to improve the quality of life in

multicultural communities in the five counties of the San Francisco Bay Area. They give

special attention to the physical, mental, social, and environmental health, of people of

color (Bay Area Consortium for Quality Health Care Annual Report, 2001).

The goals of the Bay Area Consortium for Health Care are as follows:

(1) Monitor the health and social indices of people of color and advocate for appropriate

public policies and actions to enhance research, public education, and delivery of services

to groups at high risk.

(2) Network with community based organizations and educational entities to coordinate

activities and capacity building, and form consortia to sponsor and promote community

health and environmental initiatives.

(3) Develop demonstration projects and new programs on pertinent health issues.

(4) Enhance access for low-income groups by providing them with health care and social

services.




                                                                                            4
(5) Conduct ongoing community education and public information programs on timely

issues and concerns (Bay Area Consortium for Quality Health Care Annual Report,

2001).



                The Berkeley Health Center (for Women and Men):

         During 2001, the Berkeley Health Center (for Women and Men), previously an

independent corporation, became a full partner in the Consortium (Bay Area Consortium

for Quality Health Care, 2001). The BHC is a community-based primary care clinic,

which has provided comprehensive primary care health services for uninsured and

medically underserved community residents for the past thirty-one years. The BHC

provides a special focus on women’s health, however the current goal of the clinic is to

support the health of the entire family unit, and reduce the chronic conditions of diabetes,

hypertension and poor dental health. The name of the clinic was recently changed to

reflect the fact that services are now provided to both women and men. The BHC also

provides primary care services to immigrants and their family members of all ages

(EAPC Program Request, 2004).

         The clinic’s recipients for care present with a variety of health conditions. The

most common issues include: gynecological problems, family planning services, breast

problems, STI’s/infections, urinary tract disorders, skin problems and ear, nose, throat

and eye infections. In addition, patients are seen for gastrointestinal, cardiovascular,

thyroid, musculoskeletal complaints, nervous systems disorders, and respiratory diseases.

Chronic diseases like hypertension and diabetes are prevalent among the clinic’s patient

population. These health conditions are addressed by primary care physicians that include




                                                                                             5
consultants in HIV/AIDS, gynecological, and psychiatric care. In the year 2003, the clinic

provided care to an average of 2046 patients, 4625 clinic visits. The clinic is open eight

hours per day, 5 days per week including some evenings (EAPC Program Request, 2004).



Patient Demographics

       The clinic serves primarily the Berkeley – Oakland area of Alameda County, but

also sees patients from the San Francisco Bay Area. (See appendix C- Map of Medically

Underserved Designated Areas for Service Recipients) At least 75% of the clients who

utilize the BHC services are from the MUA. This is the designation or certification that at

least 50% of the patients served have incomes at or below 200 percent of the federal

poverty level. The designated area includes the community of South Berkeley, which has

historically been a medically underserved area (EAPC Program Request, 2004).

       The racial/ethnic composition of the clinic’s population in 2003 is as follows:

Asian/Pacific Islander – 9%, African American – 33%, Latino – 15%, Native American –

0.5%, White – 41% other – 1.5%. The clinics population falls into the following age

categories: 13-19 years – 2.5%, 20 –34 years – 60%, 35-44 years – 27%, 45-64 years –

27%, 45-64 years – 10%, and 65 and over – 0.5% (EAPC Program Request, 2004).

       Many of the patients are low-income, uninsured, homeless and have very limited

access to medical care. Day to day survival becomes an immediate concern resulting in

delays in seeking health care. This can result in complications for current existing health

conditions, combined with the negative impact of alcohol and drug abuse, and the

associated stress for the clinic’s service recipients who have no other access to health care

other than Highland Hospital (local county hospital) located several miles away. Barriers




                                                                                              6
to accessing Highland Hospital include the cost of public transportation, travel time by

public transportation, and the lack of same day appointments (EAPC Program Request,

2004).



Purpose of Internship

         The Berkeley Health Center currently has no formal health education program to

meet the needs of its clients. The purpose of this community assessment was to identify

the medical and health education needs for the low-income women and men who are

served by the Berkeley Health Center. A profile of the population of low-income women

and men who attend the BHC and the surrounding community served by the clinic was

examined in terms of age, income, ethnicity, and heath insurance status. The literature

review examines the data sources on the health outcomes for the patients in the City of

Berkeley and compares that data to the five most common health care visits for the

patients who attend the BHC. The BHC clinic data was predicted to be reflective of the

leading causes of morbidity and mortality for the City of Berkeley. Socioeconomic and

racial/ethnic health disparities are examined from the National Healthcare Disparities

Report – U.S. Department of Health and Human Services, Select Indicators for Cities In

Alameda County, and the City of Berkeley Health Status Report, 2001 Mortality and

Hospitalizations. This comparison will help to demonstrate what types of health

education are needed for the BHC.

         Methodology in the form of a secondary data analysis includes an analysis of

“ICD9”` codes from the clinic’s billing database to learn the most common reasons for

the clinic visits and to determine the consistency of the data on health disparities for the




                                                                                               7
City of Berkeley. Racial/ethnic health disparities for the women and men that attend the

clinic versus the general population of women and men who are not served by the clinic

are examined.



Goals and Objectives

       The overall goal of this community assessment was to assess the individual and

community health education needs for the low-income residents of the Berkeley Health

Center (for Women and Men). This was accomplished by applying appropriate research

principles and methods in community health education, while examining socioeconomic,

and racial/ethnic health disparities in the City of Berkeley. The secondary goal as a

Culminating Experience will be to design a program plan for health education services to

meet the three most common needs of the clients of the Berkeley Health Center (for

Women and Men), based upon the results of this community assessment and guided by

the theory of behavioral health motivation for change. The objectives for this project

were as follows:



Objectives


      Examine the demographics of the women and men who are served by the

       Berkeley Health Center (for Women and Men) in terms of age, income, and

       ethnicity.




                                                                                           8
      As a research tool, conduct a secondary data analysis that will include analysis of

       the ICD9 codes from the clinic‟s database to learn the five most common reasons

       for the clinic visits from January to June of 2004.

      Conduct a literature review of the National Health Disparities Report, Select

       Health Indicators For Cities in Alameda County, and the City of Berkeley Health

       Status Report 2001, Mortality and Hospitalizations.

      Examine the specific racial/ethnic health disparities for the women and men who

       are served by the clinic, compared to the general population for the City of

       Berkeley.

      Demonstrate the types of health education needed for the low-income residents of

       the BHC within the context of a primary health care model.



Methods and Activities

The following methods and activities have been conducted:

      Patient demographics for the Berkeley Health Center have been examined and

       discussed.

      A secondary data analysis of the ICD9 codes for patient encounters from January

       to June of 2004 have been examined using Microsoft Excel to determine the five

       most common reasons for the clinic visits. This data will be cross-tabulated using

       SPSS for HED 895.

      A literature review of the socioeconomic and racial/ethnic health disparities in

       health outcomes nationally, for Alameda County, and the City of Berkeley Data

       Health Outcomes Report has been conducted. A comparison of the City of



                                                                                          9
       Berkeley Data Outcomes and an examination of the health disparities for the

       clients served by the BHC versus the population of the City of Berkeley have

       been cited in the literature search results section.

      A determination of the types of health education services needed for the BHC

       based upon the five most common patient encounters has been assessed. They are

       Hypertension, Hepatitis, and Allergic Rhinitis (See figure #1).

      I have attended miscellaneous clinic meetings, as necessary.



Methodology:

       Methodology in the form of a secondary data analysis was conducted by an

examination of the ICD9 codes from the clinic’s billing data base from January to June of

2004 to learn the five most common patient encounters and to determine the consistency

of the data in comparison to the health concerns for the broader population of the City of

Berkeley. All quantitative and qualitative information was coded using a codebook and

then entered into a Microsoft Excel spreadsheet (See Appendix D). Patient encounters

were extracted by recording the frequency that each patient diagnosis occurred. These

identified encounters were then used to determine the five most prevalent patient

encounters. Analyzing this secondary data source has determined the five most common

patient diagnosis (see figure 1 below).




                                                                                        10
                    Five Most Prevalent Patient Encounters
          Berkeley Health Center for Women and Men from January – June 2004

Hypertension                                   193 Patients

Abdominal Pain related to Hypertension         123 Patients


                                               98 patients
Low Back Pain related to Hypertension
Hepatitis                                      364 Patients

Allergic Rhinitis                              125 Patients


 Total Patient Encounters from January - June 2004 = 2,784


       This comparison has demonstrated the types of health education that are needed

for the BHC. The three most common patient encounters at the BHC are hypertension,

hepatitis, and allergic rhinitis. HTN is the most common and is reflective of the

socioeconomic, racial/ethnic health disparities data for the nation, Alameda County, and

the City of Berkeley as a whole.



REVISED TIMELINE:

             TASK:                        DATE:                       HOURS:
Examine the patient             June 25 – July 12 as          Approximately:
demographics for the            necessary.                    20
Berkeley Health Center
Conduct a secondary data        June 30 - July 15
analysis that will include an                                 40
analysis of ICD9 codes
from the BHC database.
Demonstrate the types of        July 30 – August 5
health education needed for                                   10
the low- income residents of
the BHC.
Conduct a literature review     June 26 – July 19 as


                                                                                        11
of the City of Berkeley Data   needed.                         40
Outcomes and examine
health disparities for the
clients served by the BHC
versus the population of the
City of Berkeley.
Complete mid-term report       Approximately
on status of summer            Friday, July 30                 16
internship.
Compile data and highlights    895 Proposal Completion
into a fact sheet and/or                                       80
Power Point presentation
for the staff of the BHC
using the SPSS format after
meeting with Dr. June
Coleman.
Miscellaneous weekly and       June 24 – August 5
unscheduled meetings, as                                       18
necessary.
Complete final report on       Approximately                   16
Summer internship.             Friday August 13
                               Total Hours:
                                                               240


Background and Significance

       Higher disease rates for African Americans compared to Whites are pervasive and

persistent over time, with the racial gap in mortality widening in recent years for multiple

causes of death. Other racial/ethnic minority populations also have elevated disease risk

for some health conditions. Race and socioeconomic status combine to affect health.

Socioeconomic status accounts for much of the observed racial disparities in health, yet

racism is an added burden for non-dominant populations. Individual and institutional

discrimination, along with the stigma of inferiority, can adversely affect health by

restricting socioeconomic opportunities and mobility. Racism can also affect health in

multiple ways. Residence in poor neighborhoods, racial bias in medical care, the stress of




                                                                                           12
experiences of discrimination and the acceptance of the societal stigma of inferiority can

have deleterious consequences for health (Williams, 1999).

       The most important predictor of quality of health care across all racial and ethnic

groups is access, especially insurance status and the ability to pay for health care. If we

consider populations with equal access to health care, two groups emerge with differing

qualities of health care: non-minority and minority populations. When studies control for

the stage of disease at presentation, co morbidities, severity of illness, and other

variables, substantial differences in health care based on race and ethnicity can still be

found. Raising the consciousness of this issue is an important step toward recognizing

and eliminating health care disparities (Cohen J., 2003).



Literature Search Results


Secondary Data Analysis:

       Socioeconomic and racial/ethnic health disparities data have been examined from

the National Healthcare Disparities Report – U.S. Department of Health and Human

Services, Select Indicators for Cities In Alameda County, and the City of Berkeley Health

Status Report, 2001 Mortality and Hospitalizations. The results are as follows:



National Health Disparities Report – U.S. Department of Health and Human

                                    Services

The data sources used for the National Health Disparities Report were as follows:

      Administration for Children and Families
      Administration on Aging
      Assistant Secretary for Health


                                                                                              13
      Assistant Secretary for Legislation
      Assistant Secretary for Planning and Evaluation
      Assistant Secretary for Planning and Evaluation
      Assistant Secretary for Public Affairs
      Centers for Disease Control and Prevention (CDC)
      CDC-National Center for Health Statistics
      Center for Medicare and Medicaid Services
      Food and Drug Administration
      Health Resources and Services Administration
      Indian Health Service
      National Institute of Health
      Office of Civil Rights
      Office of Minority Health
      Substance Abuse and Mental Health Services Administration
      2001 Data – Commonwealth Fund Health Care
      Note: There are surveys collected from samples of civilian,
       noninstitutionalized populations, data collected from samples of health care
       facilities, and data extracted from administrative data systems of health care
       organizations. Please see report for a brief listing of databases.

Findings and Discussion:

„”Communities of color suffer disproportionately from diabetes, heart disease,

HIV/AIDS, cancer, stroke, and infant mortality. Eliminating these and other health

disparities is a priority of HHS…”

                                  -DHHS Secretary Tommy Thompson



“The evidence of the damaging health consequences of racial and ethnic disparities in

health care continues to be overwhelming…”

                                     -John W. Rowe, M.D. Chairman and CEO of Aetna



The NHDR presented many key findings to clinicians and community members from

their report to improve health care services for all populations. In summary:

   1. Inequalities in quality of care exist.



                                                                                        14
2. Disparities come at a personal and societal price.

3. Differential access may lead to disparities in quality of care.

4. Opportunities to provide preventative care are frequently missed.

5. Knowledge of why disparities exist is limited.

6. Improvement is possible.

7. Data limitations hinder targeted improvement efforts.

8. Patients of lower socioeconomic position are less likely to receive recommended

   diabetic services and more likely to be hospitalized for diabetes and its

   complications. Blacks and poorer patients have higher rates of avoidable

   admissions.

9. While most of the population has health insurance, racial and ethnic minorities are

   less likely to report health insurance compared with whites. Lower income

   persons are also less likely to report insurance compared with higher income

   persons.

10. Higher rates of avoidable admissions by Blacks and persons of lower

   socioeconomic position may be explained, in part, by lower receipt of routine care

   by these populations.

11. Many racial and ethnic minorities and persons of lower socioeconomic position

   are less likely to receive screening and treatment for cardiac risk factors.

12. High blood pressure, high cholesterol, and smoking are three of the most

   important risk factors for heart disease that can be potentially modified by

   screening and treatment.




                                                                                    15
   13. Many racial minorities and persons of lower socioeconomic position are less

       likely to receive screening and treatment for cardiac risk factors such as smoking

       among the uninsured, lend themselves to quality improvement initiates that can

       potentially reduce heart disease disparities among populations at risk.



       In summary, access to care is a prerequisite to obtaining quality care. This report

   presented a broad array of differences related to access, use and patient experience of

   care by racial, ethic, socioeconomic and geographic groups. Many of the differences

   constitute evidence of disparity. Patient race, ethnicity, and socioecomic status are

   important indicators of the effectiveness of health care (NHDR, 2003).



              Select Indicators for Cities In Alameda County

The data sources used to elicit health indicators for Alameda County were as

folows:

      California State Department of Health Services, Immunization Branch
      Alameda County Public Health Department Communicable Disease System.
      Alameda County Public Health Department Vital Statistics Files from the
       Automated Vital Statistics System
      California Office of Statewide Health Planning and Development
      Northern California Cancer Center
      California Cancer Registry
      Department of Finance
      U.S. Census Bureau




Findings and Discussion:




                                                                                           16
   1. The three leading causes of death in each city in Alameda County were the same

       as in the county as a whole. These were diseases of the heart, cancer and stroke.

       Diseases of the heart accounted for 26% to 30% of all deaths in each city.

   2. Leading causes of death differed by race/ethnicity. Among African Americans in

       all cities, the two leading causes of death varied by city and included stroke,

       unintentional injuries, influenza/pneumonia, diabetes and homicide.

   3. Coronary heart disease is one of the major diseases of the heart. It is the leading

       cause of death for both men and women in the United States. Each year, about

       500,000 Americans die of heart attacks caused by coronary heart disease. Many of

       these deaths can be prevented through lifestyle changes in diet, physical activity

       and smoking habits. Oakland had the highest age-adjusted mortality rate for

       coronary heart disease (101 per 100,00 population), followed by Hayward and

       San Leandro. Among African Americans, the rates of death from coronary heart

       disease ranged from 108 per 100,000 in San Leandro to 293 in Berkeley. (Select

       Indicators for Cities in Alameda County)

   4. Stroke is the third leading cause of death in the United States and a leading cause

       of serious, long-term disability. The risk of stroke generally increases with age.

       Many stroke deaths can be prevented by lifestyle changes in diet, physical activity

       and smoking habits. Oakland had the highest age-adjusted mortality rate for

       stroke (34 per 100,000 populations). (Select Indicators for Cities in Alameda

       County)

       City of Berkeley Health Status Report, 2001 Mortality and Hospitalizations

The data sources for the City of Berkeley Health Status Report are as follows:




                                                                                            17
      Berkeley Public Health Division Epidemiology and health Statistics
       Automated Vital Statistics System
      California Department of Finance, Demographic Research Unit
      U.S. Census Bureau
      California office of statewide Health Planning and development (ICD-9-CM
       Codes)

Findings and Discussion:

   1. Berkeley‟s population is ethnically and racially diverse: 55.2% of residents are

       White, 16.4% Asian/Pacific Islander, 13.3% African American, 9.7%

       Hispanic/Latino, and). 3% American Indian. (City of Berkeley Health Status

       Repor,2001)

   2. African Americans comprise 13.3% of the population of Berkeley compared to

       14.6 % of the total population of Alameda County and 6.4% of the State of

       California. Among the four cites in Alameda County with greater than 100,000

       residents, Berkeley has the second largest proportion of African Americans,

       second only to Oakland (37.7%) (City of Berkeley Health Status Repor,2001t)

   3. The three leading causes of death for Berkeley residents in 1998 were heart

       disease, cancer, and stroke. Cancer is the leading cause of death for Whites in

       Berkeley and heart disease is the leading cause of death for African Americans.

       (City of Berkeley Health Status Report,2001)

   4. African Americans die at significantly younger ages than do Whites in Berkeley.

       For African Americans, 50% of deaths occur before the age of 75, whereas for

       Whites, 36% of deaths occur before the age of 75. Mortality is also significantly

       higher for African Americans between the ages for two and 34 and under the age

       of five. (City of Berkeley Health Status Repor,2001)




                                                                                         18
5. Census tracts in South and West Berkeley have the highest number of premature

   deaths each year. This data is consistent with previous analysis and reports

   showing a high concentration of population at risk for premature mortality in this

   geographical area. (This is the same geographical area for recipients of care for

   the Berkeley Health Center for Women and Men). (City of Berkeley Health Status

   Repor,2001)

6. The overall adjusted death rate for all causes of death in Berkeley is three times

   greater for African Americans than for the White population. By comparison, the

   overall age adjusted rate for African Americans in the United States, as a whole is

   1.5 times greater than the age adjusted death rates for Whites in the U.S. (City of

   Berkeley Health Status Report,2001)

7. Heart disease, cancer, and stroke are the top three causes of death in Berkeley and

   account for 59% of all deaths. Cancer is the leading cause of death for Whites and

   heart disease is the leading cause of death for African Americans in Berkeley.

   Heart disease was the leading cause of death for all Berkeley residents in 1998.

   Many of these deaths could be prevented through lifestyle changes in diet,

   exercise and smoking. The age-adjusted mortality rate for coronary heart disease

   for African Americans is more than three times that of Whites in Berkeley.

   African Americans are 12 times more likely to be hospitalized for hypertensive

   heart disease than Whites in Berkeley. Hypertension (or high blood pressure) is a

   common precursor to heart disease and stroke. Berkeley residents. The risk of

   dying from stroke is almost five times higher for African Americans than it is for




                                                                                        19
       whites in Berkeley. Many stroke deaths can also be prevented by changes in diet,

       exercise, and smoking. (City of Berkeley Health Status Report,2001)



              In conclusion this data is reflective of the ICD-9 excel data results for the

       most common patient encounters for the Berkeley Health Center for Women and

       Men from January to June of 2004. (See figure 1.) African Americans in Berkeley

       still die at a younger age overall than Whites in Berkeley. The evidence of health

       disparities among racial/ethnic groups in Berkeley is consistent with those

       originally presented in the 1999 Health Status Report. This data can help

       community groups focus efforts aimed at the elimination of these disparities. This

       report can be used to help identify gaps in services, and unmet health needs and,

       in turn, guide the development of programs, the provision of health services, and

       health education strategies. All of these are strong indicators of social equality.

       Health administrators at all levels and community members have the

       responsibility to respond and take action to eliminate health disparities in

       Berkeley (City of Berkeley Health Status Report, 2001).



Themes and Recommendations

       There are three major themes and recommendations that emerged from the
relevant literature in this field:

   1. Health targeting efforts and behavioral change through expanded health

       promotion activities and education,

   2. Cultural competency of medical staff and provider behavior, and

   3. Policy changes to address health disparities.



                                                                                             20
   Our healthcare system continues to emphasize care that occurs after an illness occurs,

rather than preventative services that could potentially prevent the illness or reduce the

burden of disease (NHDR, 2003). There are four physician roles for improving

modifiable public health-risk behavior burdens. They are preventive services, health

promotion, educator, and health promotion advocate (Dibble R., 2003). Health education

efforts should target the health conditions that account for most of the socioeconomic and

racial disparities – smoking related diseases in the case of most mortality among persons

with fewer years of education, and hypertension, HIV, diabetes mellitus, and trauma in

the case of mortality among African Americans (Wong, Shapiro, Boscardin, 2002). The

persistence of racial and ethnic disparities in health care access, quality, and outcomes

has prompted considerable interest in increasing the cultural competence of health care

providers, both as an end in its own right and as a potential means to reduce disparities

(Brach , Fraser, 2002). New solutions are needed to address this issue. Focusing efforts to

eliminate unequal burdens can strengthen existing solutions and policy formation related

to health disparities. Reducing socioeconomic disparities in health will require policy

initiatives addressing the components of socioeconomic status (income, education, and

occupation) as well as the pathways by which these affect health (Alder, Newman, 2002).



Limitations of Research Data

       Gaps in national data exist. Large gaps in the data required for a complete study

of disparities were noted. For analyses of disparities related to racial/ethnic groups, data

limitations were related to sample sizes. Data limitations for the study of socioeconomic

groups usually relate to the lack of relevant information included in many health care




                                                                                             21
provider databases. In addition, possible disparities in the care provided for many medical

conditions have yet to be addressed. More complete and reliable data would improve

understanding of disparities. Priority subpopulations i.e. racial and ethnic minorities,

often have different health care priorities and different needs for services. Measures that

capture the unique needs of specific priority populations are required for a fuller

understanding of disparities faced by each group. While we may have sufficient data

about racial disparities by race and ethnicity, it is difficult to tease out the individual

contributions of race, income, or education to these differences. While improved data

would help to measure disparities, the field would also benefit from more robust

measures that would improve our understanding of the underlying mechanisms and

causal paths that result in disparities (NHDR, 2003).




                                                                                              22
References

Agency for Healthcare Research and Quality (2003). National Health Disparities Report
[Electronic version]. Retrieved July 12, 2004 from
http://qualitytools.ahrq.gov/disparitiesreport/download_report.aspx

Adler NE., et al. (2002). Socioeconomic disparities in health: pathways and policies.
Department of Psychiatry and Pediatrics: University of California, SanFrancisco,
California

Alameda County Public Health Department Health Care Services Agency (2001). Select
Health Indicators for Cities in Alameda County [Electronic version]. Retrieved July 12,
2004 from
http://www.co.alameda.ca.us/publichealth/information/hosp_council_mreged.pdf.

Bay Area Consortium for Quality Health Care, Inc. (2004) EAPC Program Request for
Application for fiscal years 2004-2005 through 2006-2007. Berkeley Health Center (for
Women and Men). Sacramento, California: California Department of Heath Services.

Bay Area Consortium for Quality Health Care, Inc. (2001). Annual Report. Author.

Brach,C., et al. (2002). Reducing disparities through culturally competent health care: an
analysis of the business case. Center for Organization and Delivery Studies, Agency for
Healthcare Research and Quality. 10(4): 15-28.

City of Berkeley Health Status Report (2001). Mortality and Hospitalizations Executive
Summary [Electronic version]. Retrieved July 12, 2004 from
http://www.ci.Berkeley.CA.US/public health reports

Cohen, JJ. (2003). Disparities in health care: an overview. Association of American
Medical Colleges. (11): 1155-60.

(No Authors) (October 31-November 2). Programming to eliminate health disparities
among ethnic minorities. Proceedings of the Second Annual Primary Care Conference.
Atlanta, Georgia.

Dibble, R. (2003). Eliminating disparities: empowering health promotion within
preventative medicine. American Journal of Health Promotion. (2): 195-9.

Green AR., (2003). The human face of health disparites. Public Health Report.118 (4):
303-8.

Siegel, S., et al. (2004). Assessing the nation’s progress toward elimination of disparities
in health care. Center for Primary Care Prevention and Clinical Partnerships. Agency
for Healthcare Research and Quality: Rockville, MD.




                                                                                          23
Stewart AL., et al. (2003). Advancing health disparities research: can we afford to ignore
measurement issues? Center for Aging in Diverse Communities and Medical
Effectiveness Research Center. University of California San Francisco: San Francisco,
California (11): 1207-20.

Van Ryn M.,et al. (2003). Paved with good intentions: do public health and human
service providers contribute to racial/ethnic disparities in health? Center for Chronic
Disease Outcomes Research: Minneapolis Veterans Affairs Medical Center, MN.

Wong, MD., (2002). Contribution of major diseases to disparities in mortality. New
England Journal of Medicine (20): 1585-92.

Williams, DR. (1999). Race, socioeconomic status and health. The added effects of
racism and discrimination. University of Michigan, Department of Sociology and Survey
Research Center, Institute for Social Research, Ann Arbor, MI 896:173-88.




                                                                                          24
Appendix A


Bay Area Consortium for Quality Health Care Annual Report 2001


Appendix B


Bay Area Consortium for Quality Health Care Organizational Chart


Appendix C


Map of MUA Designated Areas for Service Recipients


Appendix D


Secondary Data Analysis - ICD9 Codes - January to June 2004




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