Health Disparities Forum

1.     After reading the article by Thomas et al., comment on where your research, or your research interests, fit into the generational framework for health disparities research. If your work is 1st or 2nd generation, comment on how your work could lead in the future to 3rd or 4th generation work. If your work is 3rd or 4th generation, comment on what 1rst and 2nd generation work was necessary as a foundation for your current work (or current interests).

I am interested in studying health disparities in interstitial lung disease, which presently is poorly understood and understudied.  Because of this, the work that I am compiling would be designated as 1^st generation in an attempt to identify whether disparities exist, and if so, to characterize them by including as many social determinants of health variables as I possibly can.  Currently, I can describe disparities by race and ethnicity, insurance status, access to a primary pulmonologist (since we are a tertiary care center), and distance traveled to clinic as well as drive time as individual level variables, and median household income, education level, and percent below the poverty line as group level variables at the census tract level. 

Currently, I am working on two projects that aim to identify whether health disparities exist in idiopathic pulmonary fibrosis, the first among rural and urban areas, and the second among different race and ethnicities.  To answer this question, I will focus on the project that seeks to understand whether disparities exist in rural/urban populations.  After defining disparities in IPF among urban/rural populations, I will then investigate the causes of these disparities based on my analyses using the social determinants above. 

My hope is to continue this further to 3^rd and 4^th generation work as a basis for a K award.  A project for the 3^rd generation would include interventions to help eliminate any identified disparities above, particularly with access to care if found to show differences in outcomes.  For example, this could include enhancement of our telehealth program.  This could further lead to a 4^th generation of work that involves communities that are most affected, both through ongoing improvements in access and education. 

2.     The barbershop hypertension intervention, while essentially a clinical services intervention operating at either the fence or safety-net level as described by Jones, has some engagement with the social determinants of health. Interventions like that described in the Gottleib article are designed to mitigate the impact of social determinants. How could you apply one of these two types of interventions to your area of research? Propose one or two interventions that engage with social determinants on some level.

A clinical services intervention in interstitial lung disease is somewhat complex, owing to the fact that it is a rare disease.  Despite this, an intervention such as the one described in the Gottleib article is certainly possible if one were to identify a method to engage with participants at the community level, and further, to identify enough participants with the disease process such that an analysis of differences would be possible.  Screening for ILD has not been defined, and would likely not be cost efficient unless a questionnaire was utilized.

One mechanism may be to use the information surrounding disparities generated from one of my proposed studies above regarding rural or urban populations to identify communities that demonstrate an increase in delayed referral and access to care.  This could be done initially as a pilot program, which may offset issues with identifying enough participants.  While high-resolution CT scans would not necessarily be cost efficient on everyone, you could start with a questionnaire to identify who should have pulmonary function testing based on symptoms such as cough, shortness of breath, smoking history, etc.  From there, if pulmonary function tests suggest a restrictive disease process, you could further screen those patients with a high-resolution CT scan, all of which would need to be accessible and affordable to patients.  If ILD was detected, we could generate a referral to an ILD center closest to the patient, or use our telehealth services at UCSF if needed.  While this is unlikely to have an equivalent impact to a disease such as hypertension or pediatric health, you could potentially understand barriers to diagnosing and referring patients with ILD to an ILD center, which is of great interest, owing to one study demonstrating better outcomes when patients are seen in an ILD center.