Comptroller calls on the City and State to support the expansion of primary care and encourage health clinics to open in drug stores and large retail stores in or accessible to low income neighborhoods

Says successful, multi-pronged campaign for reducing childhood asthma hospitalizations provides a model for combating other diseases

New York City Comptroller William C. Thompson, Jr. releases a new report examining health disparities in hospitalization and mortality rates based on income in New York City at a news conference in Manhattan on September 27, 2007. Pictured, (l to r) are: Glenn von Nostitz, Director, Policy Management, Office of the Comptroller; Ronda Kotelchuck, Executive Director, Primary Care Development Corporation; and, Thompson. Photo Credit: Marla S. Maritzer

View Report
View Supplementary Tables—Annual UHF Neighborhood Rates (1990-2005)

New York City Comptroller William C. Thompson, Jr. today issued a report finding that  from 1990 to 2005, disparities in hospitalization and mortality rates based on income have widened among New York City neighborhoods for heart disease, cancer and, particularly, diabetes.

Thompson’s report, “Health and Wealth: Assessing and Addressing Income Disparities in the Health of New Yorkers,” also noted that in the case of asthma, while hospitalizations have decreased due to better management of the disease, the prevalence of childhood asthma remains disturbingly high in many low income neighborhoods.

The Comptroller’s comprehensive analysis - available at www.comptroller.nyc.gov - examined the rates of various health condition hospitalizations and deaths by neighborhood since 1990, indicating that health disparities arise from a complex interaction of economic, social and environmental factors.

The Comptroller noted that anticipated hospital closures in New York City raise the prospect of more emergency room overcrowding and even fewer primary care facilities available to treat low income families.

Thompson called on City and State officials to increase reimbursement for primary and preventive care, more vigorously attack the known underlying causes of asthma, expand public education campaigns, and encourage the creation of drug and retail store health clinics in or accessible to low and moderate income neighborhoods across the city. These clinics would complement existing medical facilities, especially at night and on weekends, and provide additional cost-effective, convenient primary care for routine illnesses.  The addition of such clinics, working in association with existing facilities such as clinics and hospitals, would in part help address the scarcity of primary and preventive health care in the city’s poorest neighborhoods.

 “Simply stated, providing primary and preventive care saves lives and money, and is key to reducing disparities,” Thompson said. “Research studies have firmly established a positive correlation between the availability and utilization or primary and preventive health care in a neighborhood and the health of a neighborhood’s residents.”

The Comptroller continued:  “However, long waiting times at existing clinics, physicians’ offices, and emergency rooms are often obstacles to working people seeking treatment.  In addition, freeing up emergency rooms by offering alternatives for people seeking routine, non-emergency care has long been a goal.  While in no way supplanting primary care clinics or private doctors, retail clinics can provide a supplement to those services and help remove some obstacles to care.”

Ronda Kotelchuck, Executive Director of the Primary Care Development Corporation, supported the Comptroller’s report and its recommendations:  “It is remarkable that by offering the right kind of care, at the right time and the right place, we see that we can truly improve the lives of so many New Yorkers and reduce the disparities they now experience.  This can only happen if we build a robust primary care sector.”

Diabetes

The report noted the “dramatic” increase in the incidence of Type 2, or adult onset, diabetes both nationally and locally, with the City’s Department of Health and Mental Hygiene reporting that the percentage of adults with self-reported diabetes rising from 3.7 percent in 1994-1995 to 9.0 percent in 2003.

The Comptroller’s analysis found, that from 1990 to 2005, the total number of diabetes hospitalizations in the city increased by 82.9 percent, and during that same period, diabetes hospitalization rates more than doubled in five low income neighborhoods (Hunts Point-Mott Haven, Highbridge-Morrisania, Crotona-Tremont, East Harlem, and Fordham-Bronx Park).

Thompson noted that in 1990, there were eight neighborhoods with a rate of at least 300 diabetes hospitalizations per 100,000 population. By 1995, there were 11, by 2000 there were 15, and by 2005, there were 17.

“The trend toward higher diabetes hospitalization rates in lower income communities does not appear to be abating,” Thompson said, adding, “In each year from 2000 to 2005, the diabetes hospitalization rate in low income neighborhoods was higher than the year before.”

Heart Disease

Since 1990, the number of heart disease hospitalizations in New York City has increased substantially, from 86,747 in 1990 to 93,698 in 1995 to 101,306 in 2000 and 108,440 in 2005.  From 1990 to 2005, the heart disease hospitalization rate rose in 34 of 42 neighborhoods – with the largest increases (in excess of 40 percent) in eight mostly low income neighborhoods and the largest increases in Brooklyn.

The number of neighborhoods with heart disease hospitalization rates in excess of 1,500 per 100,000 population increased from seven in 1990 to 11 in 1995 to 13 in 2000 to 18 in 2005.

“Increases in heart disease hospitalization rates do not appear to be ending or disparities narrowing,” Thompson said, noting that for 23 of the 42 neighborhoods, including all but one of the low income neighborhoods, the highest rate since 1990 was in either 2004 or 2005.

Cancer

From 1990 to 2005, the cancer hospitalization rate dropped in all 42 neighborhoods except Hunts Point-Mott Haven and East New York. The smallest decreases – of less than 10 percent – were in seven predominantly low income neighborhoods, such as High Bridge-Morrisania, Bedford Stuyvesant-Crown Heights, and Central Harlem.

While the number of neighborhoods with high cancer hospitalization rates has declined, high cancer hospitalization rates have become more concentrated among the poorest neighborhoods.

Additionally, from 1995 to 2005, the number of cancer deaths in New York City dropped 11.7 percent. The cancer mortality rate increased in only eight of the 42 New York City neighborhoods, including the low income neighborhoods of Hunts Point-Mott Haven, Crotona-Tremont, East Harlem, and Williamsburg-Bushwick.

“Increasing numbers of New Yorkers in a range of income categories are detecting cancer earlier,” Thompson said. “However, it remains a cause for concern that cancer hospitalization and mortality rates increased in the poorest neighborhoods, contrary to the declines seen in the rest of the city.  High cancer mortality rates on Staten Island are also a cause for concern.”

Asthma

The report pointed out that disparities narrowed when it came to child asthma hospitalizations. From 1990 to 1995, the total number of New York City childhood (age 0-17) asthma hospitalizations increased very substantially, from 12,333 to 16,658, with the largest increases in low income neighborhoods. However, from 1995 to 2005, hospitalization rates plummeted, with the largest decreases observed in lower income neighborhoods. Overall, the numbers dropped from 16,658 in 1995 to 9,400 in 2005.

“The reduction in childhood asthma hospitalization rates in New York City has been remarkable,” Thompson said. “From 1995 to 2005, there was a 46.9 percent decrease in the city’s childhood asthma hospitalization rate, from 831.6 to 440.9 per 100,000 population. The New York City decrease far exceeded the national decrease.”

Thompson noted that “Government, especially City, efforts to reduce asthma disparities played a major role in achieving the large reductions.” However, Thompson cautioned that childhood asthma hospitalization rates in some low income neighborhoods remain several times the rate in wealthier communities.

For instance, although the East Harlem rate plunged from 3,241 cases per 100,000 people in 1995 to 1,059 in 2005, it is still the highest rate in the city and is almost five times the rate of 230.6 per 100,000 people in the adjoining Upper East Side neighborhood.

Thompson further noted that the sharp decline in asthma hospitalizations does not mean that childhood asthma is less prevalent. Rather, the decrease in hospitalizations indicates that childhood asthma is being better managed. Nationally, the U.S. Centers for Disease Control reports that asthma prevalence rates among children remain at historically high levels.

Infant Mortality

Meanwhile, the New York City infant mortality rate has steadily declined since at least 1990, when it stood at 11.6 per 1,000 live births, to 6.0 per 1,000 live births in 2005. The number of infant deaths fell from 1,620 in 1990 to 731 in 2005.

“Reductions in infant mortality since 1990 have been the largest in low income neighborhoods,” Thompson said. “Central Harlem-Morningside Heights had the largest decline, from 26.6 to 9.4 per 1,000 live births, followed by Highbridge-Morrisania,  which had a very substantial decrease from 16.7 to 5.3.deaths per 1,000 births.

The Comptroller noted that while the reasons behind the decline are complex, research has indicated that advances in neo-natal intensive care have greatly improved survival rates for premature infants, and that efforts by government and non-profits have played a major role.  In particular, increased access to pre-natal care for low-income women through public health insurance has played a significant role.

Recommendations

To address continuing disparities, Thompson recommended steps to increase the availability and utilization of primary and preventive care.

“Fortunately, in recent years the City of New York has grown to recognize the seriousness and complexity of the health disparities problem and has begun to respond with a very wide array of innovative and focused programs,” Thompson said.

Thompson continued:  “New York City has assumed a leadership role among the nation’s cities in advancing public health and taking steps to reduce health disparities, and expanding opportunities for primary and preventive care should be a priority.”

Among Thompson’s proposals is one to supplement existing primary and preventive care by opening clinics in drug sores, supermarkets, and “big box” stores that are directly accessible to residents of low-income neighborhoods.

Currently, several drug store clinics are partnering with area hospitals, and Thompson would like to expand such partnerships.  In addition, the Comptroller suggests that some could be operated by or in partnership with the New York City Health and Hospitals Corporation.

Retail clinics, found nationally in supermarkets, pharmacies and ‘big box’ stores, are an emerging niche in the healthcare delivery system. Designed to provide quick, convenient, relatively low cost care for common ailments, as well as basic screenings and immunizations, these clinics are generally staffed by nurse practitioners or doctors, accept insurance, and allow individuals who are uninsured or underinsured to know in advance exactly what the fees would be.

“By working with major drugstore chains and other large retailers which are accessible to low income New Yorkers, there is an important opportunity to create new access points for primary and preventive care in underserved neighborhoods where the prevalence of diabetes, heart disease, cancer and other serious health conditions is disproportionately high.”

The Comptroller would also encourage pharmacy chains to expand their presence (with clinic facilities) in low and moderate income communities, as well as offer wellness and other types of prevention programs.

Kotelchuck stated: “Chronic illnesses, like those the Comptroller examines, are the new frontier of public health.  And it’s remarkable that these are virtually all either preventable or manageable.”

Further, Thompson recommended that:

• The State take action as soon as practical on restructuring Medicaid reimbursement formulas to better support and expand primary and preventive care.

• Medicaid and private insurers reimburse health care providers for primary care case management, self-management and information technology, which are not currently paid.

• A portion of any savings from upcoming hospital closures and mergers be reinvested in community-based health providers.

• The City redouble its fight against diabetes, and create a statewide Diabetes Prevention and Management Task Force, as recommended by the Public Health Association of New York City.

• The City more vigorously attack the known underlying causes of asthma, including both indoor and outdoor air pollution.

• The City expand physical education in the public schools, particularly in the elementary and middle schools.

###