An Introduction to CVD Racial Disparities

An Introduction to Racial Disparities in the
Treatment of Cardiovascular Disease
Polishing our Lens of Research and Care

Dr. Anthony Shackelford DHA, CCP, CCT
Assistant Professor
Cardiovascular Perfusion Program
Medical University of South Carolina

Purpose
 To help increase awareness within the
perfusion community of racial disparities in
the treatment of cardiovascular disease. by
providing:
 a general overview of what health care
disparities are and are not
 the processes and programs in place to reduce
and eliminate health care disparities
 examples of evidence specific to the treatment
of heart disease in the context of racial
disparities
2

What are going to cover?
 General overview of what health care
disparities are and are not
 The processes and programs in place to
reduce and eliminate health care disparities
 Examples of evidence specific to the
treatment of heart disease in the context of
racial disparities
 Applicability to Perfusion

3

Disclaimer

I have no contractual or financial
affiliations with any of the
manufactures of any of the devices
mentioned in this presentation

4

Death Rate due to Heart Disease by
Race/Ethnicity, 2005
329.8
Deaths per 100,000
population:
262.2
228.3
192.4
173.2 170.3
141.1
129.1
115.9
91.9

White, Hispanic African-
Asian andAmerican White, NoHispanic African-
Asian andAmerican
Non- American Pacific Indian/ n- American Pacific Indian/
Hispanic Islander Alaska Hispanic Islander Alaska
Native Native
Men Women
NOTES: Rates are age-adjusted.
DATA: Centers for Disease Control and Prevention, National Center for Health Statistics, National
Vital Statistics System.
SOURCE: Health US, 2007, Table 36.

Starting Point: Health Status
 Determined by a variation
of social and behavioral risk
factors among people of:
 different race/ethnicity
 socioeconomic status (SES)
 gender

 +/- effect on mortality
 Blacks and American Indians >
Whites
 Asian and Pacific Islanders <
Whites.

7

What are Health Disparities?

 Racial or ethnic differences in the quality of
health care that is not due to:
 access-related factors
 clinical needs
 preferences
 appropriateness of intervention

8

Literature “skim” of Racial
Disparities in the Treatment of
Cardiovascular Disease

10

 Trends of CVD mortality by race and
ethnicity
 Findings: CHD mortality rates of black
men and women have declined
 the rate has been slower than white men and
women since the mid 1980’s

11

 17,000 patients for differences with respect to
noninvasive procedures and invasive procedures
(e.g. CABG, CC, PTCA)
 Findings:
 Black men and women < white men and women
to undergo costly cardiovascular procedures

 Hispanics < whites to have received CC / PTCA

(Am J Public Health. 2000;90:1128–1134) 12

 3,015 patients over a two year period
 Statistically significant difference in the utilization rates
comparing Caucasians to African-Americans for CABG

 Although not statistically significant, African-Americans
were less likely than Caucasians to receive a cardiac
catheterization and Percutaneous Transluminal Coronary
Angioplasty (PTCA).

 No significant disparities for gender for the utilization of
invasive treatments for cardiovascular disease.

Journal of Cultural Diversity, 11(3), 80-87.
13

Found that DES use was influenced by demographic,
socioeconomic and hospital characteristics.

blacks and low-income groups were significantly less likely to receive a
DES than their counterparts and differences according to facility
procedural volumes

14

Why this is more important
to North Carolina?
 % of Population Black 1990 ->2000
 United States
248,709,873 -> 281,421,906
 29,980,996 (12.1%) ->34,658,190 (12.3%)

 North Carolina
 6,628,637 -> 8,049,313
 1,456,323 (22.0%) -> 1,737,545 (21.6%)

 South Carolina
 3,486,703 -> 4,012,012
 1,039,884 (29.8%) -> 1,185,216 (29.5%) 16

Federal Policy Actions Taken to
Eliminate & Reduce Disparities
 The Healthcare Research and Quality Act of 1999
 Directed Agency for Healthcare Research and Quality
(AHRQ) to develop 2 annual reports:

 National Healthcare Quality Report (NHQR)

 National Healthcare Disparity Report (NHDR)

 Focus: a more comprehensive snapshot of the
performance of our health care system’s strengths
and areas for future improvement

17

Congress Charges
Institute of Medicine
 Assess the extent of racial and ethnic differences in
healthcare

 Evaluate potential sources of racial and ethnic
disparities
 including the role of bias, discrimination, and stereotyping
 At the individual (provider and patient), institutional, and
health system levels **

 Provide recommendations regarding interventions
to eliminate healthcare disparities.
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Sources of Disparities in Healthcare

 Complex
 Rooted in historic and
contemporary
inequities
 Involve many
participants at several
levels
 health systems
processes
 health care professionals
 patients

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IOM’s Unequal Treatment
www.nap.edu
Recommendations
 Increase awareness of existence of disparities
 Address systems of care
 Support race/ethnicity data collection, quality improvement, evidence-
based guidelines, multidisciplinary teams, community outreach
 Improve workforce diversity
 Facilitate interpretation services
 Provider education
 Health Disparities, Cultural Competence, Clinical Decisionmaking
 Patient education (navigation, activation)
 Research
 Promising strategies, Barriers to eliminating disparities

Goal: Control the System
1. How care is delivered with
respect to the varying patient
demographics.

2. At minimum our healthcare
system and its processes
should not independently
contribute to lesser/negative
outcomes in care.

22

So how are we doing?
Results form the 2011
 Health care quality and access are suboptimal, especially for minority and
low-income groups.

 Quality is improving; access and disparities are not improving.

 Progress is uneven with respect to eight national priorities:
 Two are improving in quality:

 (1) Palliative and End-of-Life Care and (2) Patient and FamilyEngagement.

 Three are lagging: (3) Population Health, (4) Safety, and (5) Access.

 Three require more data to assess:

 (6) Care Coordination,

 (7) Overuse, and

 (8) Health System Infrastructure

 All eight priority areas showed disparities related to race, ethnicity, and
socioeconomic status.
23

Federal Efforts to Address
Health Disparities
 Federal Office of Minority Health
 Efforts within HHS
 Department of Health and Human Services (DHHS)
Interagency Working Group on Health Disparities
 Health Disparities Collaboratives
 Healthy People 2020
 Data Collection
 Legislation
 Reimbursement rates to providers
 Language access laws
 Title VI of the Civil Rights Act of 1964
 Medical malpractice

Potential Policy Levers for
Eliminating Health Disparities
 Coverage
 Piecemeal efforts vs. comprehensive efforts
 Fragmentation of the health care system
 Language access (who should pay?)
 Reimbursement rates and other incentives
 Provider training for cultural competence
 Social policies (education, job training,
housing)
 Health information technology

Examples of System-Level
Efforts to Eliminate Disparities
 Insurance Companies
 National Health Plan Collaborative (NHPC)
 Pay-for-Performance (P4P)

 Disease registries

 Massachusetts General Hospital –
Disparities Solutions Center
 Johns Hopkins Center for Health
Disparities

We are including the
Core Measures for Heart
Attack, Heart Failure and
Pneumonia.

Where Does Perfusion Fit In?

 Provider education:
 Increase awareness of existence of disparities
 Health Disparities, Cultural Competence, Clinical Decision-
making
 Improve workforce diversity

 Support race/ethnicity data collection,
 quality improvement,
 evidence-based guidelines,
 multidisciplinary teams

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Take Home Messages
1. Disparities exist 5. A myriad of efforts
2. Regardless of how are underway to
they fair in the address disparities.
aggregate, all racial
groups have 6. Overall, we still have
problems. a long way to go to
3. Racial groups are eliminate
not monolithic. disparities.
4. Many factors aside
from race impact
health and health
care.

Questions

shackela@musc.edu 30

An Introduction to CVD Racial Disparities

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Editor's Notes