Charles Modlin, M.D., MBA                         Overview & Examples                         Health Disparities in•   Sta...
Disclosures•   I do not have any significant financial    interest or other relationship with the    manufacturers of any ...
Cleveland ClinicMinority Men’s Health Center
Cleveland Clinic Minority Men’s   Health Center/ Health Fair       Established 2003    Special Health Concerns in         ...
Health•   In 1947, The World Health Organization    defined health as:•   “a state of complete     - physical,     - menta...
U.S. Minorities Increasing in    Numbers & Percentage Population•   Minorities:     - African Americans (Blacks), AA     -...
Population of the United States by Race and Hispanic/Latino Origin, Census 2000 and 2010                                  ...
Race in Medicine & Research•   Active debate about meaning, importance•   Possibility of improving prevention and    treat...
Health Disparities in AA’s• Compared to general  population, each year:• 44% more AA’s die from cancer• 30% more die from ...
African Americans Life             Expectancies•   AA’s 6-8 year shorter life expectancy    than whites•   AA’s have not b...
Life Expectancy at Birth (inyears), by Race/Ethnicity, 2007              U.S.   Ohio      White   78.7   78.0      AA     ...
Life Expectancy at Birth Among Black and White Males and Females in the         United States and the Black-White Life Exp...
Number of Deaths per 100,000    Population by Race/Ethnicity,                       2005    United States             Ohio...
Infant Mortality Rate (Deaths per 1,000 Live         Births) by Race/Ethnicity                 2003-2005•   United States ...
Number of Deaths Due to Firearms       per 100,000 Population by         Race/Ethnicity, 2005•   United States            ...
High Blood Pressure Levels Vary     by Race and Ethnicity  Race of Ethnic              Men         Women      Group       ...
Hypertension         African Americans•   HTN risk factor for:    - Kidney, eye, heart, vascular disease    - 7.5 million ...
Cardiovascular Disease and       Heart Failure in AA’s•   CVD leading cause of death in all U.S.    pts.•   Greater incide...
Screening & Treatment    Differences by Race & Gender•   Blacks are less       Paula A. Johnson, MD,    likely to receive ...
Heart Disease in AA•   Heart failure from HTN is > in Blacks (40%) than    Whites (7%).•   Major risk factors: smoking, HT...
Cerebrovascular Disease in AA•   Blacks higher incidence of and    >>mortality from stroke than whites    - Blacks more he...
2005 Stroke Death Rates per     100,000 population           (Kaiser Family Foundation)United States            OhioRateWh...
Cancer in African Americans•   Cancer 2nd leading cause of U.S.    deaths•   AA’s highest death rates in U.S.•   Contribut...
Smoking in African               Americans•   AA tend to start smoking later in life    and fewer cigarettes/day than Whit...
Cancer in AA By Race, AA more likely develop and die of the 4 most common cancers:   Breast,   Prostate,   Colon,   L...
Cancer Incidence Rates by Race          (Kaiser Family Foundation)        2004 Rate Age-Adjusted per 100,000        • Unit...
Number of Cancer Deaths per          100,000 Population by       Race/Ethnicity, 2005 & 2007U.S.    2005 2007     Ohio 200...
Cancer Mortality Trends AmongMen by Race/Ethnicity: ProgressAmong white men in the           •   Among black men in the  U...
Five-year relative survival by stage at diagnosis for                            total cancers          in adults 20 years...
Lung Cancer DeathsTotal Population                                       Rate per 100,000 TOTAL                           ...
Prostate Cancer Deaths     Males                                  Rate per 100,000     TOTAL                              ...
Number of Diabetes Deaths per        100,000 Population by        Race/Ethnicity, 2005    United States   Ohio•   White 22...
Kidney Disease and            African Americans•   The incidence of ESRD in AA is 4 times    greater than in whites.•   HT...
New Cases of End-StageTotal Population                                       Renal Disease                                ...
Renal Transplantation:                 Disparities•   Currently approx.    - 100,000 pts. on Kidney Tx      Waiting list  ...
Renal Transplantation:               Disparities•   Among Appropriate Candidates for Tx, Blacks    are less likely: (UNOS ...
Why Healthcare Disparities?•   Reasons:•   Multifactorial     •   Patient and Provider Factors          •  Culture/ Cultur...
Health Disparities Solutions:        Multifaceted - Based upon our Cleveland   Clinic MMHC Observations   and Research - E...
Solutions: Step 1Health Provider Recognition,Acknowledgment of Existence,Causes & Impact of Health Disparitiesin Minority ...
Doctors on Disparities in Medical                 Care•   Doctors less likely than public to say    disparities are happen...
Health Provider Education• Regarding: - Existence and Impact of   Health Disparities in   Minority Populations
Congressman Louis StokesHealth Equity Lecture Forum,      Established 2006
Cleveland Clinic Journal Medicine       Special Series 2012:Addressing Disparities in Health Care      Guest Editor: Charl...
Disparities in prostate cancer in African American    men: what primary care physicians can do.Wu I, Modlin C. Cleveland C...
SOLUTION: Step 2      Vision & CommitmentInstitutional/Self-Belief that You     Can Make A Difference
Solutions: Step 3:Health Provider Cultural Competency &              Sensitivity•   All providers need to become sensitive...
The African American Barber Shop, Beauty Salon             and Church Initiative A Tool in Development of Medical & Nursin...
Step 4: Community Trust-Building• Key Lesson: Initiative                   Barbershop, Salon, Church• Trust is single most...
Solutions: Step 5African American Physician Leadership,        Visibility & Availability: Very Important To The African Am...
Become Part of the Community: Build Trusting Relationships
Become Part of the Community: Build Trusting Relationships
TEAMWORK & VOLUNTEERISM:             Step 6•   Dept. Urology•   Dept. Nephrology•   Medicine Institute•   Cleveland Clinic...
Community & CorporatePartners and Sponsors: Step 7
Solutions: Step 8•   Facilitated Patient Access•   Financial/ Charity Assistance Programs
Cleveland Clinic      Financial Assistance Program•   Under Ohio Hospital Care Assurance Program (HCAP)    Cleveland Clini...
Financial Assistance Program                     Family Size   HCAP 2008      CC Financial                                ...
Facilitated Patient Access:   Step 9: Preventive HealthScreenings & Health Education
“Every Life Deserves World Class Care”
10th Annual Minority Men’s        Health Fair
Health Fair Video•   Courtesy Mr. Greg Lockhart     - Frame By Frame Video        Productions     http://www.youtube.com/w...
Health Screenings: Identification of Diseases in Early Treatable States
MMHC Health Fair Screenings 2007       600       500                                                                      ...
Solutions: Step 10: Dedicated     Health Literacy Education•   Health Education/ Outreach    to Promote/ Improve Health   ...
Minority Men’s Health Center         Health Fair  Health Information You Need To               Know!  (With Pre & Post Tes...
Kidney Disease and Kidney         Transplantation•   Diabetes and high-blood pressure    cause most kidney disease and kid...
Diabetes•   Risk factors for diabetes are:    - Genetics    - Obesity    - Lack of exercise    - Other predisposing factors
Solution: Step 11:                Communications    Health Disparities Public Media Campaign•   TV Media/ News•   Print Me...
Media Awareness
Solutions: Step 12Patient Compliance: How To Improve It
Solutions: Step 13  Community Empowerment:Cleveland Clergy Ambassadors  Health Education Program
2012 Minority Men’s Health Center     Health Advocates
Solutions: Step 14Translational Medicine to Benefit  Health Disparity Populations
Solutions: Step 15Encourage Minority Patient Participation in Clinical     Research Trials
Response to Medications            African Americans•   Differences in genetics, environmental and cultural    factors may...
Etiology of Heart Failure                  in Black Patients                            HTN                             CA...
A-HeFT: Additional 43% Reduction in Mortality Beyond Current                           Standard Therapies                 ...
Solutions:Step 16: Mentorship: Developing   Future Healthcare Leaders
Increasing Diversity of Health     Provider Workforce
Solutions: Step 17:Develop Community Partnerships
Community Leadership &Celebrity Endorsement of     MMHC: Step 18
Bill Cobbs: Hollywood Actor        on Disease Prevention & Early Detection•   http://www.youtube.com/watch?v=-HE7I_J-q98&f...
Health Policy Advocacy:                Step 19:United States Congressional Black Caucus,            U.S. Capital,         ...
Healthy People 2000: Priority Areas•   1. Physical Activity and Fitness    2. Nutrition    3. Tobacco    4. Substance Abus...
Healthy People 2010•   Healthy People 2010 challenges individuals, communities,    professionals, and institutions—all of ...
Step 20:Promotion of & Celebration  of Family Support Systems andAwareness of Family Medical History
Solutions: Step 21        Outcomes Research•   Look at health outcomes in your own    practice and at your own institution...
Analysis of Disparities in Kidney  Transplantation by Race at      Cleveland ClinicSection of Renal Transplantation Minori...
Health Disparities in Renal Graph     Survival in Tx Patients by Race and             Source of AllograftCadaveric (CAD)  ...
Dialysis 1st Week Post-TxSignificant Disparities in Dialysis following the FirstWeek of Post Renal Transplantations (Post-...
Post-Tx Serum Creatinine (CAD)Creatinine Levels from Cadaveric Donors, Significant Difference at 7                        ...
STEP 22:   Putting it all together:  Develop and Implement  Multifaceted InnovativePrograms to Address Health         Disp...
•   Transplantation    Proceedings    Volume 40, Issue 4 ,    Pages 1001-1004, May    2008
Culturally Sensitive & Competent Team toPromote Organ Donor Registration
Expanding Organ DonationAcceptance and TransplantRates in African Americans            ANDPromotion of Prevention of Kidne...
Solution: Promotion of Living Kidney Donation in African          Americans
Living Unrelated Renal           Transplantation• http://www.youtube.com/watch?v=jy0CsHLL8YE
Living Related Renal  Transplantation
Standard Surgical Techniques for Kidney Transplantation
Renal Allograft
Solutions:   Innovations in Healthcare:Look to see how you can innovate      to improve outcomes•   Utilization of Expande...
Expanded Criteria DonorKidneys for Transplantation              •   Modlin CS,                  Goldfarb DA, Novick       ...
Issues and Techniques Available to Expand     the Pool of Kidneys Available For         Transplantation. MODLIN           ...
Multiple Renal Arteries
End-To-Side Arterial   Anastamosis
Dual Mate Kidney with 3 Arteries
Dual Mate Kidney with 4 Arteries
Dual Deceased Donor Allograft
Pediatric Deceased Donor     Kidneys For Transplantation•   Modlin C, Novick AC, Goormastic M, Hodge E,    Mastrioanni B, ...
Pediatric Enbloc Allografts
Pediatric Enbloc Kidneys
Pediatric Enbloc Kidney       Allografts
Pediatric Enbloc Allografts
Pediatric Enbloc Post Perfusion
Capsular Repair Vicryl Mesh
Capsular Repair
Renal Capsular Repair•   J Natl Med Assoc.    2012;104:199-201
Renal Angiomyolipomain Living Donor Kidney
Living Donor Kidney with Renal Artery Aneurysm
Dr. charles modlin nma new orleans urology presentation july 30 2012
Dr. charles modlin nma new orleans urology presentation july 30 2012
Dr. charles modlin nma new orleans urology presentation july 30 2012
Dr. charles modlin nma new orleans urology presentation july 30 2012
Dr. charles modlin nma new orleans urology presentation july 30 2012
Dr. charles modlin nma new orleans urology presentation july 30 2012
Dr. charles modlin nma new orleans urology presentation july 30 2012
Dr. charles modlin nma new orleans urology presentation july 30 2012
Dr. charles modlin nma new orleans urology presentation july 30 2012
Dr. charles modlin nma new orleans urology presentation july 30 2012
Dr. charles modlin nma new orleans urology presentation july 30 2012
Dr. charles modlin nma new orleans urology presentation july 30 2012
Dr. charles modlin nma new orleans urology presentation july 30 2012
Dr. charles modlin nma new orleans urology presentation july 30 2012
Dr. charles modlin nma new orleans urology presentation july 30 2012
Dr. charles modlin nma new orleans urology presentation july 30 2012
Dr. charles modlin nma new orleans urology presentation july 30 2012
Dr. charles modlin nma new orleans urology presentation july 30 2012
Dr. charles modlin nma new orleans urology presentation july 30 2012
Upcoming SlideShare
Loading in …5
×

Dr. charles modlin nma new orleans urology presentation july 30 2012

413
-1

Published on

Published in: Health & Medicine, Business
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
413
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
10
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide
  • This definition implies that health is a complex mechanism involving more components than freedom from physical disease and pain. It is an evolving process involving social, spiritual, emotional, physical and intellectual considerations.
  • Black Americans who are economically advantaged do not enjoy in equal measure with whites the expected positive influence of affluence on their health. One possible explanation relates to the high stress levels that middle class AA’s experience (relative to whites). Prolonged High-effort mental coping mechanisms among African Americans who succeed in white-collar work environments contributes to hypertension and increased heart rate.
  • Heart disease. Race and ethnicity influence a patient's chance of receiving many specific procedures and treatments. African Americans are 13 percent less likely to undergo coronary angioplasty and one-third less likely to undergo bypass surgery than are whites. Heart failure due to hypertension is more common in Blacks (40%) than whites (7%). The major risk factors are smoking, htn, high cholesterol, and physical inactivity. AA’s have less knowledge about risk factors than do whites, even when taking age and education into consideration. The AA diet stresses the consumption of meat, esp. pork, fried foods and eggs, and is high in cholesterol and saturated fats. Physician Decisionmaking A small study of physicians' decisions about whether to refer patients for cardiac catheterization, a diagnostic procedure for heart disease, provides supportive evidence that factors other than insurance and income can influence the quality of care people get. This study, which used actors portraying similar economic backgrounds, found that black women were significantly less likely than white men to be recommended for referral, despite reporting the same symptoms.
  • Some risk factors for stroke—age, male sex, black race and family history of stroke, are non-modifiable. Hypertension is the most important modifiable risk factor in all populations. Other important modifiable factors include diabetes, afib, tia, alcoholism, smoking, obesity, low physical exercise, poor nutrition, hypercoagulable states, and use of illicit drugs, oral contraceptives and hormone replacement therapy.
  • Cancer is the 2 nd leading cause of death in the U.S. and significant burden to AA’s, who have the highest death rates. The incidence of cervical cancer in AA is double that of whites. Contributing factors: tobacco, occupations, diet, knowledge, attitudes and practices, health/medical resources, biological factors, and socioeconomic status. 55% of deaths in AA are caused by smoking-related diseases.
  • The prevalence of smoking among young black males doubled from 14.2 to 28.2% from 1991-1997. A smoking cessation study examined the effects of physician recommendation to quit smoking and noted that people who were told by physicians to stop smoking did so twice as often successfully as those not told by a physician.
  • More research is needed on the identification, prevention, treatment, and care cancer in the minority population.
  • Approx. 37% of all internal cancers diagnosed in AA men are prostate cancer. This translates to about 225 per 100,000 new AA cases of cancer, which is more than the combined projections for the next 5 leading cancer sites. The incidence of prostate cancer in the age group 45-49 for blacks is 12.6/100,000 compared to whites 7.4/100,000
  • The incidence of ESRD in AA is 4 times greater than in whites. HTN and DM are the most commonly identified causes of kidney failure, but regardless of the diagnosis, AA are at greater risk than whites of requiring dialysis or transplantation.
  • The number of cadaveric transplants is roughly 4 per 100 dialysis patient-years among white men, 3 per 100 dialysis years among white women and black men and 2 per 100 dialysis years among black women. The demand for organs has outpaced supply. Whites are more than 2 times as likely as blacks to be wait-listed before dialysis. Factors believe to account for some of the disparities: AA once referred do not advance through the process as quickly: some reasons are related to place of recidence, educational level, functionality on dialysis, and associated medical comorbidity.
  • Poverty is the most important factor and affects the ability to afford preventive and routine health services. Other barriers to health are: transportation, long waiting times, inconvenient hours of service and confusion at the clinic or hospital atmosphere and other factors. These barriers cause AA’s to revert to public medical facilities with distant appointments, contribute to the advancement of illnesses and the high use of costly ER services. Limited education and illiteracy obstruct the ability to interpret and comprehend health-related information. The persistent association between race and lack of health care utilization, even with the same socioeconomic stratum, suggests that discrimination and physician bias is still a plausible explanation.
  • Many white health care professionals have difficulties understanding the African American culture, beliefs, and expectations. The body language between African Americans and Whites can also be a barrier. Most providers are not educated and trained to be culturally sensitive. The cultural barriers are built into the very fabric of the U.S. health system model, which emphasizes isolating and treating different ailments through specialized practitioners, rather than a holistic approach. Beware, not all African Americans think or act or react the same way. The provider needs to interact with each patient to develop his/her holistic, culturally competent plan of care. With this approach, quality is maximized, and outcomes are more successful.
  • Etiology of Heart Failure in Black Patients Retrospective analyses of V-HeFT-I, V-HeFT-II, SOLVD, US Carvedilol, BEST, and MERIT-HF have reported subgroup data demonstrating that black patients have a higher incidence of HTN as a cause of LVD than do non-blacks. HF in non-black patients is more likely to be caused by CAD than by HTN. 40%-80% of HF cases in blacks are caused by HTN. 50%-80% of HF cases in whites are caused by CAD. Reference Yancy CW. Heart failure in African Americans: pathophysiology and treatment. J Card Fail. 2003;9(suppl 5):S210-S215.
  • A-HeFT: Additional 43% Reduction in Mortality Beyond Current Standard Therapies This Kaplan-Meier curve shows an additional 43% decrease in mortality among those patients treated with BiDil plus standard therapies. This result led to the Data Safety and Monitoring Board’s recommendation to terminate the trial early. Reference BiDil [prescribing information]. Lexington, MA: NitroMed, Inc.; 2005.
  • Dr. charles modlin nma new orleans urology presentation july 30 2012

    1. 1. Charles Modlin, M.D., MBA Overview & Examples Health Disparities in• Staff Urologist Racial/ Ethnic Minority• Kidney Transplant Populations Surgeon Discuss Causes of• Founder & Health Disparities Director, Minority Men’s Health Health Disparities Center Prevention• Cleveland Clinic Highlight Cleveland Clinic Programs Designed to Address Multifaceted Health Disparities
    2. 2. Disclosures• I do not have any significant financial interest or other relationship with the manufacturers of any products or providers of services I intend to discuss.•
    3. 3. Cleveland ClinicMinority Men’s Health Center
    4. 4. Cleveland Clinic Minority Men’s Health Center/ Health Fair Established 2003 Special Health Concerns in Minority Males
    5. 5. Health• In 1947, The World Health Organization defined health as:• “a state of complete - physical, - mental, and - social well-being and - not merely the absence of disease and infirmity”
    6. 6. U.S. Minorities Increasing in Numbers & Percentage Population• Minorities: - African Americans (Blacks), AA - Hispanic/ Latinos, H/L - Asian, A - Native American, (American Indians), NA - Pacific Islander, PI• 1970: All U.S. Minorities 12.3% population• 2003: All U.S. Minorities 25%• 2006: All U.S. Minorities 30%• 2050: Projected 50%
    7. 7. Population of the United States by Race and Hispanic/Latino Origin, Census 2000 and 2010 Census Census 2010, Percent of 2000, Percent ofRace and Hispanic/Latino origin population population population populationTotal Population 308,745,538 100.0% 281,421,906 100.0%Single raceWhite 196,817,552 63.7 211,460,626 75.1Black or African American 37,685,848 12.2 34,658,190 12.3American Indian and Alaska Native 2,247,098 .7 2,475,956 0.9Asian 14,465,124 4.7 10,242,998 3.6 Native Hawaiian and other Pacific 481,576 0.15 398,835 0.1IslanderTwo or more races 5,966,481 1.9 6,826,228 2.4Some other race 604,265 .2 15,359,073 5.5Hispanic or Latino 50,477,594 16.3 35,305,818 12.5NOTE: Percentages do not add up to 100% due to rounding and because Hispanics may be of any race and are therefore countedunder more than one category.Source: U.S. Census Bureau: National Population Estimates; Decennial Census.Read more: Population of the United States by Race and Hispanic/Latino Origin, Census 2000and July 1, 2005 — Infoplease.com http://www.infoplease.com/ipa/A0762156.html#ixzz1yins01sM
    8. 8. Race in Medicine & Research• Active debate about meaning, importance• Possibility of improving prevention and treatment of diseases by predicting hard-to- ascertain factors on the basis of more easily ascertained characteristics• Race: surrogate marker of increased likelihood of certain medical conditions
    9. 9. Health Disparities in AA’s• Compared to general population, each year:• 44% more AA’s die from cancer• 30% more die from heart disease• 180% more die from strokehttp://www.cdc.gov/cancer/dcpc/data/race.htmhttp://www.kff.org/minorityhealth/index.cfm
    10. 10. African Americans Life Expectancies• AA’s 6-8 year shorter life expectancy than whites• AA’s have not benefited equally from medical advances• AAs economically advantaged do not enjoy in equal measure with whites expected +++ influence of affluence on their health.
    11. 11. Life Expectancy at Birth (inyears), by Race/Ethnicity, 2007 U.S. Ohio White 78.7 78.0 AA 74.3 73.3 H/L 83.5 80.4 Asian 87.3 83.4 NA 75.1 NSD
    12. 12. Life Expectancy at Birth Among Black and White Males and Females in the United States and the Black-White Life Expectancy Gap, 1975-2003Harper, S. et al. JAMA 2007;0:297.11.1224-1232. Copyright restrictions may apply.
    13. 13. Number of Deaths per 100,000 Population by Race/Ethnicity, 2005 United States Ohio• White 785.3 White 850.4• Black 1,016.6 Black 1,078.1• Other 476.5 Other 291.2 2008 United States Ohio White 750.3 White 828.0 Black 934.9 Black 1,029.2 Other 445.8 Other 325.7
    14. 14. Infant Mortality Rate (Deaths per 1,000 Live Births) by Race/Ethnicity 2003-2005• United States Ohio• Non-Hispanic White 5.7 6.4• Non-Hispanic Black 13.6 15.6• Hispanic 5.6 6.5• 2007 Non-HW NH-Black Hispanic• United States 5.7 13.4 5.5• Ohio 6.4 15.3 6.6
    15. 15. Number of Deaths Due to Firearms per 100,000 Population by Race/Ethnicity, 2005• United States Ohio• White 8.9 White 7.7• Black 19.4 Black 22.3• Other 4.1 Other NSDhttp://www.statehealthfacts.org/comparebar.jsp?ind=115&cat=2&sub=32&yr=63&typ=3
    16. 16. High Blood Pressure Levels Vary by Race and Ethnicity Race of Ethnic Men Women Group (%) (%) African 43.0 45.7 Americans Mexican 27.8 28.9 Americans Whites 33.9 31.3 All 34.1 32.7 http://www.cdc.gov/bloodpressure/facts.htm
    17. 17. Hypertension African Americans• HTN risk factor for: - Kidney, eye, heart, vascular disease - 7.5 million Blacks - High salt diets, urban living, poverty, psychosocial factors: stress, genetic predisposition - Greater likelihood of being untreated
    18. 18. Cardiovascular Disease and Heart Failure in AA’s• CVD leading cause of death in all U.S. pts.• Greater incidence in AA’s• Race and ethnicity influence a patients chance of receiving many specific procedures and treatments: - AA 13% less likely to have coronary angiography, 1/3 less to have bypass
    19. 19. Screening & Treatment Differences by Race & Gender• Blacks are less Paula A. Johnson, MD, likely to receive MPH major procedures Brigham and Women’s Hospital diagnosing and treating coronary Sources: Schulman KA et al, heart disease than N Engl J Med 1999;340(8); whites Ayanian JZ et al, JAMA,• Black women are 1993;269,20; Giles et al, the least likely to Arch Intern Med have such 1995;155(3); Johnson PA procedures et al, Ann Intern Med recommended 1993;119(8))
    20. 20. Heart Disease in AA• Heart failure from HTN is > in Blacks (40%) than Whites (7%).• Major risk factors: smoking, HTN, high cholesterol, physical inactivity.• AA’s: - less knowledge about risk factors than whites, even per age and education.• AA diet consumption of meat, fried foods, high in cholesterol and saturated fats.• Physician Decision-making
    21. 21. Cerebrovascular Disease in AA• Blacks higher incidence of and >>mortality from stroke than whites - Blacks more hemorrhagic vs. ischemic (Stroke 1991^22:299-304)• Race and ethnicity influence a patients chance of receiving many specific procedures and treatments.
    22. 22. 2005 Stroke Death Rates per 100,000 population (Kaiser Family Foundation)United States OhioRateWhite White44.7 48.2Black Black65.2 60.3Other Other38 31.9
    23. 23. Cancer in African Americans• Cancer 2nd leading cause of U.S. deaths• AA’s highest death rates in U.S.• Contributing factors: Tob, occupations, diet, knowledge, attitudes and practices, health/medical resources, biological factors, socioeconomic status.
    24. 24. Smoking in African Americans• AA tend to start smoking later in life and fewer cigarettes/day than Whites• More likely smoke Tar and Nicotine brands, 55% AA use only mentholated form• AA less likely than Whites to quit• AA 30% higher Nicotine intake per cigarette and differ in metabolism• Clin Immunol Immunopathol. 1991 May;59(2):187-200.
    25. 25. Cancer in AA By Race, AA more likely develop and die of the 4 most common cancers:  Breast,  Prostate,  Colon,  Lung—  Cancer Incidence and Death Rates* by Site, Race, and Ethnicity†, US, 2004-2008. American Cancer Society. Cancer Facts & Figures 2012. Atlanta: American Cancer Society; 2012.
    26. 26. Cancer Incidence Rates by Race (Kaiser Family Foundation) 2004 Rate Age-Adjusted per 100,000 • United States Ohio • White 455.4 White 426.1 • Black 469.6 Black 453.6 • Hispanic 356.5 Hispanic 403.7 0.0 - 471.7United States RateWhite 462.5Black 471.7Hispanic• 350.1 • 2007
    27. 27. Number of Cancer Deaths per 100,000 Population by Race/Ethnicity, 2005 & 2007U.S. 2005 2007 Ohio 2005 2007White 182.6 174.7 Whites 194.2 190.5Black 222.7 209.1 Blacks 249.2 238.1Other 112.4 108.5 Other 66.0 91.3
    28. 28. Cancer Mortality Trends AmongMen by Race/Ethnicity: ProgressAmong white men in the • Among black men in the United States from 1999 to United States from 1999 to 2008, deaths from— 2008, deaths from— - Colorectal cancer - Colorectal cancer decreased significantly decreased significantly by 3.0% per year. by 1.9% per year. - Lung cancer decreased - Lung cancer decreased significantly by 2.0% significantly by 2.8% per year. per year. - Prostate cancer - Prostate cancer decreased significantly decreased significantly by 3.4% per year. by 3.7% per year. - Melanoma of the skin - Melanoma of the skin increased significantly remained level. by 1.0% per year.
    29. 29. Five-year relative survival by stage at diagnosis for total cancers in adults 20 years and older by race and gender Source: SEER 1992-2001 Stage atdiagnosis Local Regional Distant All StagesDistant All stagesGender Race Diagnosed % Survival %Diagnosed % Survival % Diagnosed % Survival % Survival %Men Black 54 92 20 31 26 16 56 White 58 95 20 43 22 20 64Women Black 40 83 33 50 27 15 51 White 50 92 28 61 22 21 64Local
    30. 30. Lung Cancer DeathsTotal Population Rate per 100,000 TOTAL 57.6 Race and ethnicity American Indian or Alaska Native 38.2 Asian or Pacific Islander 29.3 Asian DNC Native Hawaiian and other Pacific Islander DNC Black or African American 66.7 White 57.5 Hispanic or Latino 22.7
    31. 31. Prostate Cancer Deaths Males Rate per 100,000 TOTAL 32.0 Race and ethnicity American Indian or Alaska Native 15.9 Asian or Pacific Islander 12.4 Asian DNC Native Hawaiian and other Pacific Islander DNC Black or African American 68.7 White 29.4 Hispanic or Latino 20.9Data source: National Vital Statistics System (NVSS), CDC, NCHS.
    32. 32. Number of Diabetes Deaths per 100,000 Population by Race/Ethnicity, 2005 United States Ohio• White 22.5 White 28.4• Black 47.0 Black 58.3• Other 20.5 Other NSD
    33. 33. Kidney Disease and African Americans• The incidence of ESRD in AA is 4 times greater than in whites.• HTN and DM are the most commonly identified causes of kidney failure• National chronic kidney disease fact sheet, 2007. http://www.cdc.gov/diabetes/pubs/factsheets/kidney.htm
    34. 34. New Cases of End-StageTotal Population Renal Disease Rate per MillionTOTAL 289Race and ethnicityAmerican Indian or Alaska Native 586Asian or Pacific Islander 344Asian DNCNative Hawaiian and other Pacific Islander DNCBlack or African American 873White 218GenderFemale 242Male 348 Data source: U.S. Renal Data System (USRDS), NIH, NIDDK.
    35. 35. Renal Transplantation: Disparities• Currently approx. - 100,000 pts. on Kidney Tx Waiting list •35% AA; 19%H/L •But AA’s only 12% U.S. population; H/L 16% • NIH News http://www.nih.gov/news/health/mar2012/niddk-08.htm • AA only get 26% of Deceased Donor Kidney Tx
    36. 36. Renal Transplantation: Disparities• Among Appropriate Candidates for Tx, Blacks are less likely: (UNOS Scientific Registry) - referred for evaluation - listed for Tx (account for only 28% new listing) - receive Tx - Post Tx have higher rejection rates (50% higher), lower patient and graft survival Blacks wait 2-4 times as long as whites
    37. 37. Why Healthcare Disparities?• Reasons:• Multifactorial • Patient and Provider Factors • Culture/ Culture Competency/ Communication • Education/ Health Literacy • Historical Factors/ Distrust/ Racism/ Stereotyping/ Bias • Socio-Economic • Lack of health insurance • Lack of Access • Environment/ Nutrition • Lack of Diverse Healthcare Workforce • Genetics/ Biologic/ Diff. Response to Medications • Lack of Minority Patients in Research Trials • Sub-specialization in Medicine & Lack of Awareness of Disparities
    38. 38. Health Disparities Solutions: Multifaceted - Based upon our Cleveland Clinic MMHC Observations and Research - Examples of our Cleveland Clinic Innovative Solutions/ Programs
    39. 39. Solutions: Step 1Health Provider Recognition,Acknowledgment of Existence,Causes & Impact of Health Disparitiesin Minority Populations
    40. 40. Doctors on Disparities in Medical Care• Doctors less likely than public to say disparities are happening “very often” or “somewhat often.”• Kaiser Family Foundation Survey, March 2002. http://www.kff.org/minorityhealth/20020321a-index.cfm
    41. 41. Health Provider Education• Regarding: - Existence and Impact of Health Disparities in Minority Populations
    42. 42. Congressman Louis StokesHealth Equity Lecture Forum, Established 2006
    43. 43. Cleveland Clinic Journal Medicine Special Series 2012:Addressing Disparities in Health Care Guest Editor: Charles Modlin, MD, MBA • Modlin CS. Addressing Disparities in Health Care Cleveland Clinic Journal of Medicine January 2012 vol. 79 (1): 44-45.
    44. 44. Disparities in prostate cancer in African American men: what primary care physicians can do.Wu I, Modlin C. Cleveland Clinic Journal of Medicine May 2012 vol. 79 5 313-320
    45. 45. SOLUTION: Step 2 Vision & CommitmentInstitutional/Self-Belief that You Can Make A Difference
    46. 46. Solutions: Step 3:Health Provider Cultural Competency & Sensitivity• All providers need to become sensitive to traditions, values, attitudes of ethnic groups - Mandated in some states, i.e. New Jersey first state• Cultural sensitiveness indicates how culture can strongly influence the amount and type of communication between patients and their health providers
    47. 47. The African American Barber Shop, Beauty Salon and Church Initiative A Tool in Development of Medical & Nursing Student & Health Provider Cultural Competency/Sensitivity
    48. 48. Step 4: Community Trust-Building• Key Lesson: Initiative Barbershop, Salon, Church• Trust is single most important prerequisite necessary for healthcare providers to have success in promoting health in AA communities.
    49. 49. Solutions: Step 5African American Physician Leadership, Visibility & Availability: Very Important To The African American Community
    50. 50. Become Part of the Community: Build Trusting Relationships
    51. 51. Become Part of the Community: Build Trusting Relationships
    52. 52. TEAMWORK & VOLUNTEERISM: Step 6• Dept. Urology• Dept. Nephrology• Medicine Institute• Cleveland Clinic Interdepartmental Clinical Collaborations• Wellness Institute• Dept. Pastoral Care Services• Dept. Social Work• Pharmacy• Division of Nursing• Nutrition Services• Institutional Services (Pt. Education, OPSA, Sponsored Research, etc.)• Corporate Communications• Governmental & Community Relations• Diversity• Bioethics• Biostatistics• Cleveland Clinic Lerner College of Medicine• Lerner Research Institute
    53. 53. Community & CorporatePartners and Sponsors: Step 7
    54. 54. Solutions: Step 8• Facilitated Patient Access• Financial/ Charity Assistance Programs
    55. 55. Cleveland Clinic Financial Assistance Program• Under Ohio Hospital Care Assurance Program (HCAP) Cleveland Clinic offers basic, medically necessary hospital-level services free of charge to individuals who are residents of Ohio, and who are currently eligible recipients of the General Assistance or the Disability Assistance Programs or whose income is at or below the Federal Poverty Income Guidelines.• In addition, Cleveland Clinic provides financial assistance on a sliding scale to patients who do not have insurance at family income levels up to four (4) times the Federal Poverty Income Guidelines, and to all patients, including patients with insurance coverage, if there are exceptional circumstances.
    56. 56. Financial Assistance Program Family Size HCAP 2008 CC Financial Federal Assistance• 2008 Federal Poverty Income Level Program (Family Income up to 400% of Poverty Income Federal Poverty Level) Guidelines 1 $10,400 $41,600 2 $14,000 $56,000 3 $17,600 $70,400 4 $21,200 $84,800 5 $24,800 $99,200 6 $28,400 $113,600 7 $32,000 $128,000 8 $35,600 $142,400
    57. 57. Facilitated Patient Access: Step 9: Preventive HealthScreenings & Health Education
    58. 58. “Every Life Deserves World Class Care”
    59. 59. 10th Annual Minority Men’s Health Fair
    60. 60. Health Fair Video• Courtesy Mr. Greg Lockhart - Frame By Frame Video Productions http://www.youtube.com/watch?v=3L4zEnecs9M
    61. 61. Health Screenings: Identification of Diseases in Early Treatable States
    62. 62. MMHC Health Fair Screenings 2007 600 500 422 439 400 400eltiT 300si 217xA 200 200 153 120 100 0 Dental Screenings Blood Pressure Stress Urinalysis Reviewed DRE Blood draws & Oral Hygiene Screening Management Medications Instruction Series1 120 153 200 217 400 422 439
    63. 63. Solutions: Step 10: Dedicated Health Literacy Education• Health Education/ Outreach to Promote/ Improve Health • Health Literacy Literacy Saves Lives - Increase awareness of preventive health - Increase health screenings - Promote healthy lifestyles - Promote participation in clinical trials by minorities - Promote awareness of family medical history
    64. 64. Minority Men’s Health Center Health Fair Health Information You Need To Know! (With Pre & Post Test Options)
    65. 65. Kidney Disease and Kidney Transplantation• Diabetes and high-blood pressure cause most kidney disease and kidney failure.• Control of your blood pressure and blood sugar may prevent kidney disease.• Kidney transplantation is a way to treat kidney failure. More AA are needed to donate their kidneys while living or after death.
    66. 66. Diabetes• Risk factors for diabetes are: - Genetics - Obesity - Lack of exercise - Other predisposing factors
    67. 67. Solution: Step 11: Communications Health Disparities Public Media Campaign• TV Media/ News• Print Media
    68. 68. Media Awareness
    69. 69. Solutions: Step 12Patient Compliance: How To Improve It
    70. 70. Solutions: Step 13 Community Empowerment:Cleveland Clergy Ambassadors Health Education Program
    71. 71. 2012 Minority Men’s Health Center Health Advocates
    72. 72. Solutions: Step 14Translational Medicine to Benefit Health Disparity Populations
    73. 73. Solutions: Step 15Encourage Minority Patient Participation in Clinical Research Trials
    74. 74. Response to Medications African Americans• Differences in genetics, environmental and cultural factors may lead to racial differences in response to medications.• Studies and Examples:• AA respond better to Calcium Antagonists - Whites respond better to ACE and B-Blockers - BiDil—New Med to treat CHF in AA - RACE-BASED MEDICINE - Immunosuppressive Medications in AA
    75. 75. Etiology of Heart Failure in Black Patients HTN CAD LVH MI HF More common cause More common cause of of HF cases in blacks HF cases in whitesLVH=left ventricular hypertrophy.Adapted from Yancy CW. J Card Fail. 2003;9(suppl 5):S210-S215.
    76. 76. A-HeFT: Additional 43% Reduction in Mortality Beyond Current Standard Therapies 100 BiDil + Standard Therapies 95 Survival (%) 90 Placebo + Standard Therapies Event rate=6.2% 43% Reduction* P=.012 by Log-Rank Test 85 Event rate=10.2% 0 100 200 300 400 500 600 Time (days) BiDil, n = 518 463 407 360 314 253 16 Placebo, n = 532 466 401 340 285 233 25*Reduction refers to relative risk in mortality 1 – (hazard ratio) =1 – 0.57 =0.43. Reduction represents full length of follow-up.BiDil [prescribing information]. Lexington, MA: NitroMed, Inc.; 2005.
    77. 77. Solutions:Step 16: Mentorship: Developing Future Healthcare Leaders
    78. 78. Increasing Diversity of Health Provider Workforce
    79. 79. Solutions: Step 17:Develop Community Partnerships
    80. 80. Community Leadership &Celebrity Endorsement of MMHC: Step 18
    81. 81. Bill Cobbs: Hollywood Actor on Disease Prevention & Early Detection• http://www.youtube.com/watch?v=-HE7I_J-q98&featu
    82. 82. Health Policy Advocacy: Step 19:United States Congressional Black Caucus, U.S. Capital, Washington, D.C.
    83. 83. Healthy People 2000: Priority Areas• 1. Physical Activity and Fitness 2. Nutrition 3. Tobacco 4. Substance Abuse: Alcohol and Other Drugs 5. Family Planning 6. Mental Health and Mental Disorders 7. Violent and Abusive Behavior 8. Educational and Community-Based Programs 9. Unintentional Injuries 10. Occupational Safety and Health 11. Environmental Health 12. Food and Drug Safety 13. Oral Health 14. Maternal and Infant Health 15. Heart Disease and Stroke 16. Cancer 17. Diabetes and Chronic Disabling Conditions 18. HIV Infection 19. Sexually Transmitted Diseases 20. Immunization and Infectious Diseases 21. Clinical Preventive Services 22. Surveillance and Data Systems
    84. 84. Healthy People 2010• Healthy People 2010 challenges individuals, communities, professionals, and institutions—all of us— to take specific steps to ensure that good health, as well as long life, are enjoyed by all.• Healthy People is managed by the Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services
    85. 85. Step 20:Promotion of & Celebration of Family Support Systems andAwareness of Family Medical History
    86. 86. Solutions: Step 21 Outcomes Research• Look at health outcomes in your own practice and at your own institution• Know how you are doing• Develop strategies to improve your outcomes
    87. 87. Analysis of Disparities in Kidney Transplantation by Race at Cleveland ClinicSection of Renal Transplantation Minority Men’s Health Center C. Modlin, C. Zaramo, J. Alster, L. Zhou, D. Goldfarb, S. Flechner, and A. Novick
    88. 88. Health Disparities in Renal Graph Survival in Tx Patients by Race and Source of AllograftCadaveric (CAD) Living Related (LR)
    89. 89. Dialysis 1st Week Post-TxSignificant Disparities in Dialysis following the FirstWeek of Post Renal Transplantations (Post-Tx, p<0.001*) 100 *p< 0.0001 Percentage (%) 80 52.14% 60 40 15% 20 8.16% 5.14% 0 African Caucasian African Caucasian (L) American (CAD) (CAD) American (L) Race/ Ethnicity
    90. 90. Post-Tx Serum Creatinine (CAD)Creatinine Levels from Cadaveric Donors, Significant Difference at 7 Days (p<0.0001), 1 month (p=0.005) and 2 Months (1 Year ) (p< 0.004) * 7 African American (CAD) p=0.0001 White (CAD 6 5 P<.0001 @ 7 days P<.008 @ 12 mos. 4 3 * p=0.005 2 1 * p=0.004 0 Day 7 1 3 6 12 36 Time
    91. 91. STEP 22: Putting it all together: Develop and Implement Multifaceted InnovativePrograms to Address Health Disparities
    92. 92. • Transplantation Proceedings Volume 40, Issue 4 , Pages 1001-1004, May 2008
    93. 93. Culturally Sensitive & Competent Team toPromote Organ Donor Registration
    94. 94. Expanding Organ DonationAcceptance and TransplantRates in African Americans ANDPromotion of Prevention of Kidney Disease in African Americans
    95. 95. Solution: Promotion of Living Kidney Donation in African Americans
    96. 96. Living Unrelated Renal Transplantation• http://www.youtube.com/watch?v=jy0CsHLL8YE
    97. 97. Living Related Renal Transplantation
    98. 98. Standard Surgical Techniques for Kidney Transplantation
    99. 99. Renal Allograft
    100. 100. Solutions: Innovations in Healthcare:Look to see how you can innovate to improve outcomes• Utilization of Expanded Criteria Donor Kidneys for Transplantation: - Single Pediatric Deceased Donor Allografts - Pediatric Enbloc Deceased Donor Allografts - Kidneys with multiple arteries - Dual Deceased Donor Allografts - Kidneys with capsular injuries - Kidneys with renal artery aneurysms
    101. 101. Expanded Criteria DonorKidneys for Transplantation • Modlin CS, Goldfarb DA, Novick AC. The use of expanded criteria cadaver and live donor kidneys for transplantation. Urol transplantation Clin North Am. 2001 Nov;28(4):687-707.
    102. 102. Issues and Techniques Available to Expand the Pool of Kidneys Available For Transplantation. MODLIN • Chapter 10. In Kidney and Pancreas Transplantation: A Practice Guide.
    103. 103. Multiple Renal Arteries
    104. 104. End-To-Side Arterial Anastamosis
    105. 105. Dual Mate Kidney with 3 Arteries
    106. 106. Dual Mate Kidney with 4 Arteries
    107. 107. Dual Deceased Donor Allograft
    108. 108. Pediatric Deceased Donor Kidneys For Transplantation• Modlin C, Novick AC, Goormastic M, Hodge E, Mastrioanni B, Myles J. Long-term results with single pediatric donor kidney transplants in adult recipients. J Urol 1996 Sep;156(3):890-895.• Hobart MG, Modlin CS, Kapoor A, Boparai N, Mastroianni B, Papajcik D, Flechner SM, Goldfarb DA, Fischer R, OMalley KJ, Novick AC. Transplantation of pediatric enbloc cadaver kidneys into adult recipients. Transplantation 1998 Dec 27;66(12):1689-1694.
    109. 109. Pediatric Enbloc Allografts
    110. 110. Pediatric Enbloc Kidneys
    111. 111. Pediatric Enbloc Kidney Allografts
    112. 112. Pediatric Enbloc Allografts
    113. 113. Pediatric Enbloc Post Perfusion
    114. 114. Capsular Repair Vicryl Mesh
    115. 115. Capsular Repair
    116. 116. Renal Capsular Repair• J Natl Med Assoc. 2012;104:199-201
    117. 117. Renal Angiomyolipomain Living Donor Kidney
    118. 118. Living Donor Kidney with Renal Artery Aneurysm

    ×