Dr. charles modlin nma new orleans urology presentation july 30 2012Presentation Transcript
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
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.•
Cleveland ClinicMinority Men’s Health Center
Cleveland Clinic Minority Men’s Health Center/ Health Fair Established 2003 Special Health Concerns in Minority Males
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”
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%
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
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
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
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.
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
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.
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
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
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
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
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
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
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))
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
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.
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
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.
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.
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.
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
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
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.
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
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
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.
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
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
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.
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
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
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
Health Disparities Solutions: Multifaceted - Based upon our Cleveland Clinic MMHC Observations and Research - Examples of our Cleveland Clinic Innovative Solutions/ Programs
Solutions: Step 1Health Provider Recognition,Acknowledgment of Existence,Causes & Impact of Health Disparitiesin Minority Populations
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
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: Charles Modlin, MD, MBA • Modlin CS. Addressing Disparities in Health Care Cleveland Clinic Journal of Medicine January 2012 vol. 79 (1): 44-45.
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
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 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
The African American Barber Shop, Beauty Salon and Church Initiative A Tool in Development of Medical & Nursing Student & Health Provider Cultural Competency/Sensitivity
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.
Solutions: Step 5African American Physician Leadership, Visibility & Availability: Very Important To The African American Community
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 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
Community & CorporatePartners and Sponsors: Step 7
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.
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
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/watch?v=3L4zEnecs9M
Health Screenings: Identification of Diseases in Early Treatable States
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
Minority Men’s Health Center Health Fair Health Information You Need To Know! (With Pre & Post Test Options)
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.
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 Media
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 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
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.
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.
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&featu
Health Policy Advocacy: Step 19:United States Congressional Black Caucus, U.S. Capital, Washington, D.C.
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
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
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• Know how you are doing• Develop strategies to improve your outcomes
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
Health Disparities in Renal Graph Survival in Tx Patients by Race and Source of AllograftCadaveric (CAD) Living Related (LR)
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
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
STEP 22: Putting it all together: Develop and Implement Multifaceted InnovativePrograms to Address Health Disparities
Culturally Sensitive & Competent Team toPromote Organ Donor Registration
Expanding Organ DonationAcceptance and TransplantRates in African Americans ANDPromotion of Prevention of Kidney Disease in African Americans
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
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
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.
Issues and Techniques Available to Expand the Pool of Kidneys Available For Transplantation. MODLIN • Chapter 10. In Kidney and Pancreas Transplantation: A Practice Guide.
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, 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.
Pediatric Enbloc Allografts
Pediatric Enbloc Kidneys
Pediatric Enbloc Kidney Allografts
Pediatric Enbloc Allografts
Pediatric Enbloc Post Perfusion
Capsular Repair Vicryl Mesh
Renal Capsular Repair• J Natl Med Assoc. 2012;104:199-201