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  • Racial and ethnic disparities in medical care are in the spotlight. The evidence supports disparities in cardiac care—the main focus of our discussion today.
  • During the presentation, we are going to answer this crucial question and others, including: What is the state of the evidence on racial and ethnic disparities in health care? What do the studies show about disparities in health care for heart disease? Why should physicians be involved? What can you do?
  • The focus of today’s discussion is primarily cardiac disease. But to put the issue in context, racial and ethnic groups experience serious disparities in health access and outcomes for many different diseases and conditions. The U.S. Department of Health and Human Services has targeted the elimination of health disparities as a priority while focusing on six areas that significantly affect minorities. Source: Centers for Disease Control and Prevention, http://www.cdc.gov/omh/AboutUs/disparities.htm
  • The future health of America as a whole will be influenced substantially by our success in improving the health of ethnic and racial minorities groups. People of color (Latinos, African Americans, Asian/Pacific Islanders, and American Indian/Alaska Natives) make up nearly a third of the U.S. population. By the year 2050, the U.S. Census estimates that these groups combined will make up nearly half of the U.S. population. Groups currently experiencing poorer health status are expected to grow as a proportion of the total U.S. population.
  • In 2002, the Institute of Medicine conducted a review of the published literature that assessed the quality of healthcare for various racial and ethnic minority groups. Racial and ethnic minorities tend to receive lower-quality health care than whites do, even when insurance status, income, age, and severity of conditions are comparable. The vast majority of studies found that minorities received fewer clinically necessary procedures. In contract to whites, minorities are more likely to receive certain less-desirable procedures, such as lower limb amputations for diabetes and other conditions.
  • Some specific examples: Cancer. Several studies show racial differences in those receiving appropriate cancer diagnostic tests and treatments. Stroke. Several studies have found that racial and ethnic minorities are less likely to receive major diagnostic and therapeutic interventions. Kidney dialysis, transplants. Minorities are less likely to be placed on waiting lists for kidney transplants or to receive dialysis. HIV/AIDS . Minorities with HIV infection are less likely to receive antiretroviral therapy and other state-of-the-art treatments that could forestall the onset of AIDS. Asthma. Asthmatic African-Americans are less likely to receive appropriate medications to manage chronic symptoms. Diabetes. Although minorities have a much higher rate of death and illness from diabetes, the disease is poorly managed among minority patients, says the report. In a study of nearly 1,400 Medicare patients, diabetic African-Americans were found less likely to receive key diagnostic tests.
  • Heart disease is the leading cause of death among every racial/ethnic group in the United States except Asian/Pacific Islanders, for whom it is the second leading cause of death.
  • Heart disease mortality rates for adults 25-64 are almost twice as high among African Americans as among whites. When heart disease mortality is examined by a measure of socioeconomic conditions, differences between African Americans and whites are reduced but not eliminated. Moreover, the disparity by income is larger than by race. African American men with family incomes less than $10,000 have a heart disease mortality rate that is nearly three times that of their counterparts with incomes greater than $15,000.
  • The Kaiser Family Foundation and American College of Cardiology Foundation reviewed this research last fall, and produced the report Racial/Ethnic Differences in Cardiac Care: The Weight of the Evidence . The report is one component of an initiative sponsored by The Kaiser Family Foundation and The Robert Wood Johnson Foundation to raise physician awareness about disparities in medical care.
  • The KFF/ACCF study assessed the quality of the evidence and examined findings separately for specific cardiac interventions.
  • Disparities exist in procedures used both to diagnose and treat heart disease. For example, in a California study, African American Medicare patients were less likely than whites to undergo catheterization, angioplasty and bypass surgery, and Latino Medicare patients were less likely than whites to undergo catheterization and angioplasty.
  • Though people of color have, in general, lower incomes than whites, these differences in income don’t seem to fully account for the differences in medical care obtained. In a study of hospitalization rates for bypass surgery among Medicare beneficiaries disparities in hospitalization rates persist across income groups, with better-off African Americans no more likely than poor African Americans to receive bypass surgery at the same rate as whites.
  • Though insurance coverage diminishes disparities in cardiac care, it does not eliminate them. For example, a nationwide study examined patients with chronic renal failure who, when they progress to end-stage renal disease (ESRD), acquire Medicare coverage. Before qualifying for Medicare, male and female African American patients with chronic renal failure were 32% and 30% as likely to receive catheterization, angioplasty and bypass surgery as white men (the study reference group). After enrolling in Medicare and entering into a comprehensive system of care, there was no difference in the cardiac procedure use between African American women and white men. However for African American men, the disparity persisted even after enrolling in Medicare.
  • Type of insurance coverage may also have an impact on disparities in care. In a California study, African American Medicaid, Medicare and uninsured patients were less likely than whites to undergo bypass surgery. Latino Medicare patients were also less likely than whites to undergo surgery. However, racial/ethnic differences in care did not exist among patients with private insurance, and Asian patients, regardless of coverage, were equally as likely as whites to undergo bypass surgery.
  • In a study of 12,000 patients at Duke University, disparities exist among patients with mild heart disease and persist among patients with severe heart disease. Disparities were also found to exist among those patients predicted to have the greatest survival benefit from the procedures. The researchers also compared survival rates in blacks and whites and found that blacks were significantly more likely to die within 5 years than were white patients.
  • A study was classified as “strong” or “less strong” by criteria agreed upon by an advisory committee that included representatives of the American College of Cardiology Foundation and the Association of Black Cardiologists which guided the framework for this review of the evidence. Two teams of researchers/analysts, one from the Kaiser Family Foundation and the other from the Morehouse School of Medicine (MSM), had responsibility for independently reviewing all studies. For example, a strong study based on clinical data would have controlled for age, sex, insurance status, co-morbidities and severity of heart disease and would have used multivariate analysis to adjust for these variables simultaneously.
  • The literature search produced 158 studies. 81 met the inclusion criteria developed by the advisory committee. Most analyzed data on more than one cardiac procedure or treatment. The report presents and analyzes information separately for diagnostic procedures, revascularization procedures, thrombolytic therapy, drug therapy, and “other” cardiac procedures and treatments. 44 of the 81 studies are methodologically strong. 56 of the 81 studies include data collected between 1991 and 2001. 51 of the 81 studies are based on clinical data. 54 of the 81 studies compare only African Americans and whites.
  • Of the 81 studies investigating racial/ethnic differences in cardiac care from 1984 to 2001, 68 find racial/ethnic differences in cardiac care. Of those 68, 46 find differences in cardiac care for all of the procedures and treatments investigated, and 22 find differences in cardiac care for some procedures and treatments and not others. The 13 remaining studies include 11 that find no racial/ethnic differences in cardiac care, and two that find the racial/ethnic minority groups are more likely than whites to receive appropriate care.
  • This trend remains when we look at the most methodologically strong studies and when we look at studies using clinical data.  Thirty-nine of the 44 strong studies find racial/ethnic differences in care, and twenty of the 24 strong clinical studies find racial ethnic differences in care.
  • Let’s look at the body of evidence on bypass surgery as an example.
  • This slide illustrates the quality and findings of studies investigating CABG rates. The first pair of bars shows the findings for all the studies investigating racial/ethnic differences in CABG rates published between 1984 and 2001. The second pair of bars shows the findings for clinical data and the third pair of bars shows that 21 of the 44 were based on administrative data. If you look at the third bar, you’ll see that 12 of the 23 studies based on clinical data are methodologically strong. Of the 12, 11 studies find that at least one racial/ethnic minority group is less likely to undergo CABG than whites, even after adjustments for age, insurance, co-morbidities and disease severity
  • The report also graphically displays the odds ratios for strong studies that compared AA and whites. If African American and white patients received cardiac procedures at equal rates, the ratio would be 1.0, which is represented by the vertical line in the center of the chart. Ratios less than 1.0, represented by dots to the left of the center line, indicate that blacks are less likely than whites to undergo bypass surgery African Americans were less likely than whites to undergo bypass surgery in 21 of the 23 strong studies that calculated odds ratios to compare bypass surgery rates The odds ratios range from 0.26 to 0.68, which means that in the 21 studies that found a statistically significant difference, AA were between 26% to 68% as likely as whites to receive bypass surgery. The only two cases in which the odds ratio was not less than one was among patients with private insurance in Carlisle 1997, and among patients for whom either a CABG or PTCA was deemed necessary, in Conigliaro 2000. These figures were developed for all of the procedures and treatments in the report.
  • Let’s sum this up: The most methodologically rigorous studies published over the past two decades provide credible evidence that: African Americans are less likely than whites to receive catheterization, angioplasty, bypass surgery and thrombolytic therapy. These racial/ethnic differences in care remain after adjustment for clinical and socioeconomic factors including heart disease severity and insurance. There are areas where the research is less conclusive. Evidence of disparities in other procedures and treatments is mixed, and data on Latinos, Asians and Native Americans is limited.
  • The evidence shows that disparities in medical care exist, but there is still research to be done on the range of patient-level, system-level and provider-level factors involved. There is also a great deal of discussion to take place about promising solutions.
  • To raise physician awareness and increase the dialogue about racial and ethnic disparities in care, in 2002 The Kaiser Family Foundation and The Robert Wood Johnson launched a national initiative to get physicians talking.
  • The primary objectives of the initiative are to: Increase awareness of disparities in cardiac care and Spark discussion in the provider community as we continue the drive towards investigation and interventions to eliminate cardiac disparities.
  • A major objective of this initiative has been an advertising campaign in leading medical publications. Some of you may have seen this ad in Cardiology Toda y or the New England Journal of Medicine . It appears in 10 major medical publications. The headline reads: “These patients have the same condition, but their treatment may be different. Help Understand Why.” The ad highlights the central theme of this initiative and encourages physicians to obtain a review of the evidence on racial/ethnic differences in cardiac care and to take concrete steps to become engaged in this issue. The intent of the ad is to provoke frank dialogue about the issue. We recognize that racial/ethnic differences in care reflect multiple factors, many of which interact and are difficult to disentangle in a chain of events. The ad seeks to recruit physicians by asking the question: WHY. The ultimate goal is to encourage physicians to be engaged actively in efforts to assure that all patients with similar need are treated equally, understanding that physicians are one of many determining factors in the care an individual will receive.
  • The ad directs physicians to a Web site, illustrated here. The Web site will serve as a central source of information on the issue and the initiative. Similar to the ad in its design, it gives the physician the option to: Download the evidence Share their thoughts on the nature of the problem and how to address disparities in care Link to existing guidelines that can improve cardiac care outcomes Obtain information about upcoming seminars, publications on this issue.
  • Once awareness has been heightened, we can embark on the next steps to confront and solve the problem. We need to consider what potential factors interact to produce the gap: Patient education and awareness Physician assumptions in clinical assessment and referrals System characteristics such as access to high-tech centers and specialists   We need further research to be conducted to better understand causes and solutions. It is critical to conduct research into the complex causative factors—psychosocial, environmental, and biological—and to author institutional etiologies of disparities. Interventions can then be designed and executed. And results evaluated and shared.  
  • This initiative serves to accelerate attention on an issue that is sensitive and difficult to address. Increasing awareness of a problem is the first step in the process of change. By joining us today to discuss the tough issues and challenges ahead, you are taking a bold first step in that process of change. We welcome the opportunity to communicate with all of you here today and look forward to hearing your thoughts on what we can all do.
  • Again, the whythedifference Web site is a tool to learn about the latest research and efforts underway to address racial/ethnic disparities in care. Please use this website to find out more about what initiative members are doing and to share your thoughts on this issue and this initiative.
  • Transcript

    1. Racial and ethnic disparities in cardiac care What evidence exists? What can we do about it? A presentation prepared by The Henry J. Kaiser Family Foundation and The Robert Wood Johnson Foundation
    2. <ul><li>Why the urgency to eliminate racial and ethnic disparities in health care? </li></ul>
    3. <ul><li>Cardiac disease </li></ul><ul><li>Infant mortality </li></ul><ul><li>Cancer screening and management </li></ul><ul><li>Diabetes </li></ul><ul><li>HIV Infections/AIDS </li></ul><ul><li>Immunizations </li></ul>Minority populations are disproportionately affected                                                      
    4. “ Disparities in the health care delivered to racial and ethnic minorities are real and are associated with worse outcomes in many cases, which is unacceptable.” -- Alan Nelson, retired physician, former president of the American Medical Association and chair of the committee that wrote the Institute of Medicine report, Unequal Treatment: Confronting Racial and Disparities in Health Care IOM Report, 2002: Assessing the Quality of Minority Health Care
    5. Evidence shows disparities exist <ul><li>Institute of Medicine Report, 2002 </li></ul><ul><ul><li>The evidence is “overwhelming” </li></ul></ul><ul><ul><li>Disparities exist even when insurance status, income, age, and severity of conditions are comparable </li></ul></ul><ul><ul><li>Minorities are less likely than whites to receive needed services </li></ul></ul><ul><ul><li>Disparities contribute to worse outcomes in many cases </li></ul></ul><ul><ul><li>Differences in treating heart disease, cancer, and HIV infection partly contribute to higher death rates for minorities </li></ul></ul><ul><ul><li>Source: Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, March 2002. </li></ul></ul>
    6. Several studies show racial/ethnic differences in the appropriate delivery of diagnostic tests and treatment for: <ul><li>Heart Disease </li></ul><ul><li>Cancer </li></ul><ul><li>Stroke </li></ul><ul><li>Kidney Dialysis, Transplant </li></ul><ul><li>HIV/AIDS </li></ul><ul><li>Asthma </li></ul><ul><li>Diabetes </li></ul>National Academy of Sciences, Web Extra, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, Documenting the Disparities.
    7. Heart Disease
    8. Leading Causes of Death, by Race/Ethnicity, 2000 CVD = Cerebrovascular disease DATA: National Center for Health Statistics, National Vital Statistics System. National Vital Statistics Report, Vol. 50, No. 16, September 16, 2002. SOURCE: Kaiser Family Foundation, Key Facts: Race, Ethnicity and Medical Care, June 2003. All ages Ages 25-44 Diabetes CVD Accidents Cancer Heart disease Latino CVD Chronic lung disease Diabetes Accidents 5 Diabetes Accidents Accidents Chronic lung disease 4 Accidents CVD CVD CVD 3 Cancer Heart disease Cancer Cancer 2 Heart disease Cancer Heart disease Heart disease 1 American Indian/ Alaska Native Asian/Pacific Islander African American, Non-Latino White, Non-Latino Rank Heart Disease HIV Homicide Cancer Accidents Latino Cancer Homicide Homicide HIV 5 Suicide Suicide Cancer Suicide 4 Heart Disease Heart Disease Accidents Heart Disease 3 Liver Disease Accidents Heart Disease Cancer 2 Accidents Cancer HIV Accidents 1 American Indian/ Alaska Native Asian/Pacific Islander African American, Non-Latino White, Non-Latino Rank
    9. Heart Disease Death Rates for Adults 25-64 , by Income, Race and Gender , 1979-1989 NOTE: These data are the most recently available by race and income. DATA: Health, United States, 1998, Socioeconomic Status and Health Chartbook, Data Table for Figure 27. SOURCE: Kaiser Family Foundation, Key Facts: Race, Ethnicity and Medical Care, June 2003. Deaths per 100,000 person years Under $10,000 Over $15,000 White, Non-Latino African American, Non-Latino
    10. Cardiac Care: The Weight of the Evidence
    11. Looked at key cardiac interventions <ul><li>Cardiac catheterization </li></ul><ul><li>Percutaneous transluminal coronary angioplasty </li></ul><ul><li>Thrombolytic therapy </li></ul><ul><li>Coronary artery bypass graft surgery </li></ul><ul><li>Drug therapy </li></ul>
    12. Rate of Cardiac Interventions Among Medicare Patients Hospitalized with an Acute Myocardial Infarction, by Race/Ethnicity, 1994-1995 *Difference is statistically significant after adjustment. NOTE: Odds ratios are adjusted for age, sex, insurance, health status, and disease severity. DATA: Ford et al. 2000. SOURCE: Kaiser Family Foundation, Key Facts: Race, Ethnicity and Medical Care, June 2003. Odds ratio < 1.0 indicates group is less likely to undergo procedure compared to white patients Equally likely as white patients
    13. Rates of Hospitalization for Coronary Artery Bypass Surgery among Medicare Beneficiaries, 1993 *Rates were adjusted for age and sex to the total Medicare population. DATA: Gornick, ME et al., 1996 Annual Income per 1000 beneficiaries per year* <$13,001 $13,001- $16,300 $16,301- $20,500 >$20,500 Whites African Americans
    14. Cardiac Procedure Use in Chronic Renal Disease Patients, by Race and Gender, 1986-1992 *Difference is statistically significant after adjustment. NOTE: Odds ratios are adjusted for age, health insurance, sociodemographic characteristics, and clinical factors. DATA: Daumit and Powe, 2001. SOURCE: Kaiser Family Foundation, Key Facts: Race, Ethnicity and Medical Care, June 2003. Odds ratio < 1.0 indicates group is less likely to undergo procedure compared to white men Equally likely as white men
    15. Coronary Artery Bypass Surgery by Race/Ethnicity and Insurance Status, 1986-1988 *Difference is statistically significant after adjustment. NOTE: Odds ratios are adjusted for age, sex, number of co-morbidities, admission type, and hospital procedure volume. DATA: Carlisle et al., 1997. SOURCE: Kaiser Family Foundation, Key Facts: Race, Ethnicity and Medical Care, June 2003. Equally likely as white patients Odds ratio < 1.0 indicates group is less likely to undergo procedure compared to white patients African American Latino Asian
    16. Figure 8 Coronary Artery Surgery Rates by Race and Disease Severity, 1984-1992 Source: Peterson, et al., 1997. Percent Receiving Bypass Surgery Mild Disease Severe Disease Whites African Americans
    17. Criteria for evaluating the strength of the evidence <ul><li>A “strong study”: </li></ul><ul><li>Had well-defined parameters </li></ul><ul><li>Had internal validity </li></ul><ul><li>Measured and controlled for critical variables </li></ul><ul><li>A “less strong” study: </li></ul><ul><li>Did not control for critical variables </li></ul><ul><li>Had design flaws that potentially undermined the validity of the evidence </li></ul>
    18. Study Results <ul><li>81 of the 158 studies produced from the literature search met the inclusion criteria and comprised the body of evidence </li></ul><ul><li>Most of the studies investigated more than one cardiac procedure or treatment </li></ul><ul><li>44 of the 81 studies are methodologically strong </li></ul>
    19. <ul><li>56 of the 81 studies include data collected </li></ul><ul><li>Between 1991 and 2001 </li></ul><ul><li>51 of the 81 studies are based on clinical data </li></ul><ul><li>54 of the 81 studies compare only African </li></ul><ul><li>Americans and whites </li></ul>Study Results (Continued)
    20. Evidence of racial/ethnic differences in cardiac care 1984-2001 68 studies find a racial/ethnic difference in care (84%) 11 studies find no racial/ethnic difference in care (14%) 2 studies find racial/ethnic minority group more likely than whites to receive appropriate care (2%) Total= 81 studies
    21. Evidence of Racial/Ethnic Differences in Cardiac Care, 1984-2001 68 studies find racial/ethnic differences in care (84%) 11 studies find no racial/ethnic differences in care (14%) 2 studies find the racial/ethnic minority group more likely to receive appropriate care (2%) All Studies (n=81) Strong Studies (n=44) Strong Clinical Studies (n=24) 39 studies find racial/ethnic differences in care (89%) 20 studies find racial/ethnic differences in care (83%) 4 studies find no racial/ethnic differences in care (9%) 1 study finds the racial/ethnic minority group more likely to receive appropriate care (2%) 4 studies find no racial/ethnic differences in care (17%) SOURCE: Kaiser Family Foundation/American College of Cardiology Foundation, Racial/Ethnic Differences in Cardiac Care:The Weight of the Evidence, 2002.
    22. Example: Coronary Artery Bypass Surgery (CABG)
    23. Evidence of Racial/Ethnic Differences in CABG Rates, 1984-2001 ‡ Total= 23 Total= 21 Number of Studies All Studies Total= 44 Clinical Data Administrative Data Found all minority groups MORE likely to receive CABG Found all minority groups AS likely to receive CABG Found at least one minority group LESS likely to receive CABG 1 ‡ Evidence from studies published from 1984-2001. (This figure includes Oberman & Cutter, 1984.)
    24. Odds Ratios for Selected Strong Studies
    25. ‘ Weight of the Evidence’ suggests… <ul><li>African Americans are less likely than whites to receive catheterization, angioplasty, bypass surgery and thrombolytic therapy. </li></ul><ul><li>These racial/ethnic differences in care remain after adjustment for clinical and socioeconomic factors, such as heart disease severity and insurance. </li></ul>
    26. Potential Sources of Disparities in Care <ul><li>Patient-Level </li></ul><ul><ul><li>Patient preferences </li></ul></ul><ul><ul><li>Treatment refusal </li></ul></ul><ul><ul><li>Care seeking behaviors and attitudes </li></ul></ul><ul><ul><li>Clinical appropriateness of care </li></ul></ul><ul><li>Health Care Systems-Level </li></ul><ul><ul><li>Lack of interpretation and translation services </li></ul></ul><ul><ul><li>Time pressures on physicians </li></ul></ul><ul><ul><li>Geographic availability of health care institutions </li></ul></ul><ul><ul><li>Changes in the financing and delivery of health care services </li></ul></ul><ul><li>Provider-Level </li></ul><ul><ul><li>Bias </li></ul></ul><ul><ul><li>Clinical uncertainty </li></ul></ul><ul><ul><li>Beliefs/stereotypes about the behavior or health of minority patients </li></ul></ul>Source: Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, March 2002.
    27. Why the Difference?
    28. Objectives of the Initiative <ul><li>To bring together leading health care organizations to focus attention on the issue </li></ul><ul><li>To increase awareness of racial/ethnic disparities in health care among physicians </li></ul><ul><li>To spark discussion among providers and solicit their input into causes and solutions </li></ul><ul><li>To continue the drive toward investigation and elimination of cardiac disparities </li></ul>
    29. Ad Campaign Ad appeared in leading medical publications: Journal of the American Medical Association Today in Cardiology Journal of the American College of Cardiology Circulation – The Journal of the American Heart Association
    30. Website <ul><li>Site visitors may do the following: </li></ul><ul><li>Review the evidence </li></ul><ul><li>Submit thoughts </li></ul><ul><li>Link to guidelines </li></ul><ul><li>Read recent news stories </li></ul><ul><li>Learn about upcoming events </li></ul><ul><li>Find related resources </li></ul>
    31. Next steps <ul><li>Continue to increase awareness of the issue </li></ul><ul><li>Promote dialogue about potential causes (patient, physician, health system factors) </li></ul><ul><li>Research causes and potential solutions </li></ul><ul><li>Evaluation of results </li></ul><ul><li>Share with other experts </li></ul>
    32. <ul><li>Get to know the evidence </li></ul><ul><li>Join the national discourse on health disparities with a genuine determination to eliminate them </li></ul><ul><li>Support innovative research to identify underlying determinants </li></ul><ul><li>Review your own practice and procedures to ensure that existing cardiac care guidelines are being followed </li></ul>What can you do?
    33. www.kff.org/whythedifference

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