However one variation in the health care system that can be controlled and improved upon is how care is delivered with respect to the varying patient demographics. The minimum performance level of our healthcare system and its processes should be that the system does not independently contribute to lesser/negative outcomes in care.
An Introduction to CVD Racial Disparities
An Introduction to Racial Disparities in the Treatment of Cardiovascular Disease Polishing our Lens of Research and Care Dr. Anthony Shackelford DHA, CCP, CCT Assistant Professor Cardiovascular Perfusion Program Medical University of South Carolina
Purpose To help increase awareness within the perfusion community of racial disparities in the treatment of cardiovascular disease. by providing: a general overview of what health care disparities are and are not the processes and programs in place to reduce and eliminate health care disparities examples of evidence specific to the treatment of heart disease in the context of racial disparities 2
What are going to cover? General overview of what health care disparities are and are not The processes and programs in place to reduce and eliminate health care disparities Examples of evidence specific to the treatment of heart disease in the context of racial disparities Applicability to Perfusion 3
Disclaimer I have no contractual or financial affiliations with any of themanufactures of any of the devices mentioned in this presentation 4
Death Rate due to Heart Disease by Race/Ethnicity, 2005 329.8 Deaths per 100,000 population: 262.2 228.3 192.4 173.2 170.3 141.1 129.1 115.9 91.9 White, Hispanic African- Asian andAmerican White, NoHispanic African- Asian andAmerican Non- American Pacific Indian/ n- American Pacific Indian/ Hispanic Islander Alaska Hispanic Islander Alaska Native Native Men WomenNOTES: Rates are age-adjusted.DATA: Centers for Disease Control and Prevention, National Center for Health Statistics, NationalVital Statistics System.SOURCE: Health US, 2007, Table 36.
Starting Point: Health Status Determined by a variation of social and behavioral risk factors among people of: different race/ethnicity socioeconomic status (SES) gender +/- effect on mortality Blacks and American Indians > Whites Asian and Pacific Islanders < Whites. 7
What are Health Disparities? Racial or ethnic differences in the quality of health care that is not due to: access-related factors clinical needs preferences appropriateness of intervention 8
Literature “skim” of RacialDisparities in the Treatment of Cardiovascular Disease 10
Trends of CVD mortality by race and ethnicity Findings: CHD mortality rates of black men and women have declined the rate has been slower than white men and women since the mid 1980’s 11
17,000 patients for differences with respect to noninvasive procedures and invasive procedures (e.g. CABG, CC, PTCA) Findings: Black men and women < white men and women to undergo costly cardiovascular procedures Hispanics < whites to have received CC / PTCA (Am J Public Health. 2000;90:1128–1134) 12
3,015 patients over a two year period Statistically significant difference in the utilization rates comparing Caucasians to African-Americans for CABG Although not statistically significant, African-Americans were less likely than Caucasians to receive a cardiac catheterization and Percutaneous Transluminal Coronary Angioplasty (PTCA). No significant disparities for gender for the utilization of invasive treatments for cardiovascular disease. Journal of Cultural Diversity, 11(3), 80-87. 13
Found that DES use was influenced by demographic, socioeconomic and hospital characteristics.blacks and low-income groups were significantly less likely to receive a DES than their counterparts and differences according to facility procedural volumes 14
Why this is more important to North Carolina? % of Population Black 1990 ->2000 United States 248,709,873 -> 281,421,906 29,980,996 (12.1%) ->34,658,190 (12.3%) North Carolina 6,628,637 -> 8,049,313 1,456,323 (22.0%) -> 1,737,545 (21.6%) South Carolina 3,486,703 -> 4,012,012 1,039,884 (29.8%) -> 1,185,216 (29.5%) 16
Federal Policy Actions Taken toEliminate & Reduce Disparities The Healthcare Research and Quality Act of 1999 Directed Agency for Healthcare Research and Quality (AHRQ) to develop 2 annual reports: National Healthcare Quality Report (NHQR) National Healthcare Disparity Report (NHDR) Focus: a more comprehensive snapshot of the performance of our health care system’s strengths and areas for future improvement 17
Congress Charges Institute of Medicine Assess the extent of racial and ethnic differences in healthcare Evaluate potential sources of racial and ethnic disparities including the role of bias, discrimination, and stereotyping At the individual (provider and patient), institutional, and health system levels ** Provide recommendations regarding interventions to eliminate healthcare disparities. 18
Sources of Disparities in Healthcare Complex Rooted in historic and contemporary inequities Involve many participants at several levels health systems processes health care professionals patients 20
IOM’s Unequal Treatment www.nap.edu Recommendations Increase awareness of existence of disparities Address systems of care Support race/ethnicity data collection, quality improvement, evidence- based guidelines, multidisciplinary teams, community outreach Improve workforce diversity Facilitate interpretation services Provider education Health Disparities, Cultural Competence, Clinical Decisionmaking Patient education (navigation, activation) Research Promising strategies, Barriers to eliminating disparities
Goal: Control the System1. How care is delivered with respect to the varying patient demographics.2. At minimum our healthcare system and its processes should not independently contribute to lesser/negative outcomes in care. 22
So how are we doing?Results form the 2011 Health care quality and access are suboptimal, especially for minority and low-income groups. Quality is improving; access and disparities are not improving. Progress is uneven with respect to eight national priorities: Two are improving in quality: (1) Palliative and End-of-Life Care and (2) Patient and FamilyEngagement. Three are lagging: (3) Population Health, (4) Safety, and (5) Access. Three require more data to assess: (6) Care Coordination, (7) Overuse, and (8) Health System Infrastructure All eight priority areas showed disparities related to race, ethnicity, and socioeconomic status. 23
Federal Efforts to Address Health Disparities Federal Office of Minority Health Efforts within HHS Department of Health and Human Services (DHHS) Interagency Working Group on Health Disparities Health Disparities Collaboratives Healthy People 2020 Data Collection Legislation Reimbursement rates to providers Language access laws Title VI of the Civil Rights Act of 1964 Medical malpractice
Potential Policy Levers for Eliminating Health Disparities Coverage Piecemeal efforts vs. comprehensive efforts Fragmentation of the health care system Language access (who should pay?) Reimbursement rates and other incentives Provider training for cultural competence Social policies (education, job training, housing) Health information technology
Examples of System-Level Efforts to Eliminate Disparities Insurance Companies National Health Plan Collaborative (NHPC) Pay-for-Performance (P4P) Disease registries Massachusetts General Hospital – Disparities Solutions Center Johns Hopkins Center for Health Disparities
We are including theCore Measures for HeartAttack, Heart Failure andPneumonia.
Where Does Perfusion Fit In? Provider education: Increase awareness of existence of disparities Health Disparities, Cultural Competence, Clinical Decision- making Improve workforce diversity Support race/ethnicity data collection, quality improvement, evidence-based guidelines, multidisciplinary teams 28
Take Home Messages1. Disparities exist 5. A myriad of efforts2. Regardless of how are underway to they fair in the address disparities. aggregate, all racial groups have 6. Overall, we still have problems. a long way to go to3. Racial groups are eliminate not monolithic. disparities.4. Many factors aside from race impact health and health care.