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HEALTHCARE DISPARITIES IN CARDIOVASCULAR DISEASE

HEALTHCARE DISPARITIES IN CARDIOVASCULAR DISEASE. RICHARD ALLEN WILLIAMS, M.D. PROFESSOR OF MEDICINE, UCLA PRESIDENT/CEO, THE MINORITY HEALTH INSTITUTE, INC. FOUNDER, ASSOCIATION OF BLACK CARDIOLOGISTS, INC. EDITOR, TEXTBOOK OF BLACK-RELATED DISEASES

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HEALTHCARE DISPARITIES IN CARDIOVASCULAR DISEASE

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  1. HEALTHCARE DISPARITIES IN CARDIOVASCULAR DISEASE

  2. RICHARD ALLEN WILLIAMS, M.D. PROFESSOR OF MEDICINE, UCLA PRESIDENT/CEO, THE MINORITY HEALTH INSTITUTE, INC. FOUNDER, ASSOCIATION OF BLACK CARDIOLOGISTS, INC. EDITOR, TEXTBOOK OF BLACK-RELATED DISEASES EDITOR, ELIMINATING HEALTHCARE DISPARITIES IN AMERICA

  3. DISCLOSURES • Speakers’ bureaus: Forest labs, Astrazeneca, The Medicines Co. • Advisory Boards: Pfizer, CV Therapeutics • Research Grants: AstraZeneca

  4. ABC International Library, Research, & Conference Center

  5. HISTORY, BACKGROUND AND IMPACT OF HEALTHCARE DISPARITIES

  6. HISTORICAL PERSPECTIVE • MYTHS • MISUNDERSTANDINGS • MISMANAGEMENT

  7. Dr. Martin Luther King, Jr.On Health Care Disparities “Of all the forms of inequality, injustice in health is the most shocking and inhumane.” Dr. Martin Luther King, Jr.

  8. By ten things is the world created, By wisdom and by understanding, And by reason and by strength, By rebuke and by might, By righteousness and by judgment, By loving kindness and by compassion. Talmud Statement – Talmud Higaga 12A

  9. Race And EthnicityDefinitions: • Race: Derived from the Latin (generatio, a beginning). A term of taxonomic or biologicalclassification which subdivides the human species (homo sapiens sapiens) into groups based upon phenotypical or physical similarities such as hair, skin, and eye color, facial features, and body proportions. Example: Black and white are racially relevant terms to describe people with darker or lighter skin color.

  10. Race And EthnicityDefinitions: • Ethnic group/Ethnicity: Terms invented by Ashley Montagu (1964) to subdivide humans according to their membership in sociallydistinctgroups rather than according to shared physical characteristics. Example: African-American and Hispanic are ethnically relevant terms to describe population subgroups sharing certain sociological characteristics.

  11. Race And EthnicityDefinitions: • Healthcare disparity: A differentialin outcomes of prevention and treatment of illness and disease which can be shown to vary according to the race, gender, and/or ethnic identity of patients. These differences may be ascribed to racism, denial of equal access to care, possession of different health-seeking behavior and idiosyncratic responses to treatment, or to poorly understood biological and genetic mechanisms.

  12. Mortality Rates Per Thousand for Slaves and the Antebellum Population Entire Age Slaves United States 0 350 179 1 – 4 201 93 5 – 9 54 28 10 – 14 37 19 15 – 19 35 28 20 – 24 40 39

  13. A black surgical ward in Charleston’s segregated “Old Roper” Hospital, c. 1950. Although patients were all black, the professional staff here were all white.Courtesy of the Waring Historical Library. Medical University of South Carolina.

  14. Those Who Fail To Heed The Lessons Of History Are Destined To Repeat Them. Words Of Wisdom -Santayana

  15. 1. Treatment of cardiac arrest 2. Selection of patients for cardiac catheterization 3. Coronary artery bypass graft surgery (CABG) 4. Thrombolytic therapy 5. Percutaneous transluminal coronary angioplasty (PTCA) 6. Selection of patients for treatment to prevent stroke Evidence of Racial and Gender Bias in Medical Procedures and Treatment

  16. Expression A Sedimentary Life Emancipated Genetic Drugs Old-Timers’ Disease Premarital Stress Valium Stress Test Public Hair I had an Autopsy Pep Smear Prostrate Tubal Litigation Cologne Trouble Cardiac Coagulation I was Castrated Translation Sedentary Emaciated Generic Drugs Alzheimer’s Disease Prementrual Stress Thallium Stress Test Pubic Hair Biopsy Pap Smear Prostate Ligation Colon Catheterization Catheterized PatientSpeak: Culturally Conditioned Medical Terms

  17. Estimated Life Expectancy: 2001 Years National Vital Statistics Reports. 2004;52:33–34.

  18. THE PROBLEM HYPERTENSION STROKE HEART FAILURE MYOCARDIAL INFARCTION END-STAGE RENAL DISEASE ALL ARE MORE COMMON IN BLACKS

  19. Cardiovascular Disease Statistics in African Americans • African Americans (AA) are about 2.5 times as likely as the general US population to die from complications of hypertension. • Approximately one third of AA adults have hypertension (age-adjusted), among the world’s highest rates. • The prevalence of MI in AA women is 3.3% compared with 2.0% in white women. • AA have a 1.3 and 1.8-fold increased risk of suffering a nonfatal or fatal stroke, respectively, compared with whites. • AA are about twice as likely as Americans in general to die from diabetes. Diabetes is the third leading cause of death in AA women Source: Nash, DT, Cardiovasc Rev Rep, 2003, 24(9): 458-463, 467

  20. HYPERTENSION: • FOUND IN 34% OF BLACKS, 28% OF WHITES • EARLIER ONSET • COMPLICATIONS (HEART ATTACK, STROKE, KIDNEY FAILURE) OCCUR EARLIER IN BLACKS • GREATER RESISTANCE TO TREATMENT

  21. Hypertension • The African American prevalence of hypertension is highest in the World • Stage 3 hypertension is more common among African Americans than Whites • AA have a higher incidence of LVH • AA have a 4 fold greater incidence of end stage renal disease than other Americans • 75% of AA women are overweight or obese

  22. STROKE: • 500,000/YR, 150,000 DEATHS • THIRD LEADING CAUSE OF DEATH AFTER MI, CANCER • HYPERTENSION IS THE MAJOR RISK FACTOR • BLACKS DIE TWICE AS FREQUENTLY AS WHITES • PREVENTION IS POSSIBLE

  23. HEART FAILURE: • 5 MILLION CASES, 500,000/YR • DEATH RATE 3 TIMES HIGHER IN BLACKS • HYPERTENSION IS MAJOR RISK IN BLACKS, CORONARY DISEASE IN WHITES

  24. Heart Failure • HT is the leading cause of HF in AA • HF affects 3.5% of AA men and 3.1% of AA female over 20 years, and 5% of over 65 years • HF outcome is poorer in AA patients with 45% higher rate of functional decline or death in 6 months c/w white

  25. MYOCARDIAL INFARCTION • GREATEST KILLER OF MANKIND • 1.5 MILLION DEATHS /YR • DEATH RATES HIGHER IN BLACKS • BLACK WOMEN ARE AT GREATEST RISK--DEATH RATE 35% HIGHER THAN WHITE WOMEN

  26. Annual Rate of First Heart Attacks by Age, Sex, and Race ARIC: 1987–2000 16 AA Men White Men AA Women White Women 12 8 Per 1,000 Persons 4 0 35-44 45-54 55-64 65-74 ARIC=Atherosclerosis Risk in Communities. Adapted from Heart Disease and Stroke Statistics—2004 Update. American Heart Association; 2003:12.

  27. Risk Factors for Disparate Healthcare Poverty Racism Discrimination Bias Language barriers Geographical barriers Socioeconomic status Immigrant status TRUST (or lack thereof) Institute of Medicine. Summary of: Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. 2003.

  28. IOM Report, 2002: Assessing the Quality of Minority Health Care “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

  29. PROBLEMS OF ACCESS • THE SCHULMAN STUDY • OTHER EXAMPLES

  30. Healthcare DisparityA race disparity in coronary revascularization was found among patients in the Veteran Affairs health system, where there are no race differences in ability to pay and providers are paid a salary. Percent of Patients Source: Ibrahim SA, Whittle J, Bean-Mayberry B, Kelley ME, Good C, Conigliaro J. Racial/ethnic variations in physician recommendations for cardiac revascularization. Am J Public Health. 2003 Oct;93(10):1689-93.

  31. “Patients” experiencing symptoms of heart disease, from Schulman et al. (1999)

  32. SUMMARY OF FINDINGS From IOM Report Racial and ethnic disparities in health care exist and, because they are associated with worse outcomes in many cases, are unacceptable. Racial and ethnic disparities in health care occur in the context of broader historic and contemporary social and economic inequality, and evidence of persistent racial and ethnic discrimination in many sectors of American life. Many sources – including health systems, health care providers, patients, and utilization managers – contribute to racial and ethnic disparities in health care.

  33. SUMMARY OF FINDINGS From IOM Report (Continued)) Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in healthcare. Racial and ethnic minority patients are more likely than white patients to refuse treatment, but differences in refusal rates are generally small, and minority patient refusal does not fully explain healthcare disparities.

  34. Does Race Impact Care Decisions? Source: Lurie N et al. Circulation 2005;111:1264-1269

  35. CDC Eliminate CVD disparities by 2010 • Reduce deaths from heart disease among AA by 30% • Reduce deaths from stroke among AA by 47%

  36. Kaiser Family Foundation 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

  37. Lessons Learned • Takes time • Takes resources • Takes commitment • Gather evidence • It is everyone’s work

  38. Summary • Biologic & Genetic factors • Environmental factors • Socio economic factors • Access & Cost • Practice Bias • Lack of Diversity in Providers • Need for Leadership and commitment

  39. Death Rate Due to Coronary Heart DiseaseSouth LA Health Districts vs. LA County

  40. SUGGESTED STRATEGIES FOR MANAGING CVD IN BLACKS • RECOGNITION OF CULTURAL DIFFERENCES • INDIVIDUALIZED TREATMENT • APPRECIATION OF RACIAL PECULIARITIES • IMPORTANCE OF OPEN ACCESS TO CARE • SELECTION OF THE MOST APPROPRIATE DRUGS • DEVELOPMENT OF IMPROVED COMMUNICATIONS SKILLS • INCREASED EFFORTS TO SCREEN AND EDUCATE PATIENTS

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