Racial Disparities in Cardiac Care

1. Racial Disparities in Cardiac Care Andrew N. Schmelz, PharmD Post-Doctoral Teaching Fellow Dept of Pharmacy Practice, Purdue University May 26, 2009 anschmel@purdue.edu

2. Discussion Questions • Do you think clinically similar patients receive different care on the basis of race/ethnicity: • In the healthcare system? • In cardiovascular care? • In your institution (ie, at Wishard)? • In patients you treat or would treat?

3. Objectives • State the rationale for reviewing racial disparities in cardiac care • Summarize recent literature describing disparities in cardiac care • Recommend future actions to reduce racial disparities in cardiac care

4. Rationale • Comment in New England Journal of Medicine (NEJM) • Call to action to reduce racial disparities • Questions raised: • What is known about racial disparities in cardiac care? • What work has been done recently? • What can be done? N Engl J Med 2009; 360:1172-4.

5. Methods • MEDLINE searched, MeSH terms: • Healthcare disparities AND • Cardiovascular diseases • Contains “Heart diseases” & “Vascular diseases” • Results: 86 hits • 22 primary lit articles selected for review • Review article related to NEJM Comment Kaiser Family Foundation/American College of Cardiology Foundation, 2002

6. Topics Investigated • Cardiovascular risk (7) • Lipids, weight gain, coronary calcification • Chest pain & MI (2) • Invasive procedures (5) • PCI, CABG • Heart failure (5) • Secondary prevention (2) • Multiple outcomes (1)

7. Cardiovascular Risk • Nasir, et al. • Black and Hispanic patients had highest prevalence of vascular calcifications • Burke, et al. • Weight gain greater in black v. white men (p<0.001) • Other measures of body size (BMI, skin fold thickness) also were significant Atherosclerosis. 2008;198:104-14 Ethn Health. 1996;1:327-35

8. Chest Pain & MI • Bell et al.; Black patients: • Had increased time to ECG • Were less likely to receive PCI • Were more likely to receive echo • Newsome et al.; Black patients: • Had no difference in mortality from white patients with GFR > 60 (HR 1.00 + 0.1) • Faired better than white patients with more severe kidney disease Am J Health Behav. 2001;25:60-71 Clin J Am Soc Nephrol 2006;1:993-9

9. Invasive Procedures • Conigliaro et al.; Black patients: • Revasc < white patients (28% v. 47%) • PCI < white patients (OR 0.30; p<0.01) • CABG < white patients (OR 0.44; p<0.1) • Had no difference in mortality at 1 year and 5 years • Gordon et al.; Black & Hispanic patients: • Had similar recommendations for PCI & CABG • More likely to refuse or not follow-up Arch Intern Med. 2000;160:1329-35 J Gen Intern Med. 2004;19:962-6

10. Invasive Procedures (cont.) Ann Intern Med. 2001;135:352-366

11. Invasive Procedures (cont.) • Kim et al. (n=71,949 CABG proc.) • Higher volume hospital more important for black CABG pts (race-by-volume interaction p<0.033) • Racial disparities in mortality only existed in lower-volume hospitals • Differences driven by regional patterns Ann Surg. 2008;248:886-92

12. Invasive Procedures (cont.) Ann Surg. 2008;248:886-92

13. Heart Failure • Bibbins-Domingo et al.; Black patients: • Had higher incidence of HF (p=0.001) • Had higher diastolic BP; HR 2.1, 1.4-3.1 • Had higher BMI; HR 1.4, 1-1.9 • Had lower HDL; HR 0.6, 0.4-1 • Philbin et al.; Black patients: • Showed higher prevalence of HF risk factors • Lower ejection fractions New Eng J Med. 2009;360:1179-90 J Card Fail. 2000;6:187-93

14. Heart Failure (cont.) • Deswal et al.; (n=18,611) Black pts: • More likely to have LVEF assessed • Had similar quality-of-care indicators to white patients • ACE or ARB; OR 1.06, 0.85-1.33 • Beta-blockers; OR 0.92, 0.79-1.07 • Were more likely to be hospitalized for HF (OR 1.43, 1.23-1.66) • Had similar 1-year mortality to white pts Am Heart J. 2006;152:348-54

15. Secondary Prevention • Nakamura et al. • Black patients had more frequent events than Asian and Whites (p=0.022) • After adjusting for covariates, black was significantly associated with events (p=0.002) • Higher education level can negate effect of race Am Heart J. 1999;138:500-6

16. Secondary Prevention (cont.) Kaiser Family Foundation/American College of Cardiology Foundation, 2002

17. Summary • Black patients have higher incidence of vascular calcifications and weight gain • Black patients are less likely to receive invasive procedures • This does not seem to affect mortality • Black patients have a higher incidence of heart failure, likely due to risk factors • Black patients also are at a higher risk of secondary events

18. Prescriber Attitudes • Only 1/3 of cardiologists believe racial/ethnic disparities exist in healthcare • 5% of cardiologists believe their own patients are treated differently based on race/ethnicity • Physicians attribute disparities in care to individual patient differences Circulation. 2005;111:1264-9

19. Prescriber Attitudes (cont.)

20. Patient-level factors Perceptions of health care discrimination Perceptions of undesirable physician behavior Faith in God to control one's destiny Provider-level factors Language differences Cultural insensitivity Bias Frank racism Factors Influencing Care Arch Intern Med. 1998;158:1450-3

21. Recommendations • Intervention: change the culture • Implications on education • Continuing education • https://cccm.thinkculturalhealth.org/ • Investigate existence of disparities in care of other racial/ethnic groups

23. Discussion Questions (Please write on evaluation or provide in email. Thanks!) • What research questions are generated from this information? • Has your attitude about racial disparities in cardiac care changed? Explain.

24. Racial Disparities in Cardiac Care Andrew N. Schmelz, PharmD Post-Doctoral Teaching Fellow Dept of Pharmacy Practice, Purdue University May 26, 2009 anschmel@purdue.edu