1. American Heart Association QCOR 2010 Disparate Health Care: Definition, Context, Consequences Clyde W. Yancy, MD, FAHA, FACC, MACP Chair, Cultural Competency Taskforce, AHA; Co-Chair, CREDO, ACC

2. DISCLOSURES Consultant/speaker/honoraria: none since 06/31/08 Editorial Boards: American Heart Journal, American Journal of Cardiology (associate editor); Circulation; Circulation-Heart Failure; Circulation- Quality Outcomes; Congestive Heart Failure Guideline writing committees: ACC/AHA, chronic HF; and ACC/AHA Guideline Taskforce Federal appointments: FDA: Past Chair, Cardiovascular Device Panel; ad hoc consultant, FDA; member, NIH CICS study section Volunteer Appointments: American Heart Association- President, American Heart Association, 2009-2010

3. AHA Mission Building healthier lives, free of cardiovascular diseases and stroke. 2020 Impact Goal By 2020, to improve the cardiovascular health of all Americans by 20% while reducing cardiovascular diseases and stroke by 20%.

4. 2006-2010 Strategic Plan Strategies devoted to reducing disparities:  Influence the healthcare system to effectively serve diverse populations.  Reduce treatment gaps for racial and ethnic populations  Reduce health gaps for racial and ethnic populations  Decrease time to treatment for stroke

5. Percentage of the Population by Race/Ethnicity: 2000 and 2025 Percentage of Population *White= Non-Hispanic. †AA= African American. US Census Bureau, 2000. †

7. Age-Adjusted Death Rates for Coronary Heart Disease, Stroke, and Lung and Breast Cancer for White and Black Females United States: 2002 Source: CDC/NCHS.

8. Differences? Disparities?

9. Contributors to Healthcare Disparities Smedley BD, Stith AY, Nelson AR, Editors et al. Unequal Treatment: What Healthcare Providers Need to Know About Racial and Ethnic Disparities in Healthcare. National Academies Press; 2002 Quality of Healthcare Non-MinorityMinority Clinical Appropriateness and Need, Patient Preference The “Ecology” of Health Care Systems and Environmental Factors Discrimination: Biases, Stereotyping, and Uncertainty Disparity Difference Differences, Disparities, and Discrimination: Populations with Equal Access to Healthcare. Source: Gomes and McGuire, 2001

10. CASE IN POINT…

11. Hypertension as a risk factor for HF in AAs Bibbins-Domingo et al. New England Journal of Medicine. 360(12):1179-1190

12. Incidence of heart failure in young AAs Bibbins-Domingo et al. New England Journal of Medicine. 360(12):1179-1190

13. The consequences of disparate health care: “There is growing and disturbing evidence that disparities in care result in preventable excess morbidity and possibly increased mortality.” Peterson, E. Yancy CW. : N Engl J Med. 2009 Mar 19;360(12):1172-4.

14. Disparity condition or fact of being unequal Diversity noticeable heterogeneity. variety Culture shared, learned, symbolic system of values, beliefs and attitudes that shapes and influences perception and behavior

15. RACIAL DISPARITIES IN AMERICA- A REPORT FROM THE INSTITUTE OF MEDICINE

16. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare Racial and ethnic disparities in healthcare exist  May be associated with worse outcomes Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare may contribute to racial/ethnic disparities in healthcare  More research is needed in this area Adapted from Smedley, B., Stith, A. and Nelson, A. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. The Institute of Medicine, National Academies Press, Washington, DC. 2002;19. Adapted from The National Center for Cultural Competence. 2005.

17. What are potential sources of disparities in care? Health systems-level factors – financing, structure of care; cultural and linguistic barriers Patient-level factors –poor adherence, biological differences Disparities arising from the clinical encounter

19. Physician Self-Assessed Attitudes Not at all important Somewhat important Very important Survey Questions: How important do you consider sociocultural issues to be in your interactions with patients? How important do you feel it is for health professionals to receive training in cultural diversity and/or multicultural health care?” Importance of multicultural health care training for healthcare professionals Importance of sociocultural issues in patient interactions

20. Physician Attitudes Importance of Multicultural Health Care Training Black (n=49) White (n=479) Asian (n=87) Survey Question: “How important do you feel it is for health professionals to receive training in cultural diversity and/or multicultural health care?”

21. Physician Self-Assessed Knowledge Survey Question: How knowledgeable are you about each of the following subject areas? Not at all knowledgeable Somewhat knowledgeable Very knowledgeable Self-assessed knowledge in sociocultural issues as reported by white, Asian and black physicians Health disparities experienced by diverse racial/ethnic groups Sociocultural characteristics of diverse racial/ethnic groups Office of Minority Health’s National Standards for CLAS in health care Different healing traditions Impact of racism, bias, prejudice, and discrimination experienced in health care Ethnopharmacology

22. Physician Self-Assessed Skills Survey Question: How skilled are you in dealing with sociocultural issues in the following areas of patient care? Not at all skilled Somewhat skilled Very skilled Self-assessed skills in dealing with sociocultural issues as reported by White, Asian and Black physicians Greeting patients in a culturally sensitive manner Prescribing/negotiating a culturally sensitive treatment plan Eliciting information about folk remedy and alternative healing modality use Providing culturally sensitive patient education and counseling Dealing with cross-cultural conflicts relating to diagnosis or treatment Assessing health literacy

23. Cultural Competency Advisory Group Charge  Identify gaps related to the current data on cultural competency that the American Heart Association can work toward filling.  Identify key opportunities related to the current data on cultural competency. Professional practice gaps Professional Education opportunities Patient Education opportunities Integrated opportunities – How can we strengthen the interactions between healthcare providers and their diverse patients? Renovation of existing programs, products, and initiatives

24. Reducing Racial and Ethnic Disparities in Cardiovascular Disease Outcomes

25. Cultural Competence

26. What is Cultural Competence? “The ability of systems to provide care to patients with diverse values, beliefs and behaviors including tailoring delivery of care to meet patients’ social, cultural, and linguistic needs. The ultimate goal is a health care system and workforce that can deliver the highest quality of care to every patient, regardless of race, ethnicity, cultural background, [language proficiency, literacy, age, gender, sexual orientation, disability, or socioeconomic status].” Adapted & expanded from the Commonwealth Fund. New York, NY, 2002

27. T.D. Goode. The National Center for Cultural Competence. 2005. Addressing Cultural Contexts in Health Care FAMILY HEALTH CARE PROVIDER HEALTH CARE SYSTEM COMMUNITY PATIENT

28. Quality focused strategies Get With The Guidelines®- HF; CAD  AHA Performance Improvement Program  Robert Woods Johnson Expecting Success  Multicenter quality improvement program targeting AMI & HF American College of Cardiology: CREDO  Coalition to reduce disparate health care American Heart Association: Cultural Competency Initiative  Provider and patient focused initiative to address cultural competency

29. Targeting Healthcare Disparities in Cardiovascular Disease Strategies to Enhance Cultural Competence Cultivate Leadership CLAS Practice Environment Resources & Tools Resources & Tools Facilitate Skill Development Impart Critical Knowledge Promote Positive Attitudes Legitimize Cultural Competency Legitimize Cultural Competency Encourage Self- Assessment

30. AHA Cultural Competency Mnemonic CULTURE C- Context  Can you establish your patient’s unique social context? U- Understanding  Do you appreciate your patient’s perspective? L- Language  Are you communicating effectively? T- Treatment  Have you engaged the patient in the treatment decision? U- Urge  Have you prompted questions? R- Reassess  How was this encounter? Would it have worked for you? E- Enlighten  Are you and the patient more aware and prepared for next steps?

31. “Knowing is not enough; we must apply. Willing is not enough; we must do.” Johann von Goethe