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

Why the urgency to eliminate racial and ethnic disparities in health care?

 Cardiac disease  Infant mortality  Cancer screening and management  Diabetes  HIV Infections/AIDS  Immunizations Minority populations are disproportionately affected

“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

Evidence shows disparities exist Institute of Medicine Report, 2002 –The evidence is “overwhelming” –Disparities exist even when insurance status, income, age, and severity of conditions are comparable –Minorities are less likely than whites to receive needed services –Disparities contribute to worse outcomes in many cases –Differences in treating heart disease, cancer, and HIV infection partly contribute to higher death rates for minorities Source: Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, March 2002.

Several studies show racial/ethnic differences in the appropriate delivery of diagnostic tests and treatment for:  Heart Disease  Cancer  Stroke  Kidney Dialysis, Transplant  HIV/AIDS  Asthma  Diabetes National Academy of Sciences, Web Extra, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, Documenting the Disparities.

Heart Disease

Leading Causes of Death, by Race/Ethnicity, 2000 RankWhite, Non-Latino LatinoAfrican American, Non-Latino Asian/Pacific Islander American Indian/ Alaska Native 1 Heart disease CancerHeart disease 2 Cancer Heart diseaseCancer 3 CVDAccidentsCVD Accidents 4 Chronic lung disease CVDAccidents Diabetes 5 AccidentsDiabetes Chronic lung disease CVD CVD = Cerebrovascular disease DATA: National Center for Health Statistics, National Vital Statistics System. National Vital Statistics Report, Vol. 50, No. 16, September 16, SOURCE: Kaiser Family Foundation, Key Facts: Race, Ethnicity and Medical Care, June RankWhite, Non-Latino LatinoAfrican American, Non-Latino Asian/Pacific Islander American Indian/ Alaska Native 1 Accidents HIVCancerAccidents 2 Cancer Heart DiseaseAccidentsLiver Disease 3 Heart DiseaseHomicideAccidentsHeart Disease 4 SuicideHIVCancerSuicide 5 HIVHeart DiseaseHomicide Cancer All ages Ages 25-44

Heart Disease Death Rates for Adults 25-64, by Income, Race and Gender, 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 White, Non-Latino African American, Non-Latino Deaths per 100,000 person years Under $10,000 Over $15,000

Cardiac Care: The Weight of the Evidence

Looked at key cardiac interventions  Cardiac catheterization  Percutaneous transluminal coronary angioplasty  Thrombolytic therapy  Coronary artery bypass graft surgery  Drug therapy

Rate of Cardiac Interventions Among Medicare Patients Hospitalized with an Acute Myocardial Infarction, by Race/Ethnicity, *Difference is statistically significant after adjustment. NOTE: Odds ratios are adjusted for age, sex, insurance, health status, and disease severity. DATA: Ford et al SOURCE: Kaiser Family Foundation, Key Facts: Race, Ethnicity and Medical Care, June Odds ratio < 1.0 indicates group is less likely to undergo procedure compared to white patients Equally likely as white patients

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

Cardiac Procedure Use in Chronic Renal Disease Patients, by Race and Gender, *Difference is statistically significant after adjustment. NOTE: Odds ratios are adjusted for age, health insurance, sociodemographic characteristics, and clinical factors. DATA: Daumit and Powe, SOURCE: Kaiser Family Foundation, Key Facts: Race, Ethnicity and Medical Care, June Odds ratio < 1.0 indicates group is less likely to undergo procedure compared to white men Equally likely as white men

Coronary Artery Bypass Surgery by Race/Ethnicity and Insurance Status, *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., SOURCE: Kaiser Family Foundation, Key Facts: Race, Ethnicity and Medical Care, June African AmericanLatinoAsian Equally likely as white patients Odds ratio < 1.0 indicates group is less likely to undergo procedure compared to white patients

Figure 8 Coronary Artery Surgery Rates by Race and Disease Severity, Source: Peterson, et al., Percent Receiving Bypass Surgery Mild DiseaseSevere Disease Whites African Americans

Criteria for evaluating the strength of the evidence A “strong study”: Had well-defined parameters Had internal validity Measured and controlled for critical variables A “less strong” study: Did not control for critical variables Had design flaws that potentially undermined the validity of the evidence

Study Results  81 of the 158 studies produced from the literature search met the inclusion criteria and comprised the body of evidence  Most of the studies investigated more than one cardiac procedure or treatment  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 Study Results (Continued)

Evidence of racial/ethnic differences in cardiac care 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

Evidence of Racial/Ethnic Differences in Cardiac Care, 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.

Example: Coronary Artery Bypass Surgery (CABG)

Evidence of Racial/Ethnic Differences in CABG Rates, ‡ Total= 23Total= 21 Number of Studies All Studies Total= 44 Clinical DataAdministrative 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 (This figure includes Oberman & Cutter, 1984.)

Odds Ratios for Selected Strong Studies

‘Weight of the Evidence’ suggests…  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, such as heart disease severity and insurance.

Potential Sources of Disparities in Care Patient-Level –Patient preferences –Treatment refusal –Care seeking behaviors and attitudes –Clinical appropriateness of care Health Care Systems-Level –Lack of interpretation and translation services –Time pressures on physicians –Geographic availability of health care institutions –Changes in the financing and delivery of health care services Provider-Level –Bias –Clinical uncertainty –Beliefs/stereotypes about the behavior or health of minority patients Source: Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, March 2002.

Why the Difference?

Objectives of the Initiative  To bring together leading health care organizations to focus attention on the issue  To increase awareness of racial/ethnic disparities in health care among physicians  To spark discussion among providers and solicit their input into causes and solutions  To continue the drive toward investigation and elimination of cardiac disparities

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

Website Site visitors may do the following:  Review the evidence  Submit thoughts  Link to guidelines  Read recent news stories  Learn about upcoming events  Find related resources

Next steps  Continue to increase awareness of the issue  Promote dialogue about potential causes (patient, physician, health system factors)  Research causes and potential solutions  Evaluation of results  Share with other experts

 Get to know the evidence  Join the national discourse on health disparities with a genuine determination to eliminate them  Support innovative research to identify underlying determinants  Review your own practice and procedures to ensure that existing cardiac care guidelines are being followed What can you do?