Racial and ethnic disparities in cardiac careWhat 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

DiabetesNational 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

Rank White,

Non-Latino

Latino African American,

Non-Latino

Asian/Pacific Islander

American Indian/ Alaska

Native

1 Heart disease Heart disease Heart disease Cancer Heart disease

2 Cancer Cancer Cancer Heart disease Cancer

3 CVD Accidents CVD CVD Accidents

4 Chronic lung disease

CVD Accidents Accidents Diabetes

5 Accidents Diabetes Diabetes Chronic lung disease

CVD

CVD = Cerebrovascular diseaseDATA: National Center for Health Statistics, National Vital Statistics System. National Vital Statistics Report, Vol. 50, No. 16, September 16, 2002.SOURCE: Kaiser Family Foundation, Key Facts: Race, Ethnicity and Medical Care, June 2003.

Rank White,

Non-Latino

Latino African American,

Non-Latino

Asian/Pacific Islander

American Indian/

Alaska Native

1 Accidents Accidents HIV Cancer Accidents

2 Cancer Cancer Heart Disease Accidents Liver Disease

3 Heart Disease Homicide Accidents Heart Disease Heart Disease

4 Suicide HIV Cancer Suicide Suicide

5 HIV Heart Disease Homicide Homicide Cancer

All ages

Ages 25-44

Heart Disease Death Rates for Adults 25-64, by Income, Race and Gender, 1979-1989

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 2003.

White, Non-Latino

African American, Non-Latino

64.8

324.1

112.2136.9

43.7

184.7

390.8

142.2

0

500

Male Female Male Female

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, 1994-1995

*Difference is statistically significant after adjustment.NOTE: Odds ratios are adjusted for age, sex, insurance, health status, and disease severity. DATA: Ford et al. 2000.SOURCE: Kaiser Family Foundation, Key Facts: Race, Ethnicity and Medical Care, June 2003.

0.42*

0.64*0.62*

0.92

0.58*

0.82*

0

1

2

Catheterization Angioplasty Bypass Surgery

African American Latino

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

4.64.94.84.8

1.82.2 2.1 2.2

0

2

4

6

*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, 1986-1992

*Difference is statistically significant after adjustment.NOTE: Odds ratios are adjusted for age, health insurance, sociodemographic characteristics, and clinical factors.DATA: Daumit and Powe, 2001.SOURCE: Kaiser Family Foundation, Key Facts: Race, Ethnicity and Medical Care, June 2003.

0.30*0.32*

0.750.66*

0.00

1.00

2.00

African American Men African American Women

Pre-Medicare Post-Medicare

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, 1986-1988

*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., 1997.SOURCE: Kaiser Family Foundation, Key Facts: Race, Ethnicity and Medical Care, June 2003.

African American Latino Asian

0.33*

0.8

0.5*0.59*

0.93

0.79*0.8

1.091.15

0.82

1.22

0.99

0.0

1.0

2.0

Private Medicaid Medicare Uninsured

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, 1984-1992

35%

45%

25%31%

0%

20%

40%

60%

80%

Source: Peterson, et al., 1997.

Percent Receiving Bypass Surgery

Mild Disease Severe 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

1984-2001

68 studies find a racial/ethnicdifference 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 appropriatecare (2%)

Total= 81 studies

Evidence of Racial/Ethnic Differencesin Cardiac Care, 1984-2001

68 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, 1984-2001‡

24

12 11

5

13

7

6

6

1

11

0

5

10

15

20

25

30

Strong LessStrong

Strong LessStrong

Strong LessStrong

Total= 23 Total= 21

Numberof Studies

All Studies

Total= 44

Clinical Data Administrative 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 1984-2001. (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 CarePatient-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

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Link to guidelines

Read recent news stories

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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?

www.kff.org/whythedifference