Racial Racial Disparities Disparities

in in Cardiac Cardiac

CareCare

Andrew N. Schmelz, PharmDAndrew N. Schmelz, PharmDPost-Doctoral Teaching FellowPost-Doctoral Teaching Fellow

Dept of Pharmacy Practice, Purdue UniversityDept of Pharmacy Practice, Purdue UniversityMay 26, 2009May 26, 2009

anschmel@purdue.eduanschmel@purdue.edu

Discussion QuestionsDiscussion Questions

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

ObjectivesObjectives

State the rationale for reviewing State the rationale for reviewing racial disparities in cardiac careracial disparities in cardiac care

Summarize recent literature Summarize recent literature describing disparities in cardiac caredescribing disparities in cardiac care

Recommend future actions to reduce Recommend future actions to reduce racial disparities in cardiac careracial disparities in cardiac care

RationaleRationale

Comment in New England Journal of Comment in New England Journal of Medicine (NEJM)Medicine (NEJM)– Call to action to reduce racial disparitiesCall to action to reduce racial disparities

Questions raised:Questions raised:– What is known about racial disparities in What is known about racial disparities in

cardiac care?cardiac care?– What work has been done recently?What work has been done recently?– What can be done?What can be done?

N Engl J Med 2009; 360:1172-4.

MethodsMethods

MEDLINE searched, MeSH terms:MEDLINE searched, MeSH terms:– Healthcare disparities ANDHealthcare disparities AND– Cardiovascular diseasesCardiovascular diseases

Contains “Heart diseases” & “Vascular Contains “Heart diseases” & “Vascular diseases”diseases”

Results: 86 hitsResults: 86 hits– 22 primary lit articles selected for review22 primary lit articles selected for review

Review article related to NEJM Review article related to NEJM CommentComment

Kaiser Family Foundation/American College of Cardiology Foundation, 2002

Topics InvestigatedTopics Investigated

Cardiovascular risk (7)Cardiovascular risk (7)– Lipids, weight gain, coronary Lipids, weight gain, coronary

calcificationcalcification Chest pain & MI (2)Chest pain & MI (2) Invasive procedures (5)Invasive procedures (5)

– PCI, CABGPCI, CABG Heart failure (5)Heart failure (5) Secondary prevention (2)Secondary prevention (2) Multiple outcomes (1)Multiple outcomes (1)

Cardiovascular RiskCardiovascular Risk

Nasir, et al.Nasir, et al.– Black and Hispanic patients had highest Black and Hispanic patients had highest

prevalence of vascular calcificationsprevalence of vascular calcifications Burke, et al.Burke, et al.

– Weight gain greater in black v. white Weight gain greater in black v. white men (p<0.001)men (p<0.001)

– Other measures of body size (BMI, skin Other measures of body size (BMI, skin fold thickness) also were significantfold thickness) also were significant

Atherosclerosis. 2008;198:104-14Ethn Health. 1996;1:327-35

Chest Pain & MIChest Pain & MI

Bell et al.; Bell et al.; Black patients:Black patients:– Had increased time to ECGHad increased time to ECG– Were less likely to receive PCIWere less likely to receive PCI– Were more likely to receive echoWere more likely to receive echo

Newsome et al.;Newsome et al.; Black patients: Black patients:– Had no difference in mortality from white Had no difference in mortality from white

patients with GFR patients with GFR >> 60 (HR 1.00 60 (HR 1.00 ++ 0.1) 0.1)– Faired better than white patients with Faired better than white patients with

more severe kidney diseasemore severe kidney diseaseAm J Health Behav. 2001;25:60-71Clin J Am Soc Nephrol 2006;1:993-9

Invasive ProceduresInvasive Procedures

Conigliaro et al.Conigliaro et al.; Black patients:; Black patients:– Revasc < white patients (28% v. 47%)Revasc < white patients (28% v. 47%)– PCI < white patients (OR 0.30; p<0.01)PCI < white patients (OR 0.30; p<0.01)– CABG < white patients (OR 0.44; p<0.1)CABG < white patients (OR 0.44; p<0.1)– Had no difference in mortality at 1 year and Had no difference in mortality at 1 year and

5 years5 years Gordon et al.Gordon et al.; Black & Hispanic ; Black & Hispanic

patients:patients:– Had similar recommendations for PCI & CABGHad similar recommendations for PCI & CABG– More likely to refuse or not follow-upMore likely to refuse or not follow-up

Arch Intern Med. 2000;160:1329-35J Gen Intern Med. 2004;19:962-6

Invasive Procedures (cont.)Invasive Procedures (cont.)

Ann Intern Med. 2001;135:352-366

Invasive Procedures (cont.)Invasive Procedures (cont.)

Kim et al. Kim et al. (n=71,949 CABG proc.)(n=71,949 CABG proc.)– Higher volume hospital more important Higher volume hospital more important

for black CABG pts (race-by-volume for black CABG pts (race-by-volume interaction p<0.033)interaction p<0.033)

– Racial disparities in mortality only Racial disparities in mortality only existed in lower-volume hospitalsexisted in lower-volume hospitals

– Differences driven by regional patternsDifferences driven by regional patterns

Ann Surg. 2008;248:886-92

Invasive Procedures (cont.)Invasive Procedures (cont.)

Ann Surg. 2008;248:886-92

Heart FailureHeart Failure

Bibbins-Domingo et al.Bibbins-Domingo et al.; Black ; Black patients:patients:– Had higher incidence of HF (p=0.001)Had higher incidence of HF (p=0.001)– Had higher diastolic BP; HR 2.1, 1.4-3.1Had higher diastolic BP; HR 2.1, 1.4-3.1– Had higher BMI; HR 1.4, 1-1.9Had higher BMI; HR 1.4, 1-1.9– Had lower HDL; HR 0.6, 0.4-1Had lower HDL; HR 0.6, 0.4-1

Philbin et al.;Philbin et al.; Black patients: Black patients:– Showed higher prevalence of HF risk factorsShowed higher prevalence of HF risk factors– Lower ejection fractions Lower ejection fractions

New Eng J Med. 2009;360:1179-90J Card Fail. 2000;6:187-93

Heart Failure (cont.)Heart Failure (cont.)

Deswal et al.Deswal et al.; (n=18,611) Black pts:; (n=18,611) Black pts:– More likely to have LVEF assessedMore likely to have LVEF assessed– Had similar quality-of-care indicators to Had similar quality-of-care indicators to

white patientswhite patients ACE or ARB; OR 1.06, 0.85-1.33ACE or ARB; OR 1.06, 0.85-1.33 Beta-blockers; OR 0.92, 0.79-1.07Beta-blockers; OR 0.92, 0.79-1.07

– Were more likely to be hospitalized for Were more likely to be hospitalized for HF (OR 1.43, 1.23-1.66)HF (OR 1.43, 1.23-1.66)

– Had similar 1-year mortality to white ptsHad similar 1-year mortality to white ptsAm Heart J. 2006;152:348-54

Secondary PreventionSecondary Prevention

Nakamura et al.Nakamura et al.– Black patients had more frequent events Black patients had more frequent events

than Asian and Whites (p=0.022)than Asian and Whites (p=0.022)– After adjusting for covariates, black was After adjusting for covariates, black was

significantly associated with events significantly associated with events (p=0.002)(p=0.002)

– Higher education level can negate effect Higher education level can negate effect of raceof race

Am Heart J. 1999;138:500-6

Secondary Prevention Secondary Prevention (cont.)(cont.)

Kaiser Family Foundation/American College of Cardiology Foundation, 2002

SummarySummary

Black patients have higher incidence of Black patients have higher incidence of vascular calcifications and weight gainvascular calcifications and weight gain

Black patients are less likely to receive Black patients are less likely to receive invasive proceduresinvasive procedures– This does not seem to affect mortalityThis does not seem to affect mortality

Black patients have a higher incidence Black patients have a higher incidence of heart failure, likely due to risk factorsof heart failure, likely due to risk factors

Black patients also are at a higher risk of Black patients also are at a higher risk of secondary eventssecondary events

Prescriber AttitudesPrescriber Attitudes

Only 1/3 of cardiologists believe Only 1/3 of cardiologists believe racial/ethnic disparities exist in racial/ethnic disparities exist in healthcarehealthcare

5% of cardiologists believe their own 5% of cardiologists believe their own patients are treated differently based patients are treated differently based on race/ethnicityon race/ethnicity

Physicians attribute disparities in Physicians attribute disparities in care to individual patient differencescare to individual patient differences

Circulation. 2005;111:1264-9

Prescriber Attitudes (cont.)Prescriber Attitudes (cont.)

Factors Influencing CareFactors Influencing Care

Patient-level factorsPatient-level factors– Perceptions of Perceptions of

health care health care discriminationdiscrimination

– Perceptions of Perceptions of undesirable undesirable physician behaviorphysician behavior

– Faith in God to Faith in God to control one's destinycontrol one's destiny

Provider-level Provider-level factorsfactors– Language Language

differencesdifferences– Cultural Cultural

insensitivityinsensitivity– BiasBias– Frank racismFrank racism

Arch Intern Med. 1998;158:1450-3

RecommendationsRecommendations

Intervention: change the cultureIntervention: change the culture– Implications on educationImplications on education– Continuing educationContinuing education

https://cccm.thinkculturalhealth.org/https://cccm.thinkculturalhealth.org/ Investigate existence of disparities in Investigate existence of disparities in

care of other racial/ethnic groupscare of other racial/ethnic groups

Discussion QuestionsDiscussion Questions

(Please write on evaluation or provide in (Please write on evaluation or provide in email. Thanks!)email. Thanks!)

What research questions are What research questions are generated from this information?generated from this information?

Has your attitude about racial Has your attitude about racial disparities in cardiac care changed? disparities in cardiac care changed? Explain.Explain.

Racial Racial Disparities Disparities

in in Cardiac Cardiac

CareCare

Andrew N. Schmelz, PharmDAndrew N. Schmelz, PharmDPost-Doctoral Teaching FellowPost-Doctoral Teaching Fellow

Dept of Pharmacy Practice, Purdue UniversityDept of Pharmacy Practice, Purdue UniversityMay 26, 2009May 26, 2009

anschmel@purdue.eduanschmel@purdue.edu