Elimination of Gender and Racial Differences in Recognition and Treatment of Patients at Risk for Su

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Elimination of Gender and Racial Differences in
Recognition and Treatment of Patients at Risk for
Sudden Cardiac Arrest
William Daniel, MD, FACC1,2 John Spertus, MD,
MPH, FACC2

• 1Cardiovascular Consultants, Pennsylvania
• 2Saint Lukes Mid America Heart Institute and
• University of Missouri-Kansas City School of
  Medicine
• Kansas City, Missouri

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Background

• Sudden cardiac arrest (SCA) is a leading cause of
  death in the United States.
• ICDs can prevent SCA in high-risk patients.
• Recent reports document gender and racial
  differences in the recognition and treatment of
  patients at risk for SCA.
• Hernandez, et al (JAMA 2007) found lt 40 of
  potentially eligible patients hospitalized for
  heart failure received ICD therapy. Rates were
  lower among eligible women and black patients.
• Novel solutions are needed to address this
  quality gap.
• Altering the processes of outpatient care with
  flowsheets or electronic health records did not
  improve recognition in IMPROVE-HF.
• In contrast, we previously reported the efficacy
  of a unique clinical decision support (CDS) tool
  to augment our EMR.
• Recognition rates increased from 24 to 93 in a
  pre-/post- evaluation with concurrent controls.

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Objective

• To examine the impact of the CDS on gender and
  racial disparities in SCA recognition and
  treatment.

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MethodsDevelopment of Clinical Decision Support
Tool (CDS)
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Study Design

• Recognition defined as at risk for SCA based on
  class I guidelines and referred for ICD or
  documented ICD implantation, patient refusal,
  patient no longer eligible for ICD, or temporary
  exclusion requiring further evaluation and
  treatment prior to consideration of ICD.
• To establish the efficacy of the SCA recognition
  program, the intervention clinic was compared
  with 3 concurrent control clinics in a series of
  analyses as diagramed in the study timeline.

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Study Timeline
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Study Design

• Analysis 1 The baseline SCA risk recognition and
  ICD implantation rate for men, women, and
  minorities was compared between the intervention
  clinic (prior to CDS) and the 3 control clinics
  to establish comparability at baseline.
• Analysis 2 Pre/post comparison of the
  recognition for women and minorities after CDS
  implementation within the intervention clinic as
  compared with the control clinics.
• Independent data collection and review of 6600
  medical charts for every patient in the active
  and control groups over a 2-month period from
  April-May 2006 was conducted.

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Results

• Analysis 1 Recognition and ICD implantation
  rates for men, women, and minorities at baseline,
  within each group, were similar in the
  intervention and control clinics.

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Results
(CDS EMR)
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Results
(CDS EMR)
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Results
(CDS EMR)
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Results
(CDS EMR)
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Conclusions

• This study demonstrates
• That CDS improved recognition and ICD
  implantation rates overall
• That gender and racial disparities which were
  present prior to CDS were no longer apparent
  afterwards
• Widespread use of such objective CDS tools may
  reduce gender and racial disparities in treatment.

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Limitations

• Single practice setting - generalizability to
  other cardiologists and primary care physicians
  is unknown
• Only addresses patients at highest risk based on
  LVEF and NYHA class

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Future Directions

• Demonstrate dissemination and scalability of CDS
  embedded into workflow across medical practices
  through multicenter trial/demonstration project
• Develop clinical decision support to address
  other patients at risk for SCA