Racial and ethnic disparities in cardiac care

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

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Minority populations are disproportionately
affected

• Cardiac disease
• Infant mortality
• Cancer screening and management
• Diabetes
• HIV Infections/AIDS
• Immunizations

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IOM Report, 2002 Assessing the Quality of
Minority Health Care
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
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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.

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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.

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Heart Disease
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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
All ages
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
Ages 25-44
CVD Cerebrovascular disease DATA 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.
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Heart Disease Death Rates for Adults 25-64, by
Income, Race and Gender, 1979-1989
Deaths per 100,000 person years
Under 10,000
Over 15,000
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.
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Cardiac Care The Weight of the Evidence
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Looked at key cardiac interventions

• Cardiac catheterization
• Percutaneous transluminal coronary
  angioplasty
• Thrombolytic therapy
• Coronary artery bypass graft surgery
• Drug therapy

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Rate of Cardiac Interventions Among Medicare
Patients Hospitalized with an Acute Myocardial
Infarction, by Race/Ethnicity, 1994-1995
Odds ratio lt 1.0 indicates group is less likely
to undergo procedure compared to white patients
Equally likely as white patients
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.
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Rates of Hospitalization for Coronary Artery
Bypass Surgery among Medicare Beneficiaries, 1993
per 1000 beneficiaries per year
lt13,001
13,001- 16,300
16,301- 20,500
gt20,500
Annual Income
Rates were adjusted for age and sex to the total
Medicare population. DATA Gornick, ME et al.,
1996
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Cardiac Procedure Use in Chronic Renal Disease
Patients, by Race and Gender, 1986-1992
Odds ratio lt 1.0 indicates group is less likely
to undergo procedure compared to white men
Equally likely as white men
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.
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Coronary Artery Bypass Surgery by Race/Ethnicity
and Insurance Status, 1986-1988
Odds ratio lt 1.0 indicates group is less likely
to undergo procedure compared to white patients
Equally likely as white patients
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.
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Figure 8Coronary Artery Surgery Rates by Race
and Disease Severity, 1984-1992
Percent Receiving Bypass Surgery
Mild Disease
Severe Disease
Source Peterson, et al., 1997.
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Criteria for evaluating the strength of the
evidence

• A less strong study
• Did not control for critical variables
• Had design flaws that potentially undermined the
  validity of the evidence

• A strong study
• Had well-defined parameters
• Had internal validity
• Measured and controlled for critical variables

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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

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Study Results (Continued)

• 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

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Evidence of racial/ethnic differences in cardiac
care1984-2001
11 studies find no racial/ethnic difference in
care (14)
68 studies find a racial/ethnic difference in
care (84)
2 studies find racial/ethnic minority group more
likely than whites to receive appropriate care
(2)
Total 81 studies
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Evidence of Racial/Ethnic Differencesin Cardiac
Care, 1984-2001
All Studies (n81)
Strong Studies (n44)
Strong Clinical Studies (n24)
68 studies find racial/ethnic differences in care
(84)
39 studies find racial/ethnic differences in care
(89)
20 studies find racial/ethnic differences in care
(83)
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)
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 CareThe Weight of the
Evidence, 2002.
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Example Coronary Artery Bypass Surgery (CABG)
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Evidence of Racial/Ethnic Differences in CABG
Rates, 1984-2001
Number of Studies
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
All Studies
Clinical Data
Administrative Data
Total 23
Total 21
Total 44
Evidence from studies published from 1984-2001.
(This figure includes Oberman Cutter, 1984.)
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Odds Ratios for Selected Strong Studies
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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.

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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.
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Why the Difference?
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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

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Cardiology Circulation The Journal of the
American Heart Association
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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

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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

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What can you do?

• 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

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www.kff.org/whythedifference