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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
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?
www.kff.org/whythedifference