Recognizing Disparities inHealthcare intheU.S.andFindingSolutions"
ClydeW.Yancy,MD,MScProfessor ofMedicine,Professor,MedicalSocialScienceChief,CardiologyAssociate Director, BluhmCVInstitute&Vice-Dean, Diversity &InclusionNorthwestern University, FSM&DeputyEditor, JAMACardiology
Whatisahealthcaredisparity? Gettingtheglossary correct
3
Disparitycondition or fact of being unequal. This is what we
wish to avoid
Diversitynoticeable heterogeneityThis is what we must embrace
Cultureshared, learned, symbolic system of values, beliefs and attitudes that shapes and influencesperception and behavior
This is what we wish to enhance
A relevant glossary:
INCLUSION
IOM Report: Differences, Disparities, and Discrimination
Disparities-racial or ethnic differences in healthcare that are not dueTo access related factors, clinical needs, patient preferences or the Appropriateness of the intervention.
Non-
Min
ority
Min
ority
Difference
Clinical Appropriatenessand Need, PatientPreferences
The Operation ofHealthcare Systems and
the Legal and Regulatory Climate
Discrimination: Biases andPrejudice, Stereotyping,and Uncertainty
Disparity
Populations with Equal Access to Health Care
Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. The Institute of Medicine, National Academies Press, Washington, DC. 2002
Istherecontemporaryevidenceofdisparities inCardiovascularMedicine?
Whoexactlyisaminority?
•TheBiologyofBias•Howdoyouseetheworld?•CulturalCompetence•Strategies toovercomebiasinCardiovascularMedicine
Whatdoyousee?
Frog or Horse?
A young woman with A distant gaze OR An older coarse woman?
TheHermanGrid
TheHermanGrid
• Doyouseegraydotsatthewhite intersections?• AretheGrayspots really there?• This isanexample ofhowwesometimes seethings thatarenot really there.Discussion:• Haveyoueverhadawrong first impression of someone whohadadifferentbackground orcamefrom another culture?
• Hassomeone from adifferent back-ground oranother culture everhad thewrong first impression ofyou?
ConnectTheDots
Connect allofthedots with four straight lines.•DoNOTlift yourpencil off thepaper.•DoNOTretraceanyline. Linesmaycross ifnecessary.
ConnectTheDots
Discussion:
•Whyisitthatmostofusdonotthinkaboutgoingoutoftheboundaries?Wehadtodrawoutsideofthelines.Thisiswhatisrequiredofuswhenweinteractwithothersaseveryonethinksdifferently (outsideofourboundariesor"box").•Whyisitsohardtoseeothers'pointofviews?Weoftenaresobusythinkingaboutourpointofview,thatwefailtoseeothers'pointofviews.•Thisactivitydemonstrates thatweoftenlimitourperspectiveandchoices.
UnconsciousBias
•https://www.youtube.com/watch?v=0veDFGo666s
•https://www.youtube.com/watch?v=vytOEbWvVjc
Understanding Diversity&Inclusion andmanagingsubconscious bias:Take-away #1
•Consideradifferentperspective
•Recognize thatmorecontent/depth/substancemaybepresentthanisinitially acknowledged
•Bewilling tothinkunconventionally
Implicit Bias
•Apreferenceforasocial groupthatisbothunconscious andautomatic.
• Itisubiquitous insociety; allpersonsareaffected• Itisinformedbyanindividual’s experiences andperceptions ofothers
• InaUSsample population, therewasanimplicitpreferenceof68%forwhitepersons
Haider, Sexton, Sriram et al. JAMA, vol 306(9); 942-51
Strategiestoovercomebias
•Uniquecohortspecific initiatives andclinicaltrials
•Addressing CulturalCompetency• EnhancingDiversity intheWorkforce, especiallyinDiscovery Science
• Enriching thepipelineoftalentedunder-representedminorities andwomen
• Increasing Diversity inClinicalTrials• Transitioning toPrecisionMedicine insteadofStereotyping inClinicalDecisionMaking
Arewebiased?
Alongitudinal survey; NorthwesternUniversity, FeinbergSchoolofMedicine
Cultural Competence; ameans toanend;asolution?
23
AddressingDiversity inClinical Trials
• TheFDAandpayers should consider economic incentives (or penalties) thatwould enable greater inclusion inclinical trials.
• Industry partners should commit tothiseffort, examining thedesign oftheirtrials, andselection of investigators andsites, both inandoutside of theU.S.
• Sitediversity, coordinator diversity andinvestigator diversity offer immediatesolutions, but incentives should becreated tofacilitate thisclinical trialconduct.
• “Enhanced cohort” recruitment inphase IVorpostapproval studies shouldbecome astandard.
• Novel ITstrategies, including theuseofsocial media, gamification andotherdigital health technologies mayprovide unique solutions andshould continuetobeexplored.
• Additional effort should beput towards theinformed consent process,assuring that language isconcordant andconsent isculturally sensitive.
• Educational efforts should beaimed atincreasing society’s overall “researchI.Q.”sothatweareallbetter able tounderstand thenature, purpose andimportance ofresearch participation.
Inpress…Ortega,R,YancyC,MehranR,BatchelorW
Jameson JL,LongoDL.NEngl JMed2015;372:2229-2234.
Implementation of Precision Medicine.
EpigeneticMechanisms
Overarching hypothesis:Disparities inHF&CKDemanate fromthebuiltenvironment
27
“Ihavebeenimpressedwiththeurgencyofdoing.Knowingisnotenough;wemustapply.Beingwilling isnotenough;wemustdo.”―LeonardodaVinci
“The roomwhere ithappens…”…