American Heart Association QCOR 2010 Disparate Health Care: Definition, Context, Consequences

Clyde W. Yancy, MD, FAHA, FACC, MACP Chair, Cultural Competency Taskforce, AHA; Co-Chair, CREDO, ACC

DISCLOSURES

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Consultant/speaker/honoraria: none since 06/31/08

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Editorial Boards: American Heart Journal, American Journal of Cardiology (associate editor); Circulation; Circulation Heart Failure; Circulation- Quality Outcomes; Congestive Heart Failure

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Guideline writing committees: ACC/AHA, chronic HF; and ACC/AHA Guideline Taskforce

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Federal appointments: FDA: Past Chair, Cardiovascular Device Panel; ad hoc consultant, FDA; member, NIH CICS study section

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Volunteer Appointments: American Heart Association-

President, American Heart Association, 2009-2010

AHA Mission

Building healthier lives, free of cardiovascular diseases and stroke.

2020 Impact Goal

By 2020, to improve the cardiovascular health of

all

Americans by 20% while reducing cardiovascular diseases and stroke by 20%.

2006-2010 Strategic Plan

• Strategies devoted to reducing disparities:  Influence the healthcare system to effectively serve diverse populations.

 Reduce treatment gaps for racial and ethnic populations  Reduce health gaps for racial and ethnic populations  Decrease time to treatment for stroke

Percentage of the Population by Race/Ethnicity: 2000 and 2025

80 70 60 50 40 30 20 10 0 71.4

61.9

White* *White= Non-Hispanic. †AA= African American. US Census Bureau, 2000.

2000 2025 12.2

12.9

AA † 11.8

18.2

0.7

0.8

3.9

6.2

American Indian, Eskimo, Aleut* Asian and Pacific Islander* Hispanic Origin (of any race)

Age-Adjusted Death Rates for Coronary Heart Disease, Stroke, and Lung and Breast Cancer for White and Black Females

United States: 2002 200 150 100 50 0 131.2

169.7

Coronary Heart Disease 53.4

71.8

Stroke 42.6

40.1

25.0

34.0

Lung Cancer Breast Cancer White Females Black Females

Source: CDC/NCHS.

Differences? Disparities?

Contributors to Healthcare Disparities

Difference Clinical Appropriateness and Need, Patient Preference The “Ecology” of Health Care Systems and Environmental Factors Discrimination: Biases, Stereotyping, and Uncertainty Disparity Differences, Disparities, and Discrimination: Populations with Equal Access to Healthcare.

Source: Gomes and McGuire, 2001 Smedley BD, Stith AY, Nelson AR, Editors et al. Unequal Treatment: What Healthcare Providers Need to Know About Racial and Ethnic Disparities in Healthcare. National Academies Press; 2002

CASE IN POINT…

Hypertension as a risk factor for HF in AAs

Bibbins-Domingo et al. New England Journal of Medicine. 360(12):1179-1190

Incidence of heart failure in young AAs

Bibbins-Domingo et al. New England Journal of Medicine. 360(12):1179-1190

The consequences of disparate health care:

“There is growing and disturbing evidence that disparities in care result in preventable excess morbidity and possibly increased mortality.” Peterson, E. Yancy CW. : N Engl J Med. 2009 Mar 19;360(12):1172-4.

Culture

shared, learned, symbolic system of values, beliefs and attitudes that shapes and influences

Diversity

noticeable heterogeneity.

perception and behavior variety

Disparity

condition or fact of being unequal

RACIAL DISPARITIES IN AMERICA- A REPORT FROM THE INSTITUTE OF MEDICINE

Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare

• • 

Racial and ethnic disparities in healthcare exist May be associated with worse outcomes



Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare may contribute to racial/ethnic disparities in healthcare More research is needed in this area

Adapted from Smedley, B., Stith, A. and Nelson, A. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. The Institute of Medicine, National Academies Press, Washington, DC. 2002;19. Adapted from The National Center for Cultural Competence. 2005.

What are potential sources of disparities in care?

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Health systems-level factors – financing, structure of care; cultural and linguistic barriers Patient-level factors –poor adherence, biological differences

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Disparities arising from the clinical encounter

Physician Self-Assessed Attitudes Importance of sociocultural issues in patient interactions Black( n=51) Asian (n=88) White (n=482) 3.4

3.7

4.0

Importance of multicultural health care training for healthcare professionals 3.5

3.5

4.5

1 Not at all important 1.5

2 2.5

3 Somewhat important 3.5

4 4.5

5 Very important

Survey Questions: How important do you consider sociocultural issues to be in your interactions with patients? How important do you feel it is for health professionals to receive training in cultural diversity and/or multicultural health c are?”

Physician Attitudes Importance of Multicultural Health Care Training Asian

(n=87)

9% 17% Black

(n=49)

White

(n=479)

5% 8% 18% 20% Not at All A Little 30% 29% Somewhat 69% 31% 44% Quite a Bit 17% Very

Survey Question: “How important do you feel it is for health professionals to receive training in cultural diversity and/or multicultural health care?”

Physician Self-Assessed Knowledge Sociocultural characteristics of diverse racial/ethnic groups Health disparities experienced by diverse racial/ethnic groups Impact of racism, bias, prejudice, and discrimination experienced in health care Ethnopharmacology Self-assessed knowledge in sociocultural issues as reported by white, Asian and black physicians 3.2

3.5

3.9

3.5

3.5

4.1

2.9

3.1

3.8

3.1

3.2

3.6

Different healing traditions 2.6

3.2

2.8

Office of Minority Health’s National Standards for CLAS in health care 2.5

2.8

3.0

Black (n=51) Asian (n=88)

1.5

Not at all knowledgeable 2

Survey Question: How knowledgeable are you about each of the following subject areas?

2.5

3 Somewhat knowledgeable 3.5

4 4.5

5 Very knowledgeable

Physician Self-Assessed Skills Self-assessed skills in dealing with sociocultural issues as reported by White, Asian and Black physicians Dealing with cross-cultural conflicts relating to diagnosis or treatment Assessing health literacy Providing culturally sensitive patient education and counseling Eliciting information about folk remedy and alternative healing modality use Prescribing/negotiating a culturally sensitive treatment plan Greeting patients in a culturally sensitive manner 2.9

3.1

3.2

3.2

3.2

3.4

3.0

3.3

3.6

3.1

3.1

3.7

3.0

3.3

3.6

3.5

3.6

4.0

Black (n=51) Asian (n=88) White (n=482) 1 Not at all skilled 1.5

2 2.5

3 Somewhat skilled

Survey Question: How skilled are you in dealing with sociocultural issues in the following areas of patient care?

3.5

4 4.5

Very skilled 5

Cultural Competency Advisory Group

• Charge  Identify gaps related to the current data on cultural competency that the American Heart Association can work toward filling.

 Identify key opportunities related to the current data on cultural competency.

• Professional practice gaps • Professional Education opportunities • Patient Education opportunities • Integrated opportunities – How can we strengthen the interactions between healthcare providers and their diverse patients?

• Renovation of existing programs, products, and initiatives

Reducing Racial and Ethnic Disparities in Cardiovascular Disease Outcomes

Cultural Competence

What is Cultural Competence?

“The ability of systems to provide care to patients with diverse values, beliefs and behaviors including tailoring delivery of care to meet patients’ social, cultural, and linguistic needs. The ultimate goal is a health care system and workforce that can deliver the highest quality of care to every patient, regardless of race, ethnicity, cultural background, [language proficiency, literacy, age, gender, sexual orientation, disability, or socioeconomic status].” Adapted & expanded from the Commonwealth Fund. New York, NY, 2002

Addressing Cultural Contexts in Health Care

HEALTH CARE SYSTEM FAMILY PATIENT COMMUNITY HEALTH CARE PROVIDER T.D. Goode. The National Center for Cultural Competence. 2005.

Quality focused strategies

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Get With The Guidelines®- HF; CAD

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AHA Performance Improvement Program

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Robert Woods Johnson Expecting Success Multicenter quality improvement program targeting AMI & HF American College of Cardiology: CREDO

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Coalition to reduce disparate health care American Heart Association: Cultural Competency Initiative

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Provider and patient focused initiative to address cultural competency

Strategies to Enhance Cultural Competence

Cultivate Leadership Legitimize Cultural Competency CLAS Practice Environment Resources & Tools

Targeting Healthcare Disparities in Cardiovascular Disease

Promote Positive Attitudes Encourage Self Assessment Facilitate Skill Development Impart Critical Knowledge

AHA Cultural Competency Mnemonic CULTURE

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C- Context

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Can you establish your patient’s unique social context?

U- Understanding

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Do you appreciate your patient’s perspective?

L- Language

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Are you communicating effectively?

T- Treatment

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Have you engaged the patient in the treatment decision?

U- Urge

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Have you prompted questions?

R- Reassess

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How was this encounter? Would it have worked for you?

E- Enlighten

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Are you and the patient more aware and prepared for next steps?

“Knowing is not enough; we must apply.

Willing is not enough; we must do.”

Johann von Goethe