Transcript Document

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
Why the urgency to eliminate
racial and ethnic disparities
in health care?
Minority populations are
disproportionately affected






Cardiac disease
Infant mortality
Cancer screening and management
Diabetes
HIV Infections/AIDS
Immunizations
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
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

Diabetes
National 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
All
ages
Ages
25-44
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
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
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.
Heart Disease Death Rates for Adults 25-64,
by Income, Race and Gender, 1979-1989
Deaths per 100,000 person years
African American, Non-Latino
500
White, Non-Latino
390.8
324.1
184.7
142.2
136.9
112.2
64.8
43.7
0
Male
Female
Male
Under $10,000
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.
Female
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
2
Odds ratio < 1.0 indicates group is
less likely to undergo procedure
compared to white patients
0.92
1
0.82*
0.62*
0.64*
0.58*
0.42*
0
Catheterization
Angioplasty
African American
Latino
*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.
Bypass Surgery
Equally likely
as white
patients
Rates of Hospitalization for Coronary Artery Bypass
Surgery among Medicare Beneficiaries, 1993
Whites
per 1000 beneficiaries per year*
African Americans
6
4.8
4.9
4.8
4.6
4
2.2
2
2.1
2.2
1.8
0
<$13,001
$13,001$16,300
$16,301$20,500
Annual Income
*Rates were adjusted for age and sex to the total Medicare population.
DATA: Gornick, ME et al., 1996
>$20,500
Cardiac Procedure Use in Chronic Renal
Disease Patients, by Race and Gender, 1986-1992
2.00
Odds ratio < 1.0 indicates group is
less likely to undergo procedure
compared to white men
1.00
0.75
0.66*
0.32*
0.30*
0.00
African American Men
Pre-Medicare
African American Women
Post-Medicare
*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.
Equally
likely as
white
men
Coronary Artery Bypass Surgery by Race/Ethnicity
and Insurance Status, 1986-1988
2.0
Odds ratio < 1.0 indicates group is less likely to
undergo procedure compared to white patients
1.22
1.15
1.09
0.99
1.0
0.93
0.8
0.8
0.79*
0.82
0.59*
0.5*
0.33*
0.0
Private
Medicaid
African American
Medicare
Latino
Uninsured
Asian
*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.
Equally
likely as
white
patients
Figure 8
Coronary Artery Surgery Rates by Race and
Disease Severity, 1984-1992
Whites
Percent Receiving Bypass Surgery
African Americans
80%
60%
45%
40%
35%
31%
25%
20%
0%
Mild Disease
Source: Peterson, et al., 1997.
Severe Disease
Criteria for evaluating the
strength of the evidence
A “strong study”:
A “less strong” study:
• Had well-defined
parameters
• Did not control for
critical variables
• Had internal validity
• Measured and
controlled 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
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
Evidence of racial/ethnic
differences in cardiac care
1984-2001
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
Evidence of Racial/Ethnic Differences
in Cardiac Care, 1984-2001
All Studies
(n=81)
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%)
Strong Studies
(n=44)
39 studies find
racial/ethnic
differences in
care (89%)
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%)
Strong Clinical Studies
(n=24)
20 studies find
racial/ethnic
differences in
care (83%)
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‡
Number
of Studies
Found all minority
groups MORE likely to
receive CABG
30
1
25
1
Found all minority
groups AS likely to
receive CABG
20
15
6
Found at least one
minority group LESS
likely to receive CABG
1
1
24
10
6
12
5
13
11
7
5
0
Strong
Less
Strong
All Studies
Total= 44
‡Evidence
Strong
Less
Strong
Clinical Data
Total= 23
Strong
Less
Strong
Administrative Data
Total= 21
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 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.
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
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
www.kff.org/whythedifference