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Faloye AO, Houston BT, Milam AJ. Racial and Ethnic Disparities in Cardiovascular Care. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00244-1. [PMID: 38876812 DOI: 10.1053/j.jvca.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 06/16/2024]
Affiliation(s)
| | - Bobby T Houston
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL
| | - Adam J Milam
- Department of Anesthesiology and Perioperative Medicine; Mayo Clinic; Phoenix, AZ
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Milam AJ, Ogunniyi MO, Faloye AO, Castellanos LR, Verdiner RE, Stewart JW, Chukumerije M, Okoh AK, Bradley S, Roswell RO, Douglass PL, Oyetunji SO, Iribarne A, Furr-Holden D, Ramakrishna H, Hayes SN. Racial and Ethnic Disparities in Perioperative Health Care Among Patients Undergoing Cardiac Surgery: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 83:530-545. [PMID: 38267114 DOI: 10.1016/j.jacc.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/08/2023] [Indexed: 01/26/2024]
Abstract
There has been little progress in reducing health care disparities since the 2003 landmark Institute of Medicine's report Unequal Treatment. Despite the higher burden of cardiovascular disease in underrepresented racial and ethnic groups, they have less access to cardiologists and cardiothoracic surgeons, and have higher rates of morbidity and mortality with cardiac surgical interventions. This review summarizes existing literature and highlights disparities in cardiovascular perioperative health care. We propose actionable solutions utilizing multidisciplinary perspectives from cardiology, cardiac surgery, cardiothoracic anesthesiology, critical care, medical ethics, and health disparity experts. Applying a health equity lens to multipronged interventions is necessary to eliminate the disparities in perioperative health care among patients undergoing cardiac surgery.
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Affiliation(s)
- Adam J Milam
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona, USA.
| | - Modele O Ogunniyi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA; Grady Health System, Atlanta, Georgia, USA
| | - Abimbola O Faloye
- Department of Anesthesiology, Emory University, Atlanta, Georgia, USA. https://twitter.com/bfaloyeMD
| | - Luis R Castellanos
- Division of Cardiovascular Medicine, Department of Medicine, University of California-San Diego, La Jolla, California, USA. https://twitter.com/lrcastel
| | - Ricardo E Verdiner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona, USA. https://twitter.com/VerdinerMD
| | - James W Stewart
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA. https://twitter.com/stewartwjames
| | - Merije Chukumerije
- Department of Cardiovascular Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA. https://twitter.com/DrMerije
| | - Alexis K Okoh
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA. https://twitter.com/OkohMD
| | - Steven Bradley
- Department of Anesthesia and Critical Care, Moffitt Cancer Center, Tampa, Florida, USA. https://twitter.com/stevenbradleyMD
| | - Robert O Roswell
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell Health, New York, New York, USA. https://twitter.com/DrRobRoswell
| | - Paul L Douglass
- Center for Cardiovascular Care, Wellstar Atlanta Medical Center, Atlanta, Georgia, USA
| | - Shakirat O Oyetunji
- Division of Cardiothoracic Surgery, University of Washington, Seattle, Washington, USA. https://twitter.com/LaraOyetunji
| | - Alexander Iribarne
- Department of Cardiothoracic Surgery, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | - Debra Furr-Holden
- Department of Epidemiology, School of Global Public Health, New York University, New York, New York, USA. https://twitter.com/DrDebFurrHolden
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sharonne N Hayes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA. https://twitter.com/SharonneHayes
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Tertulien T, Bush K, Jackson LR, Essien UR, Eberly L. Racial and Ethnic Disparities in Implantable Cardioverter-Defibrillator Utilization: A Contemporary Review. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2023; 25:771-791. [PMID: 38873495 PMCID: PMC11172403 DOI: 10.1007/s11936-023-01025-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 06/15/2024]
Abstract
Purpose of review Sudden cardiac arrest is associated with high morbidity and mortality. Despite having a disproportionate burden of sudden cardiac death (SCD), rates of primary and secondary prevention of SCD with implantable cardioverter-defibrillator (ICD) therapy are lower among eligible racially minoritized patients. This review highlights the racial and ethnic disparities in ICD utilization, associated barriers to ICD care, and proposed interventions to improve equitable ICD uptake. Recent findings Racially minoritized populations are disproportionately eligible for ICD therapy but are less likely to see cardiac specialists, be counseled on ICD therapy, and ultimately undergo ICD implantation, fueling disparate outcomes. Racial disparities in ICD utilization are multifactorial, with contributions at the patient, provider, health system, and structural/societal level. Summary Racial and ethnic disparities have been demonstrated in preventing SCD with ICD use. Proposed strategies to mitigate these disparities must prioritize care delivery and access to care for racially minoritized patients, increase the diversification of clinical and implementation trial participants and the healthcare workforce, and center reparative justice frameworks to rectify a long history of racial injustice.
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Affiliation(s)
- Tarryn Tertulien
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kelvin Bush
- Division of Cardiology, San Antonio Military Medical Center, Fort Sam Houston, TX, USA
| | - Larry R. Jackson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Utibe R. Essien
- Division of General Internal Medicine – Health Services Research, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Lauren Eberly
- Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
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Zea-Vera R, Asokan S, Shah RM, Ryan CT, Chatterjee S, Wall MJ, Coselli JS, Rosengart TK, Kayani WT, Jneid H, Ghanta RK. Racial/ethnic differences persist in treatment choice and outcomes in isolated intervention for coronary artery disease. J Thorac Cardiovasc Surg 2023; 166:1087-1096.e5. [PMID: 35248359 PMCID: PMC11092967 DOI: 10.1016/j.jtcvs.2022.01.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 12/10/2021] [Accepted: 01/23/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Studies have noted racial/ethnic disparities in coronary artery disease intervention strategies. We investigated trends and outcomes of coronary artery disease treatment choice (coronary artery bypass grafting or percutaneous coronary intervention) stratified by race/ethnicity. METHODS We queried the National Inpatient Sample for patients who underwent isolated coronary artery bypass grafting or percutaneous coronary intervention (2002-2017). Outcomes were stratified by race/ethnicity (White, African American, Hispanic, Asian). Multivariable logistic regression evaluated associations between race/ethnicity and receiving coronary artery bypass grafting versus percutaneous coronary intervention, in-hospital mortality, and costs. RESULTS Over the 15-year period, 2,426,917 isolated coronary artery bypass grafting surgeries and 7,184,515 percutaneous coronary interventions were performed. Compared with White patients, African American patients were younger (62 [interquartile range, 53-70] vs 66 [interquartile range, 57-75] years), were more likely to have Medicaid insurance (12.2% vs 4.4%), and had more comorbidities (Charlson-Deyo index, 1.9 ± 1.6 vs 1.7 ± 1.6) (all P < .01). After adjustment for patient comorbidities, presence of acute myocardial infarction, insurance status, and geography, African Americans were the least likely of all racial/ethnic groups to undergo coronary artery bypass grafting (odds ratio, 0.76; P < .01), a consistent trend throughout the study. African American patients had higher risk-adjusted mortality after coronary artery bypass grafting (odds ratio, 1.09; P < .01). Race/ethnicity was not associated with increased mortality after percutaneous coronary intervention. African American patients had higher hospitalization costs for coronary artery bypass grafting (+$5816; P < .01) and percutaneous coronary intervention (+$856; P < .01) after controlling for confounders. CONCLUSIONS In this contemporary national analysis, risk-adjusted frequency of coronary artery bypass grafting versus percutaneous coronary intervention for coronary artery disease differed by race/ethnicity. African American patients had lower odds of undergoing coronary artery bypass grafting and worse outcomes. Reasons for these differences merit further investigation to identify opportunities to reduce potential disparities.
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Affiliation(s)
- Rodrigo Zea-Vera
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Sainath Asokan
- Department of Surgery, Boston University School of Medicine, Boston, Mass
| | - Rohan M Shah
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Christopher T Ryan
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - Matthew J Wall
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Joseph S Coselli
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - Todd K Rosengart
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - Waleed T Kayani
- Section of Cardiology, Department of Internal Medicine, Baylor College of Medicine, Houston, Tex
| | - Hani Jneid
- Section of Cardiology, Department of Internal Medicine, Baylor College of Medicine, Houston, Tex
| | - Ravi K Ghanta
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex.
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Kiernan K, Dodge SE, Kwaku KF, Jackson LR, Zeitler EP. Racial and ethnic differences in implantable cardioverter-defibrillator patient selection, management, and outcomes. Heart Rhythm O2 2022; 3:807-816. [PMID: 36589011 PMCID: PMC9795300 DOI: 10.1016/j.hroo.2022.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Racial and ethnic differences in treatment-cardiovascular and otherwise-have been documented in many aspects of the American health care system and can be seen in implantable cardioverter-defibrillator (ICD) patient selection, counseling, and management. ICDs have been demonstrated to be a powerful tool in the prevention of sudden cardiac death, yet uptake across all eligible patients has been modest. Although patients who do not identify as White are disproportionately eligible for ICDs in the United States, they are less likely to see specialists, be counseled on ICDs, and ultimately have an ICD implanted. This review explores racial and ethnic differences demonstrated in ICD patient selection, outcomes including shock effectiveness, and postimplantation monitoring for both primary and secondary prevention devices. It also highlights barriers for uptake at the health system, physician, and patient levels and suggests areas of further research needed to clarify the differences, illuminate the driving forces of these differences, and investigate strategies to address them.
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Affiliation(s)
- Katherine Kiernan
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Shayne E. Dodge
- Division of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Kevin F. Kwaku
- Division of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Larry R. Jackson
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Emily P. Zeitler
- Division of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- The Dartmouth Institute, Lebanon, New Hampshire
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Gowdar S, Hussain N, Ahlberg AW, Elsadany M, Kowlgi GN, Silverman D, Duvall WL. Non-traditional factors affecting referral for coronary angiography following SPECT myocardial perfusion imaging. J Nucl Cardiol 2022; 29:1141-1155. [PMID: 33152097 DOI: 10.1007/s12350-020-02419-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 10/15/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The use of myocardial perfusion imaging (MPI) in the management of coronary artery disease (CAD) is well established. Although prior studies have shown disparities in the use of invasive angiography in patients with acute MI, data on factors affecting referral to angiography post-MPI are lacking. We sought to evaluate the primary determinants of referral to invasive angiography post-MPI and specifically assess the role of non-traditional non-clinical factors such as race/ethnicity, socioeconomic factors, insurance status, and marital status. METHODS All patients without known CAD who underwent stress SPECT MPI over 15 years were reviewed and the performance of coronary angiography within 90 days of their MPI was recorded. Multiple factors were analyzed for an association with referral to angiography, including exercise and MPI results, baseline demographics, traditional cardiac risk factors, and non-traditional factors such as ethnicity, insurance, marital and socioeconomic status. In a secondary analysis, these factors were assessed with regard to abnormal MPI results. RESULTS Out of 27,895 total patients, 2,150 (7.7%) underwent invasive coronary angiography. On multivariate analysis, inpatient location, positive ECG response, and abnormal MPI results were the strongest predictors of angiography. Non-traditional factors such as race/ethnicity and insurance status had a significant association with referral to angiography with Caucasians (OR 1.42, 95% CI 1.18-1.71, P < .0001) and those with private insurance (OR 1.35, 95% CI 1.13-1.62, P = .001) or Medicare (OR 1.30, 95% CI 1.08-1.56, P = .006) having higher rates of angiography despite controlling for traditional risk factors and test results. CONCLUSION Our study results indicate that non-traditional factors such as race/ethnicity and insurance status influence patient management decisions and impact the performance of downstream cardiac invasive testing after stress MPI. Higher rates of angiography in Caucasians, privately insured and Medicare patients were seen despite controlling for traditional risk factors and abnormal test results. Further research is needed to better understand these disparities, especially in the current healthcare environment.
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Affiliation(s)
- Shreyas Gowdar
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Nasir Hussain
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Alan W Ahlberg
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Mohammad Elsadany
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Guru N Kowlgi
- Department of Medicine, University of Connecticut School of Medicine, Farmington, CT, USA
| | - David Silverman
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - W Lane Duvall
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA.
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Hammarlund N. Racial treatment disparities after machine learning surgical risk-adjustment. HEALTH SERVICES AND OUTCOMES RESEARCH METHODOLOGY 2021. [DOI: 10.1007/s10742-020-00231-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Yuan N, Boscardin C, Lisha NE, Dudley RA, Lin GA. Is Better Patient Knowledge Associated with Different Treatment Preferences? A Survey of Patients with Stable Coronary Artery Disease. Patient Prefer Adherence 2021; 15:119-126. [PMID: 33531798 PMCID: PMC7847412 DOI: 10.2147/ppa.s289398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 12/22/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND In stable coronary artery disease (CAD), shared decision-making (SDM) is encouraged when deciding whether to pursue percutaneous coronary intervention (PCI) given similar cardiovascular outcomes between PCI and medical therapy. However, it remains unclear whether improving patient-provider communication and patient knowledge, the main tenets of SDM, changes patient preferences or the treatment chosen. We explored the relationships between patient-provider communication, patient knowledge, patient preferences, and the treatment received. METHODS We surveyed stable CAD patients referred for elective cardiac catheterization at seven hospitals from 6/2016 to 9/2018. Surveys assessed patient-provider communication, medical knowledge, and preferences for treatment and decision-making. We verified treatments received by chart review. We used linear and logistic regression to examine relationships between patient-provider communication and knowledge, knowledge and preference, and preference and treatment received. RESULTS Eighty-seven patients completed the survey. More discussion of the benefits and risks of both medical therapy and PCI associated with higher patient knowledge scores (β=0.28, p<0.01). Patient knowledge level was not associated with preference for PCI (OR=0.78, 95% CI 0.57-1.03, p=0.09). Black patients had more than four times the odds of preferring medical therapy to PCI (OR=4.49, 1.22-18.45, p=0.03). Patients preferring medical therapy were not significantly less likely to receive PCI (OR=0.67, 0.16-2.52, p=0.57). CONCLUSIONS While communicating the risks of PCI may improve patient knowledge, this knowledge may not affect patient treatment preferences. Rather, other factors such as race may be significantly more influential on a patient's treatment preferences. Furthermore, patient preferences are still not well reflected in the treatment received. Improving shared decision-making in stable CAD therefore may require not only increasing patient education but also better understanding and including a patient's background and pre-existing beliefs.
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Affiliation(s)
- Neal Yuan
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Correspondence: Neal Yuan Smidt Heart Institute, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Davis 1015, Los Angeles, CA90048, USA Email
| | - Christy Boscardin
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Nadra E Lisha
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - R Adams Dudley
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
- School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Grace A Lin
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, CA, USA
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Kim EJ, Kressin NR, Paasche-Orlow MK, Lopez L, Rosen JE, Lin M, Hanchate AD. Racial/ethnic disparities among Asian Americans in inpatient acute myocardial infarction mortality in the United States. BMC Health Serv Res 2018; 18:370. [PMID: 29769083 PMCID: PMC5956856 DOI: 10.1186/s12913-018-3180-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 05/02/2018] [Indexed: 01/10/2023] Open
Abstract
Background Acute myocardial infarction (AMI) is a common high-risk disease with inpatient mortality of 5% nationally. But little is known about this outcome among Asian Americans (Asians), a fast growing racial/ethnic minority in the country. The objectives of the study are to obtain near-national estimates of differences in AMI inpatient mortality between minorities (including Asians) and non-Hispanic Whites and identify comorbidities and sociodemographic characteristics associated with these differences. Method This is a retrospective analysis of 2010–2011 state inpatient discharge data from 10 states with the largest share of Asian population. We identified hospitalization with a primary diagnosis of AMI using the ICD-9 code and used self-reported race/ethnicity to identify White, Black, Hispanic, and Asian. We performed descriptive analysis of sociodemographic characteristics, medical comorbidities, type of AMI, and receipt of cardiac procedures. Next, we examined overall inpatient AMI mortality rate based on patients’ race/ethnicity. We also examined the types of AMI and a receipt of invasive cardiac procedures by race/ethnicity. Lastly, we used sequential multivariate logistic regression models to study inpatient mortality for each minority group compared to Whites, adjusting for covariates. Results Over 70% of the national Asian population resides in the 10 states. There were 496,472 hospitalizations with a primary diagnosis of AMI; 75% of all cases were Whites, 10% were Blacks, 12% were Hispanics, and 3% were Asians. Asians had a higher prevalence of cardiac comorbidities, including hypertension, diabetes, and kidney failure compared to Whites (p-value< 0.01). There were 158,623 STEMI (ST-elevation AMI), and the proportion of hospitalizations for STEMI was the highest for Asians (35.2% for Asians, 32.7% for Whites, 25.3% for Blacks, and 32.1% for Hispanics). Asians had the highest rates of inpatient AMI mortality: 7.2% for Asians, 6.3% for Whites, 5.4% for Blacks, and 5.9% for Hispanics (ANOVA p-value < 0.01). In adjusted analyses, Asians (OR = 1.11 [95% CI: 1.04–1.19]) and Hispanics (OR = 1.14 [1.09–1.19]) had a higher likelihood of inpatient mortality compared to Whites. Conclusions Asians had a higher risk-adjusted likelihood of inpatient AMI mortality compared to Whites. Further research is needed to identify the underlying reasons for this finding to improve AMI disparities for Asians.
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Affiliation(s)
- Eun Ji Kim
- General Internal Medicine, Zucker School of Medicine at Hofstra/Northwell, 2001 Marcus Avenue Suite S160, Lake Success, NY, 11042, USA.
| | - Nancy R Kressin
- General Internal Medicine, Boston University School of Medicine, 801 Massachusetts Avenue, Crosstown Two, Boston, MA, 02118, USA.,VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA, 02130, USA
| | - Michael K Paasche-Orlow
- General Internal Medicine, Boston University School of Medicine, 801 Massachusetts Avenue, Crosstown Two, Boston, MA, 02118, USA
| | - Lenny Lopez
- University of California San Francisco School of Medicine, 4150 Clement Street, San Francisco, CA, 94121, USA
| | - Jennifer E Rosen
- MedStar Washington Hospital Center, 106 Irving Street NW POB South 124, Washington, DC, 20010, USA
| | - Mengyun Lin
- General Internal Medicine, Boston University School of Medicine, 801 Massachusetts Avenue, Crosstown Two, Boston, MA, 02118, USA
| | - Amresh D Hanchate
- General Internal Medicine, Boston University School of Medicine, 801 Massachusetts Avenue, Crosstown Two, Boston, MA, 02118, USA.,VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA, 02130, USA
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Vina ER, Ran D, Ashbeck EL, Ibrahim SA, Hannon MJ, Zhou JJ, Kwoh CK. Patient preferences for total knee replacement surgery: Relationship to clinical outcomes and stability of patient preferences over 2 years. Semin Arthritis Rheum 2016; 46:27-33. [PMID: 27132535 DOI: 10.1016/j.semarthrit.2016.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 03/16/2016] [Accepted: 03/25/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Evaluate the relationship between patient preferences for total knee replacement (TKR) with receipt of TKR, and assess participant characteristics that may influence change in willingness to undergo TKR. METHODS Structured interviews of knee osteoarthritis (OA) patients were conducted. Logistic regression models were conducted to assess the association between baseline willingness and eventual receipt of TKR, adjusted for sociodemographic and clinical variables. Mixed models for repeated measures were used to estimate the effects of sex, race, social support, Δ WOMAC, and orthopedic consult on change in willingness. RESULTS A total of 589 participants were willing, and 215 participants were unwilling to undergo TKR. Willing participants, compared to others, were more often White (69.4% vs. 48.4%), with more than a high school education (60.8% vs. 47.0%) and employed (39.1% vs. 26.5%). At follow-up, the odds of having TKR were twice as high among those who were willing to have the procedure at baseline, but this was no longer significant when adjusted for demographic variables (adjusted OR = 1.82, 95% CI: 0.89-3.69). Willingness to undergo TKR declined over 2 years. Among those who were willing to undergo TKR at baseline but did not obtain one, only 66.5% were still willing at the 2-year follow-up. This decline was less among those who had a greater increase (>median) in WOMAC disability (adjusted Δ = -0.34, 95% CI: -0.47 to -0.20) than those who had minimal change in their WOMAC disability (p = 0.08). The decline in willingness was also less among those who had seen an orthopedic surgeon (adjusted Δ = -0.32, 95% CI: -0.46 to -0.17) than those who did not (p = 0.05). CONCLUSIONS Preference for TKR was consistent with TKR surgery utilization, but not after controlling for patient demographic characteristics. Willingness to undergo TKR declined over time, but this decrease was mitigated by worsening OA-related disability and by consultation with an orthopedic surgeon.
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Affiliation(s)
- Ernest R Vina
- Division of Rheumatology, Department of Medicine, University of Arizona Arthritis Center, University of Arizona, 1501 N Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093.
| | - Di Ran
- Division of Rheumatology, Department of Medicine, University of Arizona Arthritis Center, University of Arizona, 1501 N Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093; Epidemiology and Biostatistics Department, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ
| | - Erin L Ashbeck
- Division of Rheumatology, Department of Medicine, University of Arizona Arthritis Center, University of Arizona, 1501 N Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093
| | - Said A Ibrahim
- Department of Medicine, Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, University of Pennsylvania, Philadelphia, PA
| | - Michael J Hannon
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh, Philadelphia, PA
| | - Jin J Zhou
- Epidemiology and Biostatistics Department, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ
| | - C Kent Kwoh
- Division of Rheumatology, Department of Medicine, University of Arizona Arthritis Center, University of Arizona, 1501 N Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093
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Abstract
Patients from racial and ethnic minorities experience higher mortality after cardiac surgery compared to white patients, both during the early postoperative phase as well as long term. A number of factors likely explain poor outcomes in black and minority patients, which include differences in biology, comorbid health conditions, socioeconomic background, and quality of hospital care. Recent evidence suggests that a major factor underlying excess mortality in these groups is due to their over-representation in low-quality hospitals, where all patients regardless of race have worse outcomes. In this review, we examine the factors underlying racial disparities in outcomes after cardiac surgery, with a primary focus on the role of hospital quality.
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Mitchell SE, Paasche-Orlow MK, Orner MB, Stewart SK, Kressin NR. Patient Decision Control and the Use of Cardiac Catheterization. Glob Adv Health Med 2015; 4:24-31. [PMID: 26331101 PMCID: PMC4533655 DOI: 10.7453/gahmj.2015.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: Shared decision-making is a key determinant of patient-centered care. A lack of patient involvement in treatment decisions may explain persistent racial disparities in rates of cardiac catheterization (CCATH). To date, limited evidence exists to demonstrate whether patients who engage in shared decision-makingare more or less likely to undergo non-emergency CCATH. Objective: To assess the relationship between participation in the decision to undergo a CCATH and the use of CCATH. We also examined whether preference for or actual engagement in decision-making varied by patient race. Methods: We analyzed data from 826 male Veterans Administration patients for whom CCATH was indicated and who participated in the Cardiac Decision Making Study. Results: After controlling for confounders, patients reporting any degree of decision control were more likely to receive CCATH compared with those reporting no control (doctor made decision without patient input) (54% vs 39%, P<.0001). Across racial groups, patients were equally likely to report a preference for control over decision-making (P=.53) as well as to experience discordance between their preference for control and their perception of the actual decision-making process (P=.59). Therefore, these factors did not mediate racial disparities in rates of CCATH use. Conclusion: Shared decision-making is an essential feature of whole-person care. While participation in decision-making may not explain disparities in CCATH rates, further work is required to identify strategies to improve congruence between patients' desire for and actual control over decision-making to actualize patient-centered care.
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Affiliation(s)
- Suzanne E Mitchell
- Department of Family Medicine, Boston University School of Medicine/Boston Medical Center, United States (Dr Mitchell)
| | - Michael K Paasche-Orlow
- Section of General Internal Medicine, Boston University School of Medicine/Boston Medical Center, United States (Dr Paasche-Orlow)
| | - Michelle B Orner
- Bedford VA Medical Center, Massachusetts, United States (Dr Orner)
| | - Sabrina K Stewart
- Department of Family Medicine, Boston University School of Medicine/Boston Medical Center, United States (Ms Stewart)
| | - Nancy R Kressin
- Section of General Internal Medicine, Boston University School of Medicine/Boston Medical Center, United States (Dr Kressin)
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13
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Okwuosa IS, Lewsey SC, Adesiyun T, Blumenthal RS, Yancy CW. Worldwide disparities in cardiovascular disease: Challenges and solutions. Int J Cardiol 2015; 202:433-40. [PMID: 26433167 DOI: 10.1016/j.ijcard.2015.08.172] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 08/21/2015] [Indexed: 12/20/2022]
Abstract
The 20th century saw cardiovascular disease ascend as the leading cause of death in the world. In response to the new challenge that heart disease imposed, the cardiovascular community responded with ground breaking innovations in the form of evidence based medications that have improved survival, imaging modalities that allow for precise diagnosis and guide treatment; revascularization strategies that have not only reduced morbidity, but also improved survival following an acute myocardial infarction. However the benefits have not been distributed equitably and as a result disparities have arisen in cardiovascular care. There is tremendous data from the United States demonstrating the many phenotypical forms of disparities. This paper takes a global view of disparities and highlights that disparate care is not limited to the United States and it is another challenge that the medical community should rise and face head on.
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Affiliation(s)
- Ike S Okwuosa
- Department of Medicine, Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD, United States.
| | - Sabra C Lewsey
- Department of Medicine, Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Tolulope Adesiyun
- Department of Medicine, Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Roger S Blumenthal
- Department of Medicine, Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Clyde W Yancy
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
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14
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Thomas KL, Zimmer LO, Dai D, Al-Khatib SM, Allen LaPointe NM, Peterson ED. Educational videos to reduce racial disparities in ICD therapy via innovative designs (VIVID): a randomized clinical trial. Am Heart J 2013; 166:157-63. [PMID: 23816035 DOI: 10.1016/j.ahj.2013.03.031] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 03/07/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Black individuals eligible for an implantable cardioverter/defibrillator (ICD) are considerably less likely than white individuals to receive one. This disparity may, in part, be explained by racial differences in patient preferences. We hypothesized that a targeted patient-centered educational video could improve knowledge of sudden cardiac arrest (SCA) and ICDs and reduce racial differences in ICD preferences. We conducted a pilot study to assess the feasibility of testing this hypothesis in a randomized trial. METHODS We created a video that included animation, physician commentary, and patient testimonials on SCA and ICDs. The primary outcome was the decision to have an ICD implanted as a function of race and intervention. Between January 1, 2011, and December 31, 2011, 59 patients (37 white and 22 black) were randomized to the video or health care provider counseling/usual care. RESULTS Relative to white patients, black patients were younger (median age, 55 vs 68 years) and more likely to have attended college or technical school. Baseline SCA and ICD knowledge was similar and improved significantly in both racial groups after the intervention. Black patients viewing the video were as likely as white patients to want an ICD (60.0% vs 79.2%, P = .20); and among those in the usual care arm, black patients were less likely than white patients to want an ICD (42.9% vs 84.6% P = .05). CONCLUSION Among individuals eligible for an ICD, a video decision aid increased patient knowledge and reduced racial differences in patient preference for an ICD.
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Affiliation(s)
- Kevin L Thomas
- Duke Clinical Research Institute, Durham, NC 27710, USA.
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15
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Martin KD, Naert L, Goldstein LB, Kasl S, Molinaro AM, Lichtman JH. Comparing the use of diagnostic imaging and receipt of carotid endarterectomy in elderly black and white stroke patients. J Stroke Cerebrovasc Dis 2011; 21:600-6. [PMID: 21411337 DOI: 10.1016/j.jstrokecerebrovasdis.2011.02.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Revised: 01/13/2011] [Accepted: 02/02/2011] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Previous studies show that black patients undergo carotid endarterectomy (CEA) less frequently than white patients. Diagnostic imaging is necessary to determine whether a patient is a candidate for the operation. We determined whether there were differences in the use of diagnostic carotid imaging and the frequency of CEA between elderly black and white ischemic stroke patients. METHODS Medicare fee-for-service beneficiaries with discharge diagnoses of ischemic stroke (International Classification of Diseases, 9th revision codes 433, 434, and 436) were randomly selected for inclusion in the National Stroke Project 1998-1999, 2000-2001. Receipt of at least one type of carotid imaging study was compared for black and white patients. Binomial logistic regression models were used to evaluate the associations between race and receipt of carotid imaging and CEA with adjustment for demographics, degree of carotid artery stenosis, and other clinical covariates. RESULTS Among 19,639 stroke patients (1974 black, 17,655 white), 69.6% received at least 1 diagnostic carotid imaging test (blacks 68.4%; whites 69.7%; P = .233). After risk adjustment, blacks were less likely to receive carotid imaging (adjusted odds ratio [OR] 0.87; 95% confidence interval [CI] 0.78-0.97). There was no relationship between race and the receipt of CEA after adjustment for degree of carotid stenosis and other covariates (adjusted OR 1.14; 95% CI 0.66-1.96). CONCLUSIONS Black ischemic stroke patients were less likely to receive diagnostic carotid imaging than white patients, although the difference was small and only significant after risk adjustment. There was no difference in the proportion having CEA after adjustment for degree of carotid artery stenosis and other clinical factors.
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Affiliation(s)
- Kimberly D Martin
- Yale School of Public Health, New Haven, Connecticut 06520-8034, USA
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16
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Ayotte BJ, Kressin NR. Race differences in cardiac catheterization: the role of social contextual variables. J Gen Intern Med 2010; 25:814-8. [PMID: 20383600 PMCID: PMC2896597 DOI: 10.1007/s11606-010-1324-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2009] [Revised: 01/28/2010] [Accepted: 02/12/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Race differences in the receipt of invasive cardiac procedures are well-documented but the etiology remains poorly understood. OBJECTIVE We examined how social contextual variables were related to race differences in the likelihood of receiving cardiac catheterization in a sample of veterans who were recommended to undergo the procedure by a physician. DESIGN Prospective observational cohort study. PARTICIPANTS A subsample from a study examining race disparities in cardiac catheterization of 48 Black/African American and 189 White veterans who were recommended by a physician to undergo cardiac catheterization. MEASURES We assessed social contextual variables (e.g., knowing somebody who had the procedure, being encouraged by family or friends), clinical variables (e.g., hypertension, maximal medical therapy), and if participants received cardiac catheterization at any point during the study. KEY RESULTS Blacks/African Americans were less likely to undergo cardiac catheterization compared to Whites even after controlling for age, education, and clinical variables (OR = 0.31; 95% CI, 0.13, 0.75). After controlling for demographic and clinical variables, three social contextual variables were significantly related to increased likelihood of receiving catheterization: knowing someone who had undergone the procedure (OR = 3.14; 95% CI, 1.70, 8.74), social support (OR = 2.05; 95% CI, 1.17, 2.78), and being encouraged by family to have procedure (OR = 1.45; 95% CI, 1.08, 1.90). After adding the social contextual variables, race was no longer significantly related to the likelihood of receiving catheterization, thus suggesting that social context plays an important role in the relationship between race and cardiac catheterization. CONCLUSIONS Our results suggest that social contextual factors are related to the likelihood of receiving recommended care. In addition, accounting for these relationships attenuated the observed race disparities between Whites and Blacks/African Americans who were recommended to undergo cardiac catheterization by their physicians.
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Affiliation(s)
- Brian J Ayotte
- Center for Organizational, Leadership, and Management Research, VA Boston Healthcare System, Boston, MA, USA.
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17
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Borrero S, Nikolajski C, Rodriguez KL, Creinin MD, Arnold RM, Ibrahim SA. "Everything I know I learned from my mother...Or not": perspectives of African-American and white women on decisions about tubal sterilization. J Gen Intern Med 2009; 24:312-9. [PMID: 19107540 PMCID: PMC2642577 DOI: 10.1007/s11606-008-0887-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2008] [Revised: 11/18/2008] [Accepted: 11/25/2008] [Indexed: 12/01/2022]
Abstract
BACKGROUND African-American women have had higher rates of female sterilization compared to white women since its emergence as a contraceptive method. The reasons underlying this observed racial difference are unknown. OBJECTIVES The goals of this study were to (1) explore what factors shape black and white women's decisions about tubal sterilization as a contraceptive method and (2) generate hypotheses about the relationship of race to the decision-making process. DESIGN We conducted six focus groups stratified by tubal sterilization status and race. During each of the audio-recorded sessions, participants were asked to discuss reasons that women choose sterilization as a contraceptive method. PARTICIPANTS The participants of the study were 24 African-American women and 14 white women. APPROACH Transcripts of the sessions were qualitatively analyzed with particular attention to factors that might be unique to each of the two racial groups. RESULTS Personal factors shaped black and white women's decisions regarding tubal sterilization. Preference for a convenient, highly effective contraceptive method was the main reason to get a tubal sterilization for women of both racial groups. We also identified socio-cultural differences that might explain why black women are more likely than white women to choose tubal sterilization over other contraceptive methods. An unanticipated, but clinically important, finding was that women often reported feeling that their doctors and the health-care system served as barriers to obtaining the desired procedure. CONCLUSION Socio-cultural differences may help explain why black and white women choose different contraceptive methods.
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Affiliation(s)
- Sonya Borrero
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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18
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Saha S, Freeman M, Toure J, Tippens KM, Weeks C, Ibrahim S. Racial and ethnic disparities in the VA health care system: a systematic review. J Gen Intern Med 2008; 23:654-71. [PMID: 18301951 PMCID: PMC2324157 DOI: 10.1007/s11606-008-0521-4] [Citation(s) in RCA: 204] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2007] [Revised: 11/29/2007] [Accepted: 01/04/2008] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To better understand the causes of racial disparities in health care, we reviewed and synthesized existing evidence related to disparities in the "equal access" Veterans Affairs (VA) health care system. METHODS We systematically reviewed and synthesized evidence from studies comparing health care utilization and quality by race within the VA. RESULTS Racial disparities in the VA exist across a wide range of clinical areas and service types. Disparities appear most prevalent for medication adherence and surgery and other invasive procedures, processes that are likely to be affected by the quantity and quality of patient-provider communication, shared decision making, and patient participation. Studies indicate a variety of likely root causes of disparities including: racial differences in patients' medical knowledge and information sources, trust and skepticism, levels of participation in health care interactions and decisions, and social support and resources; clinician judgment/bias; the racial/cultural milieu of health care settings; and differences in the quality of care at facilities attended by different racial groups. CONCLUSIONS Existing evidence from the VA indicates several promising targets for interventions to reduce racial disparities in the quality of health care.
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Ochroch EA, Troxel AB, Frogel JK, Farrar JT. The influence of race and socioeconomic factors on patient acceptance of perioperative epidural analgesia. Anesth Analg 2007; 105:1787-92, table of contents. [PMID: 18042884 DOI: 10.1213/01.ane.0000290339.76513.e3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Ethnic minorities and patients of lower socioeconomic status may be more averse to the acceptance of epidural analgesia than nonminority counterparts and those of higher socioeconomic status, despite evidence for substantial benefit to the patient. METHODS A scripted telephone survey was developed from the 2000 United States Census by a panel of experts. Contact was attempted at least twice for all patients listed for surgery at the Hospital of the University of Pennsylvania over a 4-mo period. RESULTS Three thousand seven hundred thirty-nine patients were called and 1265 subjects were successfully contacted and 1193 consented, whereas 72 refused to participate. Seven hundred sixty-two subjects (64%) would accept an epidural if recommended by an anesthesiologist and 425 (36%) would refuse. If the epidural was recommended by both the anesthesiologist and surgeon acceptance increased to 932 (78.5%). The univariate predictor of refusal of perioperative epidural analgesia was African American race. Univariate predictors of acceptance include full- or part-time employment, total household income >$50,001/yr, college graduate, prior epidural treatment, and knowledge of what an epidural is. When the potential confounders of race, total household income, employment, and education were included in a multivariate logistic regression model, African American race predicted refusal (odds ratio [OR], 0.58; P < 0.006; confidence interval [CI], 0.41-0.81) and was the only factor that predicted refusal or acceptance of epidural analgesia. CONCLUSIONS Acceptance of perioperative epidural analgesia is strongly affected by race and socioeconomic status. Anesthesiologists need to recognize this potential barrier when trying to maximize patient comfort and outcome.
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Affiliation(s)
- Edward Andrew Ochroch
- Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, University of Pennsylvania, Pennsylvania, USA.
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20
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Davis AM, Vinci LM, Okwuosa TM, Chase AR, Huang ES. Cardiovascular health disparities: a systematic review of health care interventions. Med Care Res Rev 2007; 64:29S-100S. [PMID: 17881625 PMCID: PMC2367222 DOI: 10.1177/1077558707305416] [Citation(s) in RCA: 148] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Racial and ethnic disparities in cardiovascular health care are well documented. Promising approaches to disparity reduction are increasingly described in literature published since 1995, but reports are fragmented by risk, condition, population, and setting. The authors conducted a systematic review of clinically oriented studies in communities of color that addressed hypertension, hyperlipidemia, physical inactivity, tobacco, and two major cardiovascular conditions, coronary artery disease and heart failure. Virtually no literature specifically addressed disparity reduction. The greatest focus has been African American populations, with relatively little work in Hispanic, Asian, and Native American populations. The authors found 62 interventions, 27 addressing hypertension, 9 lipids, 18 tobacco use, 8 physical inactivity, and 7 heart failure. Only 1 study specifically addressed postmyocardial infarction care. Data supporting the value of registries, multidisciplinary teams, and community outreach were found across several conditions. Interventions addressing care transitions, using telephonic outreach, and promoting medication access and adherence merit further exploration.
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21
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Kennedy BS, Fortmann SP, Stafford RS. Elective and isolated carotid endarterectomy: health disparities in utilization and outcomes, but not readmission. J Natl Med Assoc 2007; 99:480-8. [PMID: 17534005 PMCID: PMC2576064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
BACKGROUND Carotid endarterectomy (CEA) has been shown to decrease future ischemic stroke risk in selected patients. However, clinical trials did not examine the risk-benefit ratio for nonwhites, who have a greater ischemic stroke risk than whites. In general, few studies have examined the effects of race on CEA use and complications, and data on race and CEA readmission are lacking. METHODS This study used administrative data for patients discharged from California hospitals between January 1 and December 31, 2000. Selection criteria of cases included: ICD-9 principal procedure code 38.12, principal diagnostic code 433 and diagnosis-related group 5. There were 8,080 white and 1196 nonwhite patients (228 blacks, 643 Hispanics, 325 Asians/Pacific Islanders) identified that underwent an elective and isolated CEA. For both groups, CEA rates were compared. Logistic regression was used to examine the independent effects of race on in-hospital death and stroke, as well as CEA readmission. RESULTS Rates of CEA use were more than three times greater for whites than nonwhites, although nonwhites were more likely to have symptomatic disease. For all patients, the complication rate was 1.9%. However, the odds of in-hospital death and stroke were greater for nonwhites than whites, but after adjustment for patient and hospital factors, these differences were only significant for stroke (OR = 1.7, P = 0.013). For both outcomes, the final models had good predictive accuracy. Overall, CEA readmission risk was 7%, and no significant racial differences were observed (P = 0.110). CONCLUSIONS The data suggest that CEA is performed safely in California. However, nonwhites had lower rates of initial CEA use but higher rates of in-hospital death and stroke than whites. Racial differences in stroke risk persisted after adjustment for patient and hospital factors. Finally, this study found that despite significant racial disparities in initial CEA use, whites and nonwhites were similar in their CEA readmission rates. These findings may suggest that screening initiatives are lacking for nonwhites, which may increase their risk for poorer outcomes.
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Affiliation(s)
- Byron S Kennedy
- Department of Family Medicine, Georgetown University School of Medicine, Washington, DC 20011, USA.
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22
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Jha AK, Staiger DO, Lucas FL, Chandra A. Do race-specific models explain disparities in treatments after acute myocardial infarction? Am Heart J 2007; 153:785-91. [PMID: 17452154 PMCID: PMC2128703 DOI: 10.1016/j.ahj.2007.02.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2006] [Accepted: 02/09/2007] [Indexed: 11/30/2022]
Abstract
BACKGROUND Racial differences in healthcare are well known, although some have challenged previous research where risk-adjustment assumed covariates affect whites and blacks equally. If incorrect, this assumption may misestimate disparities. We sought to determine whether clinical factors affect treatment decisions for blacks and whites equally. METHODS We used data from the Cardiovascular Cooperative Project for 130,709 white and 8286 black patients admitted with an acute myocardial infarction. We examined the rates of receipt of 6 treatments using conventional common-effects models, where covariates affect whites and blacks equally, and race-specific models, where the effect of each covariate can vary by race. RESULTS The common-effects models showed that blacks were less likely to receive 5 of the 6 treatments (odds ratios 0.64-1.10). The race-specific models displayed nearly identical treatment disparities (odds ratios 0.65-1.07). We found no interaction effect, which systematically suggested the presence of race-specific effects. CONCLUSIONS Race-specific models yield nearly identical estimates of racial disparities to those obtained from conventional models. This suggests that clinical variables, such as hypertension or diabetes, seem to affect treatment decisions equally for whites and blacks. Previously described racial disparities in care are unlikely to be an artifact of misspecified models.
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Affiliation(s)
- Ashish K Jha
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA 02115, USA.
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23
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Horner RD, Leonard AC. Factors associated with a provider's recommendation of carotid endarterectomy: implications for understanding disparities in the use of invasive procedures. J Vasc Surg 2007; 45:124-9. [PMID: 17210396 DOI: 10.1016/j.jvs.2006.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2006] [Accepted: 09/04/2006] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study assessed the relative importance of clinical and nonclinical factors in a provider's decision to recommend carotid endarterectomy (CEA) for a patient, with emphasis on the role of the patient's race in the provider's assessment of the risks and benefits of the procedure. METHODS The study was a secondary analysis of data on the use of CEA conducted in a patient sample of 355 white and black patients who were referred for evaluation for CEA and were adjudicated preoperatively as appropriate candidates for the procedure by objective criteria. The patients were from five VA medical centers nationally. The primary outcome was the provider's recommendation that the patient receive CEA. Patient factors included age, race, the degree of carotid artery stenosis, clinical status, trust in the provider, and aversion to surgery. Provider factors were assessment of the patient's risks and benefits from CEA, including perceived efficacy of the surgery, perceived risk of stroke < or =1 year without the surgery, and perceived risk of stroke < or =30 days from the surgery. RESULTS The primary factor associated with a provider's decision to recommend CEA was his or her assessment of the patient's risk of stroke without the surgery. The patient's race was not associated with the provider's assessments of the patient's risks or benefits from CEA. CONCLUSION A major determinant of a provider's recommendation for a patient to receive CEA endarterectomy is the assessment of the patient's likely future risk of stroke, regardless of the patient's race.
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Affiliation(s)
- Ronnie D Horner
- Institute for the Study of Health, University of Cincinnati Medical Center, Cincinnati, Ohio 45267, USA.
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24
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Gordon HS, Street RL, Sharf BF, Souchek J. Racial differences in doctors' information-giving and patients' participation. Cancer 2006; 107:1313-20. [PMID: 16909424 DOI: 10.1002/cncr.22122] [Citation(s) in RCA: 255] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Whether doctor-patient communication differs by race was investigated in patients with pulmonary nodules or lung cancer. METHODS Eligible patients (n = 137) had pulmonary nodules or lung cancer and were seen in thoracic surgery or oncology clinics for initial treatment recommendations at a large southern Veterans Affairs Medical Center from 2001-2004. Doctor-patient consultations were audiotaped. Audiotapes were transcribed, unitized into utterances, and utterances were coded as doctors' information-giving or patients' and companions' active participation (asking questions, expressing concerns, and making assertions). Data were compared by patient race and doctor-patient racial concordance using t-tests or chi-square tests as appropriate. Mixed linear regression was used to determine the independent predictors of doctor's information-giving after controlling for clustering of patients by doctor. RESULTS Patient age, gender, marital status, clinical site, and health status were similar by race (P > .20), but black patients were somewhat less likely to have education beyond high school and to bring a companion to the visit (P = .06) than white patients. Black patients and their companions received significantly less information from doctors (49.3 vs. 87.3 mean utterances; P < .001) and produced significantly fewer active participation utterances (21.4 vs. 37.2; P < .001) than white patients. In mixed regression analyses, after adjusting for patients' and companions' participation, clustering by doctor, and other factors, race no longer predicted information-giving (P = .54). Patients in racially discordant interactions received significantly less information and were significantly less active participants (P < .001) when compared with patients in racially concordant interactions, and after controlling for patients' participation and other factors using mixed regression, racial discordance did not predict information-giving. CONCLUSIONS The results indicate a pattern of communication that may perpetuate patient passivity and limited information exchange where black patients and patients in discordant interactions do less to prompt doctors for information and doctors in turn provide less information to these patients.
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Affiliation(s)
- Howard S Gordon
- Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois, USA.
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Barnhart JM, Wassertheil-Smoller S. The effect of race/ethnicity, sex, and social circumstances on coronary revascularization preferences: a vignette comparison. Cardiol Rev 2006; 14:215-22. [PMID: 16924161 DOI: 10.1097/01.crd.0000214180.24372.d5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Disparities in cardiac care cannot be explained by clinical factors alone. We previously found that physicians' perceived nonclinical factors such as patient preferences influenced decisions for coronary revascularization. For this study, we mailed a questionnaire to a random sample of family medicine physicians, internists, cardiologists, and cardiothoracic surgeons to examine whether the patient's sex, race/ethnicity, and social circumstances impacted treatment preferences for different physician subgroups. All physicians were randomized to receive 1 of 4 questionnaires that contained a vignette describing certain hypothetical situations (desire for an active lifestyle, heavy career or family demands) for a 50-year patient who was a candidate for coronary revascularization who was 1) female, 2) male, 3) black male, or 4) white male. The response rate was 70% (544 of 777). The patient's race/ethnicity and sex did not significantly affect the physicians' treatment preferences. However, significant differences were found according to the social circumstance. More male physicians (78%) than female physicians (66%) recommended revascularization for patients with heavy family demands (P < 0.05). In logistic regression analyses, if the patient desired an active lifestyle, black and Hispanic physicians and fee-for-service physicians preferred revascularization less often than white and salaried physicians, respectively (odds ratio [OR] = 0.45 [0.21-0.94] for black/Hispanic; OR = 0.40 [0.18-0.86] for fee-for-service). Based on these results, certain social circumstances might influence treatment preferences among physician subgroups more than sex- or race-based patient factors. Research examining for causes of disparities in cardiac care should consider the effects of sociocultural issues on management decisions.
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Affiliation(s)
- Janice M Barnhart
- Department of Epidemiology & Population Health, Division of Epidemiology, Albert Einstein College of Medicine, Bronx, New York 10461, USA.
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Hravnak M, Ibrahim S, Kaufer A, Sonel A, Conigliaro J. Racial disparities in outcomes following coronary artery bypass grafting. J Cardiovasc Nurs 2006; 21:367-78. [PMID: 16966914 PMCID: PMC3660098 DOI: 10.1097/00005082-200609000-00007] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
More than 12 million people in the United States have coronary heart disease, the second leading cause of hospitalization in the United States. It is known that persons within racial minorities, specifically African Americans, have a higher prevalence of coronary heart disease, yet are much less likely to undergo invasive cardiac treatment interventions. An invasive intervention commonly used to treat coronary heart disease is coronary artery bypass grafting, with over 140,000 operations performed annually in the United States. However, blacks are known to experience higher post-coronary artery bypass graft morbidity and mortality. The causes for racial disparities in post-coronary artery bypass graft outcomes are not well known but may include factors related to the individual, provider, system, and society/environment, either alone or in combination. The purpose of this article is to provide an overview of the literature regarding disparities in the health and healthcare of black patients with coronary heart disease with respect to CABG, and examine potential hypotheses for variant outcomes after surgery.
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Affiliation(s)
- Marilyn Hravnak
- School of Nursing, University of Pittsburgh, Pittsburgh, Pa 15261, USA.
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Mensah GA, Mokdad AH, Ford ES, Greenlund KJ, Croft JB. State of disparities in cardiovascular health in the United States. Circulation 2005; 111:1233-41. [PMID: 15769763 DOI: 10.1161/01.cir.0000158136.76824.04] [Citation(s) in RCA: 875] [Impact Index Per Article: 46.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Reducing health disparities remains a major public health challenge in the United States. Having timely access to current data on disparities is important for policy and program development. Accordingly, we assessed the current magnitude of disparities in cardiovascular disease (CVD) and its risk factors in the United States. METHODS AND RESULTS Using national surveys, we determined CVD and risk factor prevalence and indexes of morbidity, mortality, and overall quality of life in adults > or =18 years of age by race/ethnicity, sex, education level, socioeconomic status, and geographic location. Disparities were common in all risk factors examined. In men, the highest prevalence of obesity (29.2%) was found in Mexican Americans who had completed a high school education. Black women with or without a high school education had a high prevalence of obesity (47.3%). Hypertension prevalence was high among blacks (39.8%) regardless of sex or educational status. Hypercholesterolemia was high among white and Mexican American men and white women in both groups of educational status. Ischemic heart disease and stroke were inversely related to education, income, and poverty status. Hospitalization was greater in men for total heart disease and acute myocardial infarction but greater in women for congestive heart failure and stroke. Among Medicare enrollees, congestive heart failure hospitalization was higher in blacks, Hispanics, and American Indians/Alaska Natives than among whites, and stroke hospitalization was highest in blacks. Hospitalizations for congestive heart failure and stroke were highest in the southeastern United States. Life expectancy remains higher in women than men and higher in whites than blacks by approximately 5 years. CVD mortality at all ages tended to be highest in blacks. CONCLUSIONS Disparities in CVD and related risk factors remain pervasive. The data presented here can be invaluable for policy development and in the planning, implementation, and evaluation of interventions designed to eliminate health disparities.
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Affiliation(s)
- George A Mensah
- Office of the Director, Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Mail Stop K-40, 4770 Buford Hwy NE, Atlanta, GA 30341-3717, USA.
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Gordon HS, Street RL, Kelly PA, Souchek J, Wray NP. Physician–patient communication following invasive procedures: an analysis of post-angiogram consultations. Soc Sci Med 2005; 61:1015-25. [PMID: 15955403 DOI: 10.1016/j.socscimed.2004.12.021] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2004] [Accepted: 12/16/2004] [Indexed: 11/29/2022]
Abstract
Although rarely studied, physician-patient interactions immediately following diagnostic tests are significant medical events because during these encounters the physician and patient often make decisions about major and sometimes invasive treatment. This investigation analyzed patterns of physician-patient communication following coronary angiography with particular attention to behaviors important to decision-making: physician information-giving, physician use of partnership-building, and active forms of patient participation (e.g., asking questions, being assertive, expressing concerns). We were particularly interested in effects related to the patient's race in light of documented evidence of racial disparities in cardiac care and outcomes. From audiotape recordings, 93 physician-patient interactions after coronary angiogram in a catheterization laboratory in a large US Veterans Affairs Medical Center were coded to measure the frequency of physicians' information-giving and partnership-building and the frequency of active patient participation. We also stratified these behaviors according to whether the behavior was prompted (e.g., physician information in response to a patient's question; a patient's opinion solicited by the doctor) or self-initiated. Several findings were noteworthy. First, these interactions were very brief and dominated by the physician. Second, although physician information-giving increased with more active patient participation, which in turn was correlated with physicians' use of partnership-building, proportionally little of the physicians' information (8%) and active patient participation (9%) was directly prompted by the other interactant. Finally, there was a tendency for physicians to self-initiate less information giving to black patients and for black patients to self-initiate less active participation than white patients. Although these differences were attenuated when other variables (e.g., the physician's training, disease severity) were included in the analysis, the pattern suggests a potential cycle of passivity where certain patients tend to receive fewer informational resources and these patients in turn do less to prompt the doctor for more.
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Affiliation(s)
- Howard S Gordon
- Houston Center for Quality of Care and Utilization Studies, Houston, TX, USA.
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