Disparities In Cardiovascular Care Research Articles

Abstract 16082: Racial Differences Among Patients Undergoing Nuclear Myocardial Perfusion Imaging

Introduction: Noninvasive cardiac stress testing is valuable for early diagnosis and optimizing management of patients with coronary artery disease (CAD). Historically, Black patients have experienced both underdiagnosis and undertreatment of CAD. We evaluated racial disparities in patients undergoing nuclear myocardial perfusion imaging (MPI). Different modalities (MPI (SPECT, PET) vs. stress echocardiography) have variations in accuracy, cost and radiation exposure, which may reflect provider biases. Methods: Patient-reported demographics, clinician-reported cardiac risk factors and MPI study characteristics from a large Connecticut health system (2016 - 2022) were compared for Black and White patients in both general and matched cohorts (1:1 matched for demographics and risk factors). Results: The study included 123,069 cardiac stress tests from 10.5% Black and 76.2% White patients (largely similar to overall Connecticut population: 12.7% Black, 78.8% White). Black patients were younger (56.7±13.3 vs. 62.1±13.4 years, p< 0.001), more likely female (58.7 vs. 44.7%, p<0.001) and had more risk factors (Table 1). Black patients were more likely to undergo MPI (66.6 vs. 50.5%, p<0.001), inpatient or observation status testing (17.0 vs. 8.4%, p< 0.001), with pharmacological rather than exercise stress (53.9 vs. 37.0%, p<0.001) than White patients. On analysis of the 1:1 matched cohort, Black patients younger than 65 years were more likely to undergo MPI than White patients (62.1 vs. 57.4%, p<0.001), while the reverse is seen for patients over 65 years old (37.5 vs. 42.5%, p<0.001). Conclusion: Significant demographic and stress testing pattern differences were found between Black and White patients. These findings may reflect racial disparities in cardiovascular care, including access and clinical referral patterns. Further studies are needed to determine if these differences in stress testing strategies impact downstream clinical outcomes.

Differences in Use of Clinical Decision Support Tools and Implementation of Aspirin, Blood Pressure Control, Cholesterol Management, and Smoking Cessation Quality Metrics in Small Practices by Race and Sex

Practice-level evidence is needed to clarify the value of population-based clinical decision support (CDS) tools in reducing racial and sex disparities in cardiovascular care. To evaluate the association between CDS tools and racial and sex disparities in the aspirin use, blood pressure control, cholesterol management, and smoking cessation (ABCS) care quality metrics among smaller primary care practices. This cross-sectional study used practice-level data from the Agency for Healthcare Research and Quality-funded EvidenceNOW initiative. The national initiative from May 1, 2015, to April 30, 2021, spanned 12 US states and focused on improving cardiovascular preventive care by providing quality improvement support to smaller primary care practices. A total of 576 primary care practices in EvidenceNOW submitted both survey data and electronic health record (EHR)-derived ABCS data stratified by race and sex. Practice-level estimates of disparities between Black and White patients and between male and female patients were calculated as the difference in proportions of eligible patients within each practice meeting ABCS care quality metrics. The association between CDS tools (EHR prompts, standing orders, and clinical registries) and disparities was evaluated by multiply imputed multivariable models for each CDS tool, adjusted for practice rurality, ownership, and size. Across the 576 practices included in the analysis, 219 (38.0%) had patient panels that were more than half White and 327 (56.8%) had panels that were more than half women. The proportion of White compared with Black patients meeting metrics for blood pressure (difference, 5.16% [95% CI, 4.29%-6.02%]; P < .001) and cholesterol management (difference, 1.49% [95% CI, 0.04%-2.93%] P = .04) was higher; the proportion of men meeting metrics for aspirin use (difference, 4.36% [95% CI, 3.34%-5.38%]; P < .001) and cholesterol management (difference, 3.88% [95% CI, 3.14%-4.63%]; P < .001) was higher compared with women. Conversely, the proportion of women meeting practice blood pressure control (difference, -1.80% [95% CI, -2.32% to -1.28%]; P < .001) and smoking cessation counseling (difference, -1.67% [95% CI, -2.38% to -0.95%]; P < .001) metrics was higher compared with men. Use of CDS tools was not associated with differences in race or sex disparities except for the smoking metric. Practices using CDS tools showed a higher proportion of men meeting the smoking counseling metric than women (coefficient, 3.82 [95% CI, 0.95-6.68]; P = .009). The findings of this cross-sectional study suggest that practices using CDS tools had small disparities that were not statistically significant, but CDS tools were not associated with reductions in disparities. More research is needed on effective practice-level interventions to mitigate disparities.

Gender disparities in cardiovascular care: the need to educate and advocate for equal care for women

Following the International Women’s Day campaign in March, Fitzsimons and colleagues highlight current gender disparities in cardiovascular disease care, diagnosis and treatment and discuss how gender equality can be promoted in clinical practice

Interaction Between Race, Ethnicity, Severe Mental Illness, and Cardiovascular Disease.

ABSTRACTSevere mental illnesses, such as schizophrenia or bipolar disorder, affect ≈1% of the population who, as a group, experience significant disadvantage in terms of physical health and reduced life expectancy. In this review, we explore the interaction between race, ethnicity, severe mental illness, and cardiovascular disease, with a focus on cardiovascular care pathways. Finally, we discuss strategies to investigate and address disparities in cardiovascular care for patients with severe mental illness.

E-23 | Gender, Racial and Ethnic Differences in Clinical Characteristics, Procedural andClinical Outcomes in Patients Hospitalized with Acute Coronary Syndromes and In-stent restenosis

Contrary to well-documented disparities in cardiovascular care, there are knowledge gaps in gender, race and ethnicity associated outcomes in patients with acute coronary syndromes (ACS) and in-stent restenosis (ISR).

Heartbeat: racial and ethnic healthcare disparities in cardiovascular care

Racial and ethnic healthcare disparities in cardiovascular care have been magnified during the COVID-19 pandemic. In this issue of Heart , Rashid and colleagues1 compared admission rates, treatment and mortality...

Disparities in Cardiovascular Care and Outcomes for Women From Racial/Ethnic Minority Backgrounds.

Purpose of reviewRacial, ethnic, and gender disparities in cardiovascular care are well-documented. This review aims to highlight the disparities and impact on a group particularly vulnerable to disparities, women from racial/ethnic minority backgrounds.Recent findingsWomen from racial/ethnic minority backgrounds remain underrepresented in major cardiovascular trials, limiting the generalizability of cardiovascular research to this population. Certain cardiovascular risk factors are more prevalent in women from racial/ethnic minority backgrounds, including traditional risk factors such as hypertension, obesity, and diabetes. Female-specific risk factors including gestational diabetes and preeclampsia as well as non-traditional psychosocial risk factors like depressive and anxiety disorders, increased child care, and familial and home care responsibility have been shown to increase risk for cardiovascular disease events in women more so than in men, and disproportionately affect women from racial/ethnic minority backgrounds. Despite this, minimal interventions to address differential risk have been proposed. Furthermore, disparities in treatment and outcomes that disadvantage minority women persist. The limited improvement in outcomes over time, especially among non-Hispanic Black women, is an area that requires further research and active interventions.SummaryUnderstanding the lack of representation in cardiovascular trials, differential cardiovascular risk, and disparities in treatment and outcomes among women from racial/ethnic minority backgrounds highlights opportunities for improving cardiovascular care among this particularly vulnerable population.

Myocardial infarction classification and its implications on measures of cardiovascular outcomes, quality, and racial/ethnic disparities.

Heart disease continues to be the leading cause of death in the United States, with approximately 805 000 cumulative deaths from myocardial infarctions (MI) from 2005 to 2014. Gender and racial/ethnic disparities in MI diagnoses are becoming more evident in quality review audits. Although recent changes in diagnostic codes provided an improved framework, clinically distinguishing types of MI remains a challenge. MI misdiagnoses and health disparities contribute to adverse outcomes in cardiac medicine. We conducted a literature review of relevant biomedical sources related to the classification of MI and disparities in cardiovascular care and outcomes. From the studies analyzed, African Americans and women have higher rates of mortality from MI, are more probably to be younger and present with other comorbidities and are less probably to receive novel therapies with respect to type of MI. As high‐sensitivity troponin assays are adopted in the United States, implementation should account for how race and sex differences have been demonstrated in the reference range and diagnostic threshold of the newer assays. More research is needed to assess how the complexity of health disparities contributes to adverse cardiovascular outcomes. Creating dedicated medical quality teams (physicians, nurses, clinical documentation improvement specialists, and medical coders) and incorporating a plan‐do‐check‐adjust quality improvement model are strategies that could potentially help better define and diagnose MI, reduce financial burdens due to MI misdiagnoses, reduce cardiovascular‐related health disparities, and ultimately improve and save lives.

Disparities in cardiovascular care: Past, present, and solutions

Cardiovascular disease has been the leading cause of death in the United States since the early 20th century. With advances in prevention and treatment, cardiovascular mortality rates are on the decline. Nevertheless, disparities in care persist, with devastating impact in select populations in the United States. This paper reviews the impact of disparate care on risk-factor burden, coronary artery disease, heart failure, and cardiovascular research.

Disparities in Cardiac Care of Women: Current Data and Possible Solutions.

Cardiovascular disease remains the leading cause of death in women. The goal of this review is to address known disparities in cardiovascular care with regard to diagnosis and treatment of heart disease in women. Gender-specific differences in regard to the incidence, treatment, and outcomes of common cardiovascular pathology are increasingly recognized. Particular attention to ischemic heart disease, arrhythmia, congestive heart failure, and structural heart disease are reviewed in this article. There is a clear racial and ethnic discrepancy among women which is particularly concerning with a progressively diverse patient population. Medical and surgical treatment differences between men and women must be addressed by providers in order to optimize long-term outcomes among all patients. Understanding the unique cardiovascular risk profile and barriers to optimal treatment outcomes in women is imperative to eliminate the current disparities in cardiovascular disease.

Improvements in Outcomes and Disparities of ST-Segment-Elevation Myocardial Infarction Care: The Miami-Dade County ST-Segment-Elevation Myocardial Infarction Network Project.

The strategy of primary percutaneous coronary intervention (PCI) for ST-segment–elevation myocardial infarction (STEMI) has led to major outcome improvements in this patient population, and within this strategy, early reperfusion remains a critical component for improved survival. Although outcomes after percutaneous revascularization have improved, disparities in cardiovascular care remain an important challenge, particularly in large metropolitan areas in the United States. The Miami-Dade County STEMI Network is an Emergency Medical Services (EMS)–led program established in 2007 with the goal to improve quality of care for patients with STEMI by reducing time from 911 contact to reperfusion. South Florida has a unique patient population with diverse ethnic and racial backgrounds, highest proportion of older adults as compared with other states, and with women outnumbering men at older ages.1 A probability-sampled, household-based survey in Miami-Dade County found that non-Hispanic whites constitute only 9.4% of the population with the majority being blacks, Hispanic, or Haitian blacks (non-English speaking ≈37.8%).1 In this population, 53% of the residents had high school equivalent (or less) degree as formal education, and 34.5% were below the US poverty threshold.1 Furthermore, one quarter of all households had at least 1 member who was uninsured at some point, and 3 of 5 households had at least 1 member who used Medicare for coverage. Although potentially significant component of disparities is related to patients’ clinical characteristics and socioeconomic factors, these vulnerable groups are at increased risk for suboptimal care, particularly for patients with cardiovascular disease. In a random sample from South Florida, one quarter of all households had at least 1 member who had a heart attack or acute cardiovascular illness within 5 years of the study.1 Within Miami-Dade County and South East Florida, the presence of 6 EMS response systems with different directors and administrative staff, the …

All else being equal, men and women are still not the same: using risk models to understand gender disparities in care.

Despite growing awareness of the burden of cardiovascular disease (CVD) in women over the past 2 decades, reports of disparities in the delivery of health care for these diseases have persisted over time.1 Under-treatment of women as compared with men has been described for primary prevention, stable coronary artery disease (CAD) and suspected or diagnosed acute coronary syndromes in both observational studies and controlled experiments.2–6 However, because men and women are nonidentical in many ways that might be relevant for treatment decisions, a critical question for policy makers and clinicians is whether these gender-based variations in treatment correspond to lower quality care. A demonstration of clinical inequity (unequal treatment despite equal clinical need) rather than strict inequality (unequal treatment regardless of need or condition) has been proposed as a framework to identify inappropriate variations in healthcare utilization.7 Following this model, it is important to consider whether observed gender differences correspond to inequities or may reflect appropriate variations explained by differences in treatment indications and contraindications or patient preferences.7 In a well-known study published over a decade ago, investigators devised a clever experiment to address just this question of identifying inappropriate healthcare variations.8 Using actors posing as patients with chest pain, primary care physicians were less likely to refer women for cardiac catheterization than men. Because these patients were carefully designed to be identical in age, cardiac risk factors, and symptoms, followed a script standardizing patient communication, and only differed by gender (and race), it seemed obvious that biased decision-making must account for treatment differences. In this commentary, we illustrate why analyses that attempt to control for all known cardiac risk factors that affect treatment decisions might still yield misleading findings about the presence, magnitude, and causes of gender disparities. This residual bias occurs …

The current state of ethnic and racial disparities in cardiovascular care: lessons from the past and opportunities for the future.

Significant racial/ethnic disparities have been documented in cardiovascular care. Although health care quality is improving for many Americans, differences in clinical outcomes have persisted between racial/ethnic minority patients and non-minorities, even when income, education level, and site of care are taken into consideration. Potential causes of disparities are complex and are related to differences in risk factor prevalence and control, use of evidence-based procedures and medications, and social and environmental factors. Minority patients are more likely to receive care from lower-quality health care providers and institutions and experience more barriers to accessing care. Factors such as stereotyping and bias in medicine are hard to quantify, but likely contribute to differences in treatment. Recent trends suggest that some disparities are decreasing. Opportunities for change and improvement exist for patients, providers, and health care systems. Promising interventions, such as health policy changes, quality improvement programs, and culturally targeted community and clinic-based interventions offer hope that high-quality health care in the USA can be provided to all patients.

Racial Disparities in Cardiovascular Care: A Review of Culprits and Potential Solutions

Cardiovascular disease is the leading cause of death for white and black Americans. Despite the presence of therapies that improve survival and quality of life in cardiac patients, African-Americans continue to have the worst heart disease survival rates of all racial groups. The literature has described racial disparities in cardiovascular care for at least 25 years. We review the current status of racial disparities in four areas of cardiovascular care: automatic implantable cardioverter-defibrillator (AICD) implantations in patients at risk for sudden cardiac death, cardiac resynchronization therapy with defibrillator (CRT-D) implantation in patients with severely depressed left ventricular function and refractory heart failure, reperfusion therapy in patients presenting with acute myocardial infarction, and revascularization in patients with critical limb ischemia. We will discuss potential culprits for these disparities with a particular focus on hospital quality, physician bias, and the relative lack of diversity among cardiovascular physicians in the USA. Finally, we will discuss strategies already in progress that hold promise to reduce or eliminate racial disparities in cardiovascular care.

Eliminating medication copayments reduces disparities in cardiovascular care.

Substantial racial and ethnic disparities in cardiovascular care persist in the United States. For example, African Americans and Hispanics with cardiovascular disease are 10-40 percent less likely than whites to receive secondary prevention therapies, such as aspirin and beta-blockers. Lowering copayments for these therapies improves outcomes among all patients who have had a myocardial infarction, but the impact of lower copayments on health disparities is unknown. Using self-reported race and ethnicity for participants in the Post-Myocardial Infarction Free Rx Event and Economic Evaluation (MI FREEE) trial, we found that rates of medication adherence were significantly lower and rates of adverse clinical outcomes were significantly higher for nonwhite patients than for white patients. Providing full drug coverage increased medication adherence in both groups. Among nonwhite patients, it also reduced the rates of major vascular events or revascularization by 35 percent and reduced total health care spending by 70 percent. Providing full coverage had no effect on clinical outcomes and costs for white patients. We conclude that lowering copayments for medications after myocardial infarctions may reduce racial and ethnic disparities for cardiovascular disease.

Early results of Massachusetts healthcare reform on racial, ethnic, and socioeconomic disparities in cardiovascular care.

Insured adults receive invasive cardiovascular procedures more frequently than uninsured adults. We examined the impact of healthcare reform in Massachusetts on use of coronary revascularization procedures and in-hospital and 1-year mortality by race/ethnicity, education, and sex. Using hospital claims data, we compared differences in coronary revascularization rates (coronary artery bypass grafting or percutaneous coronary intervention) and in-hospital mortality by race/ethnicity, education, and sex among Massachusetts residents aged 21 to 64 years hospitalized with a principal discharge diagnosis of ischemic heart disease before (November 1, 2004, to July 31, 2006) and after (December 1, 2006, to September 30, 2008) reform; 1-year mortality was calculated for those undergoing revascularization. Adjusted logistic regression assessed 24 216 discharges before reform and 20 721 discharges after reform. Blacks had 30% lower odds of receiving coronary revascularization than whites in the prereform period. Compared with whites in the postreform period, blacks (odds ratio=0.73; 95% confidence interval, 0.63-0.84) and Hispanics (odds ratio= 0.84; 95% confidence interval, 0.74-0.97) were less likely and Asians (odds ratio=1.29; 95% confidence interval, 1.01-1.65) were more likely to receive coronary revascularization. Patients living in more educated communities, men, and persons with private insurance were more likely to receive coronary revascularization before and after reform. Compared with the prereform period, the adjusted odds of in-hospital mortality were higher in patients living in less-educated communities in the postreform period. No differences in 1-year mortality by race/ethnicity, education, or sex for revascularized patients were observed before or after reform. Reducing insurance barriers to receipt of coronary revascularization procedures has not yet eliminated preexisting demographic and educational disparities in access to these procedures.

Successful Efforts to Increase Diversity in a Cardiology Fellowship Training Program

A large volume of literature has documented racial disparities in the delivery of cardiovascular care in the United States and that decreased access to procedures and undertreatment lead to worse outcomes. A lack of diversity among physicians is considered to be a major contributor. The fellowship training program in cardiovascular medicine at The Ohio State University Medical Center had never trained a fellow from a minority group underrepresented in medicine (URM) before 2007. In 2005, the fellowship made it a priority to recruit and match URM candidates in an effort to address the community's lack of diversity and disparities in cardiovascular care. Program leaders revised the recruitment process, making diversity a high priority. Faculty met with members of diverse residency programs during visits to other institutions, the focus of interview day was changed to highlight mentorship, additional targeted postinterview communications reached out to highly competitive applicants, and a regular mentoring program was constructed to allow meaningful interaction with URM faculty and fellows. Since these changes were implemented, the program has successfully matched a URM fellow for 5 consecutive years. Such candidates currently make up 4 of 16 total trainees (25%) in the fellowship in cardiovascular medicine. The cardiovascular medicine fellowship training program at The Ohio State University was able to revise recruitment to attract competitive URM applicants as part of a concerted effort. Other educational programs facing similar challenges may be able to learn from the university's experiences.

Residents' awareness of racial and ethnic disparities in cardiovascular care.

To characterize attitudes of residents toward racial/ethnic disparities in health care and to explore the effect of a simple intervention to improve awareness of these disparities. The authors surveyed residents in internal and emergency medicine rotating through the Coronary Care Unit of a major teaching hospital about their attitudes toward disparities in cardiovascular care before and after an intervention that fostered discussion of evidence for the existence of disparities, possible causes of disparities, and clinically focused approaches to quality improvement tailored to the residents' practice environment. Before the intervention, 35% of residents agreed that racial/ethnic disparities might occur for patients within the US health care system in general, and only 7% agreed that patients they personally treated might experience racial/ethnic disparities in healthcare. These proportions increased significantly after the intervention: 85% agreement at level of US health care system and 32% at the level of individual practice (P < .001). Changes in awareness did not differ by sex, postgraduate year of training, race/ethnicity, reported prior diversity training, or plans to subspecialize. Awareness of racial/ethnic disparities in care among residents remains low, particularly at the level of individual practice, but is amenable to intervention.

Disparity of Care in the Acute Care of Patients With Heart Failure

It has been well documented that screening, prevention, and treatment disparities in cardiovascular care exist. Most studies have focused on the outpatient setting. The purpose of the present analysis was to assess if a disparity of care exists in the care of emergency department (ED) patients with acute heart failure in a secondary analysis of the Heart Failure and Audicor Technology for Rapid Diagnosis and Initial Treatment (HEARD-IT) multinational study. Only patients with an adjudicated diagnosis of acute heart failure were included in this analysis. Racial groups included in this analysis were limited to white and African American or black patients, due to their predominance in the cohort. Logistic regression including clinically relevant demographics, past medical history, exam, diagnostic tests, and adjudicated diagnosis of acute heart failure as covariates was performed to assess the association of race with treatment with a diuretic or nitroglycerin and 30-day death or readmission. Of the cohort, 418 of 1,076 (38.8%) were included in the analysis. Median age was 69 years (interquartile range [IQR]=55-79 years), 49% were white, and 51% were African American or black. There was no difference in the correct admitting diagnosis in the two groups (p=0.83). Multivariate adjustment revealed that African American or black race was not associated with treatment with diuretics (adjusted odds ratio [OR]=1.00, 95% confidence interval [CI]=0.55 to 1.82) or nitrates (adjusted OR=1.27, 95% CI=0.76 to 2.13) in the ED. In a separate regression analysis there was no association with African American or black race with 30-day adverse events (adjusted OR=1.22, 95% CI=0.68 to 2.16). This secondary analysis of HEARD-IT data did not identify racial disparities in the treatment of adults with acute heart failure in the ED.

Improving Primary Percutaneous Coronary Intervention Performance in an Urban Minority Population Using a Quality Improvement Approach

It has been well established that there are racial and ethnic disparities in cardiovascular care. Quality improvement initiatives have been recommended to proactively address these disparities. An initiative was implemented to improve timeliness of and access to primary percutaneous coronary intervention (PCI) procedures among myocardial infarction patients at an academic medical center serving a predominantly minority population. The effort was part of a national quality improvement collaborative focused on improving cardiovascular care for Hispanic/Latino and African American/ black populations. The proportion of primary PCI procedures performed within 90 minutes improved significantly from 17% in the first quarter of 2006 to 93% in the fourth quarter of 2008 (P < .001). There were no significant differences in the frequency with which Hispanic/Latino or African American/black patients received primary PCI therapy in comparison to nonmembers of these groups. Quality improvement techniques can improve the quality of and access to acute cardiovascular care for minority populations.