American Heart Association QCOR 2010 Disparate Health Care:
Definition, Context, Consequences Clyde W. Yancy, MD, FAHA, FACC,
MACP Chair, Cultural Competency Taskforce, AHA; Co-Chair, CREDO,
ACC Slide 2 DISCLOSURES Consultant/speaker/honoraria: none since
06/31/08 Editorial Boards: American Heart Journal, American Journal
of Cardiology (associate editor); Circulation; Circulation-Heart
Failure; Circulation- Quality Outcomes; Congestive Heart Failure
Guideline writing committees: ACC/AHA, chronic HF; and ACC/AHA
Guideline Taskforce Federal appointments: FDA: Past Chair,
Cardiovascular Device Panel; ad hoc consultant, FDA; member, NIH
CICS study section Volunteer Appointments: American Heart
Association- President, American Heart Association, 2009-2010 Slide
3 AHA Mission Building healthier lives, free of cardiovascular
diseases and stroke. 2020 Impact Goal By 2020, to improve the
cardiovascular health of all Americans by 20% while reducing
cardiovascular diseases and stroke by 20%. Slide 4 2006-2010
Strategic Plan Strategies devoted to reducing disparities:
Influence the healthcare system to effectively serve diverse
populations. Reduce treatment gaps for racial and ethnic
populations Reduce health gaps for racial and ethnic populations
Decrease time to treatment for stroke Slide 5 Percentage of the
Population by Race/Ethnicity: 2000 and 2025 Percentage of
Population *White= Non-Hispanic. AA= African American. US Census
Bureau, 2000. Slide 6 Slide 7 Age-Adjusted Death Rates for Coronary
Heart Disease, Stroke, and Lung and Breast Cancer for White and
Black Females United States: 2002 Source: CDC/NCHS. Slide 8
Differences? Disparities? Slide 9 Contributors to Healthcare
Disparities Smedley BD, Stith AY, Nelson AR, Editors et al. Unequal
Treatment: What Healthcare Providers Need to Know About Racial and
Ethnic Disparities in Healthcare. National Academies Press; 2002
Quality of Healthcare Non-MinorityMinority Clinical Appropriateness
and Need, Patient Preference The Ecology of Health Care Systems and
Environmental Factors Discrimination: Biases, Stereotyping, and
Uncertainty Disparity Difference Differences, Disparities, and
Discrimination: Populations with Equal Access to Healthcare.
Source: Gomes and McGuire, 2001 Slide 10 CASE IN POINT Slide 11
Hypertension as a risk factor for HF in AAs Bibbins-Domingo et al.
New England Journal of Medicine. 360(12):1179-1190 Slide 12
Incidence of heart failure in young AAs Bibbins-Domingo et al. New
England Journal of Medicine. 360(12):1179-1190 Slide 13 The
consequences of disparate health care: There is growing and
disturbing evidence that disparities in care result in preventable
excess morbidity and possibly increased mortality. Peterson, E.
Yancy CW. : N Engl J Med. 2009 Mar 19;360(12):1172-4. Slide 14
Disparity condition or fact of being unequal Diversity noticeable
heterogeneity. variety Culture shared, learned, symbolic system of
values, beliefs and attitudes that shapes and influences perception
and behavior Slide 15 RACIAL DISPARITIES IN AMERICA- A REPORT FROM
THE INSTITUTE OF MEDICINE Slide 16 Unequal Treatment: Confronting
Racial and Ethnic Disparities in Healthcare Racial and ethnic
disparities in healthcare exist May be associated with worse
outcomes Bias, stereotyping, prejudice, and clinical uncertainty on
the part of healthcare may contribute to racial/ethnic disparities
in healthcare More research is needed in this area Adapted from
Smedley, B., Stith, A. and Nelson, A. Unequal Treatment:
Confronting Racial and Ethnic Disparities in Healthcare. The
Institute of Medicine, National Academies Press, Washington, DC.
2002;19. Adapted from The National Center for Cultural Competence.
2005. Slide 17 What are potential sources of disparities in care?
Health systems-level factors financing, structure of care; cultural
and linguistic barriers Patient-level factors poor adherence,
biological differences Disparities arising from the clinical
encounter Slide 18 Slide 19 Physician Self-Assessed Attitudes Not
at all important Somewhat important Very important Survey
Questions: How important do you consider sociocultural issues to be
in your interactions with patients? How important do you feel it is
for health professionals to receive training in cultural diversity
and/or multicultural health care? Importance of multicultural
health care training for healthcare professionals Importance of
sociocultural issues in patient interactions Slide 20 Physician
Attitudes Importance of Multicultural Health Care Training Black
(n=49) White (n=479) Asian (n=87) Survey Question: How important do
you feel it is for health professionals to receive training in
cultural diversity and/or multicultural health care? Slide 21
Physician Self-Assessed Knowledge Survey Question: How
knowledgeable are you about each of the following subject areas?
Not at all knowledgeable Somewhat knowledgeable Very knowledgeable
Self-assessed knowledge in sociocultural issues as reported by
white, Asian and black physicians Health disparities experienced by
diverse racial/ethnic groups Sociocultural characteristics of
diverse racial/ethnic groups Office of Minority Healths National
Standards for CLAS in health care Different healing traditions
Impact of racism, bias, prejudice, and discrimination experienced
in health care Ethnopharmacology Slide 22 Physician Self-Assessed
Skills Survey Question: How skilled are you in dealing with
sociocultural issues in the following areas of patient care? Not at
all skilled Somewhat skilled Very skilled Self-assessed skills in
dealing with sociocultural issues as reported by White, Asian and
Black physicians Greeting patients in a culturally sensitive manner
Prescribing/negotiating a culturally sensitive treatment plan
Eliciting information about folk remedy and alternative healing
modality use Providing culturally sensitive patient education and
counseling Dealing with cross-cultural conflicts relating to
diagnosis or treatment Assessing health literacy Slide 23 Cultural
Competency Advisory Group Charge Identify gaps related to the
current data on cultural competency that the American Heart
Association can work toward filling. Identify key opportunities
related to the current data on cultural competency. Professional
practice gaps Professional Education opportunities Patient
Education opportunities Integrated opportunities How can we
strengthen the interactions between healthcare providers and their
diverse patients? Renovation of existing programs, products, and
initiatives Slide 24 Reducing Racial and Ethnic Disparities in
Cardiovascular Disease Outcomes Slide 25 Cultural Competence Slide
26 What is Cultural Competence? The ability of systems to provide
care to patients with diverse values, beliefs and behaviors
including tailoring delivery of care to meet patients social,
cultural, and linguistic needs. The ultimate goal is a health care
system and workforce that can deliver the highest quality of care
to every patient, regardless of race, ethnicity, cultural
background, [language proficiency, literacy, age, gender, sexual
orientation, disability, or socioeconomic status]. Adapted &
expanded from the Commonwealth Fund. New York, NY, 2002 Slide 27
T.D. Goode. The National Center for Cultural Competence. 2005.
Addressing Cultural Contexts in Health Care FAMILY HEALTH CARE
PROVIDER HEALTH CARE SYSTEM COMMUNITY PATIENT Slide 28 Quality
focused strategies Get With The Guidelines- HF; CAD AHA Performance
Improvement Program Robert Woods Johnson Expecting Success
Multicenter quality improvement program targeting AMI & HF
American College of Cardiology: CREDO Coalition to reduce disparate
health care American Heart Association: Cultural Competency
Initiative Provider and patient focused initiative to address
cultural competency Slide 29 Targeting Healthcare Disparities in
Cardiovascular Disease Strategies to Enhance Cultural Competence
Cultivate Leadership CLAS Practice Environment Resources &
Tools Resources & Tools Facilitate Skill Development Impart
Critical Knowledge Promote Positive Attitudes Legitimize Cultural
Competency Legitimize Cultural Competency Encourage Self-
Assessment Slide 30 AHA Cultural Competency Mnemonic CULTURE C-
Context Can you establish your patients unique social context? U-
Understanding Do you appreciate your patients perspective? L-
Language Are you communicating effectively? T- Treatment Have you
engaged the patient in the treatment decision? U- Urge Have you
prompted questions? R- Reassess How was this encounter? Would it
have worked for you? E- Enlighten Are you and the patient more
aware and prepared for next steps? Slide 31 Knowing is not enough;
we must apply. Willing is not enough; we must do. Johann von
Goethe
