credo and State Chapter Breakout

Presented at the Annual BOG Meeting

January 2010

Presenter Disclosure Information

The following relationships exist related to this presentation:

• Krishnaswami Vijayaraghavan, M.B.B.S., F.A.C.C. – Consultant Fees/Honoraria from Gilead; BMS. Speaker’s Bureau for Abbott; Forrest; GSK; Novartis.

Objectives

• What is credo?• State chapter CVD profile – Arizona• Breakout and small group discussion

Program Support

• credo sponsors:

• Independent educational grant support for credo educational initiatives provided by: • AstraZeneca, Daiichi Sankyo, Inc., Eli Lilly

USA, LLC, Medtronic, and Novartis

What is credo?

• Identify evidence-based principles of provider education that lead to equitable CVD care and outcomes

• Recognize and facilitate dissemination of educational activities that meet credo principles

• Develop, implement, and publish a PI-CME educational activity that targets specific CVD clinical area using ACC’s NCDR™

The Case for Addressing CVD Disparities

• CVD disparities exist and lead to avoidable, premature morbidity and mortality

• Evidence-based care can reverse CVD disparities

• Tools for redressing disparities are consistent with providing patient-centered, evidenced-based care

• Trends in population and cardiology compound CVD disparities

Increasing Diversity in the US

Non-hispanic, Single-race White Hispanic

Black Asian

American Indian/Alaska Native Native Hawaiian/Other Pacific Islander

2+ Races

2008 2050

What are the keys to reducing disparities?

• Performance measure-based quality improvement

• Provider/patient education• Team care

Evidence-based Reduction in Health Disparities

Data show:• Across health conditions QI and cultural

competency training can increase quality, provider knowledge/attitudes, and patient satisfaction/health

• In CVD, physician education necessary but not sufficient; team care and patient education can be effective

• In acute hospital ACS care, QI can improve quality and reduce disparities

AHRQ, Evidence Report/Technology Assessment: Strategies for Improving Minority Healthcare Quality, January 2004. Davis AM et al., “Cardiovascular Health Disparities: A Systematic Review of Health Care Interventions,” Med Care Res and Rev. 2007; 64; 29S. Expecting Success: Excellence in Cardiac Care Results from Robert Wood Johnson Foundation Quality Improvement Collaborative. 2008.

Keeping PACE Overview

Stage A: Review performance data from associated hospital participating in ACTION-GWTG Registry

Stage C: Re-examine hospital performance data

Stage B: Select Education • Online interactive case study • Local grand rounds program

• Optional QI tools • Optional patient education tools/survey

credo Keeping PACE Program Example

Aspirin Clopidogrel Beta Blocker ACE Inhibitor or ARB

Statin0%

25%

50%

75%

100% 99%

88%

100%94% 97%100%

58%

100%

83%

94%92%

75%

92%

33%

100%

White Black Other

State Chapter CVD Profile: Arizona

• Population demographics• CVD in Arizona• Healthcare Quality in Arizona• State requirements for cultural competency• Health reform and disparities• ACC membership in Arizona• NCDR Representation in Arizona• Health literacy and language proficiency

Race in Arizona vs US  Arizona United States

Total: 6,324,865 301,461,533

White alone 77.6% 74.5%

Black or African American alone 3.6% 12.4%

American Indian and Alaska Native alone 4.5% 0.8%

Navajo Tribal Grouping 2.2% 0.1%

Other American Indian or Alaska Native 2.3% 0.7%

Asian alone 2.4% 4.4%

Native Hawaiian and Other Pacific Islander alone

0.2% 0.1%

Some other race alone 9.1% 5.6%

Two or more races 2.6% 2.2%

Source: U.S. Census Bureau, 2005-2009 American Community Survey

Ethnicity and Age in Arizona vs US  Arizona United States

Ethnicity

Hispanic or Latino of any race 29.8% 15.1%

Mexican 26.7% 9.7%

Other Hispanic or Latino 3.1% 5.4%

Not Hispanic or Latino 70.2% 84.9%

Age

Median Age (years) 34.8 36.5

Under 5 years 7.9% 6.9%

18 years and over 73.6% 75.4%

65 years and over 12.9% 12.6%

Source: U.S. Census Bureau, 2005-2009 American Community Survey

Poverty and Rural/Urban Residence in AZ  Arizona United States

Poverty

Per capital income (2009 dollars) $25,203 $27,041

Individuals below poverty level 14.7% 13.5%

Residence

Rural 10.1% 16.4%

Urban 89.9% 83.6%

Source: U.S. Census Bureau, 2005-2009 American Community Survey

Poverty Rate by Race/Ethnicity

The Kaiser Family Foundation, statehealthfacts.org. Data Source: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2009 and 2010 Current Population Survey

AZ Heart Disease Rate by Race/Ethnicity

National Minority Quality Forum, the American College of Cardiology, and the Association of Black Cardiologists

AZ Heart Disease by Gender

AZ Heart Disease by Age

National Healthcare Quality Report Arizona Findings

National Healthcare Quality Report Arizona Findings

Ambulatory Care-Sensitive Discharges by Race

Patient Satisfaction Findings in CAHPS

Heart Failure Outcomes in Hispanic and American Indian Populations

CMS Quality Improvement Organization Program, 2007.

US Cultural Competency Legislation

Text from Legislation

• House bill 2544 (47th Legislature, 2006)

– Will create a Task Force on Cultural Competence that will, “study and make annual recommendations on specific course curricula for each health-related education field offered by a university…and by a community college.”

– Components of cultural competence health courses shall include: “1)cross-cultural communication; 2)culturally and linguistically appropriate health policy considerations; 3) exploration of health beliefs and explanatory models; 4)culturally competent health care delivery; 5)health disparities, privilege and equity factors in the health system; 6)culturally and linguistically competent care supported by policy, administration and practice.”

Arizona Department of Health ServicesCultural Competency Advisory Committee

• Work Plan for 2009-2011 requires compliance with CMS and AZ Heath Care Cost Containment System requirements

• Initiatives include:– Education and Training – annual CC training– Mandatory oral interpreters and bilingual staff– Annual Diversity Report– Collaboration with Community Based Organizations– Provider and Organizational Self-Assessments of

Cultural Competence

Health Reform and Disparities – Provisions Specific to Race/Ethnicity

Patient Protection and Affordable Care Act

contains provisions to:• Mandate collection of patient race/ethnicity,

language, gender data (section 4302)• Funding for cultural competence training (5301 and

5307)• Health disparities research (6301)• Indian Health Care Improvement Act – permanent

reauthorization to improve access and modernize facilities (10221)

Health Reform and Disparities – General Provisions Impacting Diverse Populations

• Coverage expansions – Medicaid, employer mandate, health exchange (2001,1513,1311)

• Community health center expansion (10503)• Quality improvement incentives (3011 and 3501)• Public health initiatives and prevention –

National Prevention & Public Health Council and Prevention & Public Health Fund (4001 and 4002)

Kaiser Family Foundation. Health Reform and Communities of Color: Implications for Racial and Ethnic Health Disparities. September 2010.Joint Center for Political an Economic Studies. Patient Protection and Affordable Care Act of 2010: Advancing Health Equity for Racial and Ethnically Diverse Populations. July 2010.

Arizona ACC Membership - PhysiciansArizona Chapter ACC Membership

Member Type

AA 11.0% 9.4%

AF .9% 0.8%

CCA 18.1% 13.0%

Practice Administrator 1.6% 1.3%

FF 61.8% 64.1%

FIT 6.7% 11.3%

MA  0% 0.1%

Gender

Female 10.1% 10.5%

Male 89.9% 89.5%

Age

Less than 30  0% .1%

31-40 12.6% 9.9%

41-50 31.0% 29.7%

51-60 29.9% 36.6%

61-70 22.0% 19.5%

71 or Older 4.4% 4.1%

Arizona ACC Membership - Physicians

Specialty

Arizona Chapter ACC MembershipAdult Cardiology 51.4% 53.3%

Echocardiology 3.8% 2.2%

Electrophysiology 5.0% 5.7%

Heart Failure/Transp 0.5% 1.0%

Interventional Cardi 19.3% 11.6%

Invasive Cardiology 2.6% 1.7%

MR/CT Cardiology 0.7% 0.2%

Non-invasive Cardiol 0.5% 1.2%

Nuclear Cardiology 4.7% 4.8%

Other Specialty 3.3% 10.0%

Pediatric Cardiology 5.7% 5.1%

Surgery 2.6% 3.2%

Arizona ACC Membership - CCAsArizona Chapter ACC Membership

Member Type

CNS 1.0% 2.9%

NP 61.4% 43.0%

PA 18.8% 17.4%

PharmD 2.0% 2.5%

RN 16.8% 34.1%

Gender

Female 87.8% 86.8%

Male 12.2% 13.2%

Age

Less than 30 2.4% 5.3%

31-40 29.8% 24.6%

41-50 26.2% 30.5%

51-60 33.3% 33.7%

61-70 8.3% 5.6%

71 or Older 0% 0.3%

NCDR in Arizona

• 47 NCDR sites (hospitals and practices) enrolled in ACTION, CARE, CathPCI, ICD and PINNACLE– Six sites enrolled in at least 3 registries

• Arizona Regional Medical Center• Casa Grande Regional Medical Center• Flagstaff Medical Center• Maricopa Integrated Health System• Scottsdale Healthcare Osborn• Verde Valley Medical Center

Health Literacy

• Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions

• 12% of adults have proficient health literacy

U.S. Department of Health and Human Services. (2000). Healthy People 2010 (2nd ed.)

Language Proficiency in Arizona

Total Percent of specified language speakers

Speak English "very well"Speak English less than

"very well"

Speak only English 72.1% --- ---

Speak a language other than English

27.9% 57.4% 42.6%

Spanish or Spanish Creole

21.7% 53.9% 46.1%

Other Indo- European languages

2.1% 73.5% 26.5%

Asian and Pacific Island languages

1.6% 55.5% 44.5%

Other languages 2.5% 75.2% 24.8%

Source: U.S. Census Bureau, 2005-2009 American Community Survey

Suggested Resources– Unified Health Communication (UHC): Addressing Health Literacy,

Cultural Competency, and Limited English Proficiency: Free Online CME Course - http://www.hrsa.gov/publichealth/healthliteracy/

– Rapid Estimate of Adult Literacy in Medicine—Short Form (REALM-SF): 7-item word recognition test for quick assessment of patient health literacy - http://www.ahrq.gov/populations/sahlsatool.htm

– HRET Disparities Toolkit: A Toolkit for Collecting Race, Ethnicity, and Primary Language Information from Patients - http://www.hretdisparities.org/

– NCQA’s Multicultural Health Care (MHC) product offers distinction to organizations that engage in efforts to improve culturally and linguistically appropriate services and reduce health care disparities. - http://www.ncqa.org/tabid/1195/Default.aspx

For more information about credo and a full listing of resources, visit www.cardiosource.org/credo

Patient Education – Cardiac Rehab

• Placehold for clip from cardiac rehab video

credo CME Online Webinar

www.cardiosource.org/credowebcast

Cultural Competency Mini-Training

www.cardiosource.org/culturalcompetence

Breakout – Questions for Discussion

• What challenges do you face treating diverse patient populations? How do you address these challenges?

• Do issues of disparities/cultural competence/health literacy impact members in your chapter?

• What tools, resources or trainings would be beneficial for your chapter?