Martin Luther King, Jr 2017-06-22 06:02:08
Inequity in Cardiovascular Medicine: What Can We Do in Our Practice? Of all the forms of inequality, injustice in health is the most shocking and the most inhuman. Health equity can be a daunting topic, seemingly beyond our control and perhaps even the capacity of everyday practice. The issue of health care access is particularly vexing and complex, and the current political climate may make many believe that solutions are not forthcoming or the fixes may worsen access and increase financial burdens. The socioeconomic contributors to disparities in health and the delivery of health care and outcomes require broad and coordinated multi-stakeholder solutions. The burden of cardiovascular disease is substantial – and highlighted with new data elsewhere in this issue of Cardiology – and the disparities in the cardiovascular space increasingly recognized. Yet, at a local and practice level, are there steps cardiovascular professionals can take to reduce and eliminate disparities in the community they serve? Awareness, as with any issue, is a first step, and here we bring you insights from the Health Equity Intensive held at ACC.17, along with some recently published data on disparities in cardiovascular medicine. The intent of all physicians is to deliver care that best serves each patient, without consideration of race, ethnicity, sex, gender, age, language, income, education, insurance or geography, or any other difference that could lead to a disparity in care or outcomes. But unrecognized bias, stereotyping and prejudice can impair decision making and contribute to differences in the delivery of care. A survey of cardiologists revealed a low rate who agreed there were racial and ethnic disparities that affected care overall in the U.S. health care system (34 percent) and even in their own institution (12 percent) and their own patients (five percent).1 Insurance and insurance type were perceived as very/somewhat often influencing health care, at 70 and nearly 60 percent respectively, followed by English language at nearly 60 percent and education at about 45 percent. Such surveys highlight a need for professional education of health care providers across the spectrum, including cultural competency and conscious and subconscious bias, to increase awareness and reverse disparities. This education is needed in professional schools, residencies and fellowships and as continuing education. The Medical School of South Carolina is an example of including cultural competency and a focus on racial and ethnic disparities in the curriculum. The University of California (UC), through its Program in Medical Education initiative, is committed to developing physicians who are culturally and linguistically competent and training physicians to address the needs of underserved communities. Under this initiative, UC San Diego is developing a new curriculum for medical students with a concentration in health equity and the potential for a dual degree, and it is implementing a joint minority health disparities curriculum for its medical students and graduate students in public health at San Diego State University. Ileana L. Piña, MD, MPH, FACC, a speaker in the Intensive session, also notes a need for performance measure-based quality improvement, team care and patient education. She adds that five essential elements, if manifested at every level of the service delivery system, as reflected in attitudes, policies, structures and services can contribute to a health care system becoming more culturally competent: • Value diversity • Capacity for cultural self-assessment • Consciousness of the “dynamics” inherent when cultures interact • Institutionalization of cultural knowledge • Develop adaptations to service delivery reflecting an understanding between and within cultures. Burden of Cardiovascular Disease What is the scope of the disparities in the cardiovascular arena? Four snapshots of data illustrate the differences in the burden of cardiovascular disease as a function of race and ethnicity, some of which are driven by decision making that mixes with an element of bias, says Clyde W. Yancy, MD, Msc, MACC. The achievement of seven criteria for ideal cardiovascular health, recognized as being associated with good health outcomes and survival free of heart disease, varies greatly across racial and ethnic groups.2 The rates of high blood pressure are higher in non-Hispanic black women and men than in non-Hispanic whites and Mexican Americans.3 Black men have the highest rate of mortality from myocardial infarction (MI) or coronary heart disease (CHD), followed by black women and then white men and women.3 Interestingly, the prevalence of heart failure varies by geography, with higher rates in areas more heavily populated by blacks and in some instances Latinos,4 despite the risk factors associated with heart failure such as high blood pressure, obesity and diabetes being fairly ubiquitous, says Yancy. Geography also matters in terms of CHD incidence, with a four-fold higher rate in the Appalachian region of the U.S. vs. Oregon, notes Wayne H. Giles, MD, MS. Geography and income combine to affect other outcomes. Among Medicare beneficiaries, despite declines in the rate of hospitalization for an acute MI in both low-income and high-income counties from 1999 to 2013, the rate remained higher in the low-income counties; mortality rates did not differ.5 Income also influences the burden of cardiovascular risk factors and two recently published studies provide additional supporting data. In a study of nearly 24,000 adults participating in the National Health and Nutrition Examination Surveys (NHANES) between 2005 and 2014, Adam L. Beckman, BS, and Erica S. Spatz, MD, MHS, et al, found an increase in the size of the lowest income group, from 10 to 14 percent, but a decrease in the highest income group, from 55 to 51 percent.6 The lowest income group was defined as a poverty-income ratio (PIR) <100 percent of the federal poverty level and the highest income group as a PIR =300 percent of the federal poverty level. In their study, of participants living below the poverty line, half have hypertension and a third smoke. The absolute difference in the proportion of participants with hypertension increased, due to a 2.4 percent rise and 10.5 percent decrease in the lower and higher income groups. For diabetes, there was an increase in the prevalence in the higher income group, closing the gap between the groups, but a higher rate remains in the lower income group. Smoking rates decreased in both income groups, but it was less in the lower income group. Obesity increased in both income groups, but was greater in the lower income group. Dyslipidemia increased two-fold in the lower vs. the higher income group. In another study using NHANES data, in 17,199 participants aged 40-79 years without established cardiovascular disease, between 1999 and 2014, differences were found in relation to income strata for the predicted absolute cardiovascular risk of 20 percent or more, mean systolic blood pressure and percentage of current smokers, with reductions for the high-income stratum but no change for the low-income stratum.7 Women with cardiovascular disease are too often unrecognized and/or under-treated. And women continue to be under-represented in cardiovascular clinical trials, at only about 25 percent of study populations; minorities represent less than five percent, says Sharonne N. Hayes, MD, FACC. She notes the reporting of trial results by race, ethnicity and sex continues to be an exception. This lack of inclusion causes medical decisions to be based on absent or inadequate data and over-, under- or mis-treatment. Indeed, blacks and Hispanics, vs. whites, are more likely to receive care that is low-value or deemed ineffective, according to a recent study in Health Affairs. Gender independently affects outcomes in addition to sex, and clinicians “must be conscious of this to better understand how to care for women,” says Hayes. Understanding sex- and gender-based differences is important to optimize prevention, diagnosis and treatment of women and men. Go Local: Strategies at the Practice and Community Level In its report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, the Institute of Medicine defined disparities as racial or ethnic differences in health care that are not due to access-related factors, clinical needs, patient preferences or the appropriateness of the intervention. The report illustrated the factors that can affect clinical decision making and can subjectively affect the interpretation of data and patient input and ultimately the intervention selected (Figure). “At the crux, it is the interpretative moment that determines how patients receive care,” says Yancy. If it is with a cultural context that is aligned with, not identical to, the patient, there is a good likelihood of making favorable decisions, he adds. Could precision medicine – the customization of medical decisions and course of treatment based on an individual patient – remove or reduce the subjectivity of this decision-making process and bring greater parity to health care delivery? Can this approach that incorporates the use of informatics and decision support make race and ethnicity obsolete in this regard? Although this has been hypothesized by some, Yancy remains uncertain whether precision medicine has this capacity, because it does not address the implicit and subtle bias that remains in medicine. The need to understand the intersection of the objective information, cultural information and the decision-making process still matters. Hayes reminds us that individualized cardiology treatment must incorporate sex, gender, culture and race/ethnicity, along with consideration of the pathophysiology and natural history, genetic and hormonal influences, symptoms, risk factors, optimal diagnostic testing, benefits and risks of therapeutic interventions, education and psychosocial needs and styles, and cultural beliefs, trust and language. A diverse workforce that reflects the diversity of patients could better ensure delivering health care that respects the needs of each patient. The development of this workforce is one of the objectives of the ACC Task Force on Diversity, led by Chair Pamela Douglas, MD, MACC, and Co-Chair Kim Allan Williams, Sr, MD, MACC. At the most basic level, focus on the simple things – the ABCs of aspirin/antiplatelets, blood pressure, cholesterol, smoking and sodium – in all patients, along with supporting physical activity and better diet, says Robert M. Califf, MD, MACC. Digital health data should bring rational access to effective therapies, says Califf, noting, however, that criteria to define appropriateness will be required. While many of his 10 action items to achieve health equity are at the public health and policy level, Califf also counsels a focus on what one can control within their own practice and perhaps at the service level within their hospital. For achievements to be gained, health equity must be explicitly identified, prioritized and measured over time – including at the personal practice and health system service levels. And now there is the ability to measure the status of health behaviors and outcomes and to use those measurements to access current interventions and develop new ones. “Leverage the power of integrated health systems – the dominant economic force and largest resource in most parts of America – to improve inequities,” says Califf. He notes that states will be more and more responsible for local solutions, and Califf thinks that Medicaid block grants will unleash a lot of hard discussion and creativity. One strategy is putting clinics and services where they’ll have the most impact and improve the accessibility of care, rather than the current approach of putting them in the locations with better reimbursement rates and payer mix. Evidence supports the relation between the locale and emergency department visits, for example. In fact, a paper published in the June issue of Health Affairs, with the theme of health equity, showed that mortality is higher in blacks than whites who have an MI when ambulances must be diverted because of emergency department capacity. The Centers of Disease Control’s (CDC) Interactive Atlas of Heart Disease and Stroke is an online mapping tool that creates county-level maps that can be stratified by age, sex, race and ethnicity, along with maps of social and economic factors and health services. Such data can be used to optimize the location of services and clinics and the development of community outreach programs. The 500 Cities project, a collaboration between the CDC Foundation and the Robert Wood Johnson Foundation, is working to provide local-level data to the 500 largest cities in the U.S. These data include risk factors for chronic disease, health outcomes and clinical preventive services, to assist the planning of public health interventions based on understanding the local burden and geographic distribution. By way of illustration, Giles notes that by combining these data with data from electronic health records, it was possible to determine the area of Chicago with the greatest density of high blood pressure. Taking it a step further, overlaying patient data with locations of supermarkets and parks can help drive the development of effective community programs. Interventions can be more targeted using these data, and provide tools necessary to encourage action on health equity at the local level, says Giles. Participation by individual physicians in such programs does provide benefits for patients. Giles notes that some 115,000 cardiovascular events were prevented during the first two years of the Million Hearts initiative, hypertension control is projected to increase by 8.3 percent between 2009-2010 and 2015-2016, and across diverse clinical settings, at least a 70 percent improvement in care has been demonstrated. The ACC is a partner in Million Hearts, a national initiative co-led by the CDC and Centers for Medicare and Medicaid Services, with the goal of preventing 1 million Mis and strokes within five years. References Lurie N, Fremont A, Jain AK, et al. Circulation 2005;111:1264-9. Mozaffarian D, Benjamin EJ, Go AS, et al. Circulation 2015;131:e29-e322. Go AS, Mozaffarian D, Roger VL, et al. Circulation 2014;129:e28-e292. CDC National Vital Statistics System. Spatz ES, Beckman AL, Wang Y, et al. JAMA Cardiol 2016;1:255-65. Beckman AL, Herrin J, Nair K, et al. JAMA Cardiol 2017;June 7:[Published early online]. Odutay A, Gill P, Shepherd S, et al. JAMA Cardiol 2017;June 7:[Published early online]. No discussion of health equity is complete without acknowledging the impact of limited access to health care because of the lack of insurance or under insurance, along with the burden of copays and deductibles and prior authorization, and the high and seemingly rising costs of treatments. Drug pricing has been the subject of scrutiny with some high-profile cases of price escalations making the news. The EpiPen saga has been staggering.In the cardiovascular arena, there is concern about the high cost of new and highly effective medications, including evolocumab and sacubitril/valsartan, and the new diabetes drugs that have been shown to have cardiovascular benefit, such as the SGLT-2 inhibitors. Will it be possible for patients to afford these evidencebased and effective therapies?The ACC continues to work to address this issue along with prior authorization. But, what is fair pricing?Will continually rising drug costs limit access? The World Health Organization (WHO) is now addressing this issue, and held its first international Fair Pricing Forum in May 2017. A report from the WHO’s advisory board meeting for the Fair Price Forum states that access to essential medicines is part of attaining universal health coverage, a key aim of the United Nations Sustainable Development Goals. Affordability of medications for individuals and for national health systems is a challenge. Over the next five years, the global market for prescription medicines is expected to increase by a third, reaching nearly $1.5 trillion by 2021. The multi-stakeholder Forum, including WHO Member State governments, patient associations, civil society, insurers and the pharmaceutical industry, aims to bring greater involvement of the global health community to understanding this issue and finding solutions. It also intends to understand what the pharmaceutical industry needs to improve research and development and innovation from a public health perspective and to keep old and generic essential medicines on the market. Sanofirecently announced its principles and perspectives on prescription medicine pricing and committed to greater transparency on how they price their medicines and keeping prices in the U.S. below medical inflation for that year. In its statement, Sanofiacknowledged there are actions they can take to help improve access for patients and affordability for the health system, while recognizing there are many factors, including patient cost-sharing and coverage, that are controlled by other health care players. It also stated its support of a transition to a value-driven health care system that provides incentives for the highest-quality care, which will enable affordable access to treatment and continued investment in medical innovation. The three pillars of Sanofi’s pricing principles are a clear rationale for pricing globally at the launch of a new medicine, which will include a rigorous and structured process and consultation with external stakeholders, limited price increases on their medicines over time in the U.S., and greater transparency around pricing decisions. The company also committed to releasing its average aggregate list price increase and average aggregate net price annually for its entire U. S. portfolio. For 2016, relative to 2015, these numbers were an increase of 4.0 percent and a decrease of 2.1 percent.
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