Chapters Transcript Video Racial Disparities in HF Management Dr. Mark East discusses racial bias in the delivery of healthcare treatment. Um this is an interesting topic that um uh really in part drove me to uh study uh cardiovascular disease. I, a mentor of mine came from the Brigham and went to Duke Eric Peterson and followed him there. And um it's a very interesting field. There's a lot of data that has uh emerged over the last 20 years or so. So there's a lot to cover here. I'm gonna try to cover as much as I can. Um So we'll jump right into it. Uh I do want to acknowledge um the institutional leadership of Doctor John Brush, Doctor Eric Peterson International Leadership, uh and former mentor Dr John Harry and all the work that he's done tireless uh efforts. Uh Doctor Barrier, Doctor Ross, I really appreciate it. These guys have been so gracious to me and of course, I have to mention the advanced heart failure treatment team when we're managing these patients. I'm an independent uh cardiologist and uh we don't, we need a team and uh these guys are absolutely phenomenal to work with. So we'll cover a bit of the epidemiology of heart failure. I'm sure you've heard it before. We won't spend a lot of time on it. Uh, we'll look at race as an independent predictor of uh, cardiovascular outcomes including heart failure. Uh We'll examine the question of race differences in cardiovascular outcomes, whether they're biological or social, um, racial differences in receipt of cardiovascular care, uh, and future outcomes uh, of quality as a care determinant. Patient factors provide a bias and future goals. Um, what we know is that if you look at, um outcomes, uh African Americans or blacks self reported um have a higher event rate. You can see that here. Uh they're labeled in blue black men and black women are at the top of these curves. And uh the higher the uh number, the more event rates uh we see here across different uh ethnicities. Uh black uh does tend to stand out. So this focus, the focus of this talk will highlight black or self reported black patients um uh in this data plus, that's where the majority of this data lies. Um Here. Um what we know is that the prevalence of heart failure and African Americans uh is persistently higher. Um We know that the lifetime risk of heart failure um amongst uh African Americans, um uh the onset is sooner and the outcomes are worse. Uh Black race is associated again as an independent predictor of heart failure. So if you put it in a multi variable model along with other clinical variants, other um uh demographics, you're gonna see race pan out as an independent predictor of outcomes. This has been consistently shown um over the last about 35 40 years. Um the incidence and recurrence of hospitalized patients with acute decompensated heart failure uh is significantly higher in African Americans than uh Caucasians. A lot of this data has been perpetuated by many of my former colleagues and um we've just done an outstanding standing job of uh really elucidating this as a as a still very present and prevalent issue. Um uh The other thing to note is that um there are some uh because of probable comorbidity and other factors, there's longer hospitalization, media survival is about 50% of that of uh uh Caucasian or white uh counterparts. Um African Americans uh both sexes uh are disproportionately uh dying from heart disease. Um And again, compared to other ethnicities, um African Americans have higher event rates, um domains of quality at the end of the day, um uh health equity is a quality measure and it needs to be treated as one. Um The uh in terms of biological differences. Um There is no genetic uh difference. Uh There is no black gene. Um I'm sure most of us know that. Uh but it, it's worth noting uh we're much more similar, however, it doesn't mean that there aren't some genetic variances. Um So, um the real question is, and this has been stated uh and I think stated, well, racial categorization is only a surrogate. And we've known that in the past oftentimes use as a proxy for low socioeconomic status and other factors. Um It however, um as was stated, uh after 400 years of social disruption, geographic dispersion and genetic inter, there are no alleles that define the Black people of North America as a unique population differences between blacks and whites and pathophysiology and responses to treatment are not necessarily genetic. And so we need to keep that in context. We don't have the data to really support that. That claim consistently. Uh We found that uh blacks have higher event rates and lower receipt of care, whether it's percutaneous implantable devices or advanced heart failure therapies. What we learned in the champ registry is that um uh Hispanics um or Latin Americans had uh were less likely to receive uh goal directed medical therapy as well as African Americans. Um interestingly in the A trial, um we found that um the A F trial demonstrated about a 43% risk reduction in mortality. The study was stopped less than two years by the data safety Monitoring Board because it was considered unethical. However, despite this, um African Americans, we found that uh the penetration of uh has, has been very poor somewhere around 11% usage amongst African Americans despite class is a class one level eight indication. Um We found that there are differences. Uh One of my former colleagues, Adrian Hernandez uh they looked at IC DS implantation and found differences by race. So we see that there is differences in procedure utilization. Um However, um based on the get with the guidelines, um um uh Doctor Hernandez and, and uh uh they found that some of these differences are improving. So there is hope um that uh we can improve the outcomes of, of some of these uh differences um by improving uh utilization fundamentally. initially, in this study, we had to determine whether it was under utilization or not. I think that it has been quite well established um over the last 30 years that this is low um usage amongst uh African Americans or black self reported black patients. Um We've also seen the um differences persist in terms of advanced heart failure, therapies. However, multidisciplinary teams are making a difference um in uh in proven equity. And so it's to be encouraged and we're blessed to have uh a multidisciplinary team here and uh um uh to help address uh this, this issue amongst all patients. Um goals of care. Um You know, there are a number and most of this we know um but um we want to stick to providing goal directed medical therapy. The fundamental question when we look at differences in outcomes and differences in procedure utilization, um the question becomes, what about the patient factors? Uh This was looked at Nancy Crescent and uh others looked at this in the past, we didn't really see amongst a um a cohort of va patients, similar patients uh differences in health related be beliefs or attitudes, explaining the differences in uh outcomes. Um I hope that's not my phone. Um So um the other question is um patient related factors are the genetic polymorphisms. The only study that to date has demonstrated a race by treatment interaction is the eight half trial. There is some data to suggest says that there are some polymorphisms. Uh However, you can't extrapolate that to everything we do. Race should not be at the forefront of your presentation. I often remind the medical students and the residents uh explain to me why you've mentioned that um it has to has to be plausible. Now, uh we know that the differences in utilization go back to and 1984 a lot of data has um come forth over the years and controlling for disease presentation, prevalent socioeconomic status, clinical characteristics, regional patterns, patient refusal, there are the those differences don't explain the outcomes. It really came down to Schulman, Kevin Schulman when he was at uh Georgetown. Prior to moving on, he did this study and he looked at um patients by race in different age stratum. And uh these were actors and asked a group of physicians, uh what would you recommend in terms of cat versus medical therapy? Um And what they found is that there was a powerful interaction by race and gender uh about a 40% lower risk of receiving um an uh recommendation for a calf if you were a black female compared to a white male. Um uh Other data, they actually went as far as to look at medical students thinking, well, maybe these are old guys and they just have some old beliefs and they demonstrated that uh the differences persist even among medical students. Very interesting. There could be some type two error here. But what we found was that um uh that black patients um were less likely uh compared to white men uh with identical presentations to have to be referred for uh for the work up. Um And again, these were students, uh medical students, they demonstrated that their perceptions uh of the symptoms were, were being affected by non medical factors in this case raised. Um So it's not just an age thing, whatever it is, it's institutional, we're carrying it with us into the patient um uh rooms. Um The other thing that we know is that, um and this has been well stated that uh physicians tend to associate African Americans and patients of low socioeconomic status as being less intelligent, more likely to engage in risky behaviors and less likely to comply. So, um what we've learned over the years is that there are a number of, of differences uh that cannot be explained uh when we look at um outcomes other than race. Uh there's a lot to be uh determined from here, race is an independent predict predictor of outcomes. Uh bias does exist in the delivery of health care. Um The I consider the institutional fault lines, they're there and they affect everybody but they disproportionately affect African Americans. So self reported black patients um to the extent that racial categorization does affect deliver of care, I think it reflects more of a cultural sin. It's not intentional. Um It's it and I think in part, we don't take accountability of because we don't really see it in us. Uh So there's a lot to do. Um I think we need greater collective and individual accountability. We need more institutional um uh responsibility in terms of looking at this data in our own institutions and then taking some personal responsibility of doing something about it. Um We've come a long way over the last 35 years, but um we still have a long way to go. Thank you. Published October 18, 2023 Created by Related Presenters Mark East, M.D. East Cardiovascular Specialists
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