credo: Why, What and How Laura Lee Hall, Ph.D. Associate Director, Strategic Educational Initiatives American College of Cardiology

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2 credo: Why, What and How Laura Lee Hall, Ph.D. Associate Director, Strategic Educational Initiatives American College of Cardiology National Minority Quality Forum Washington, DC April 19 th, 2010

3 Disclosures Nothing to disclose

4 Acknowledgment First credo sponsor: 4

5 Advisory Group Members Clyde W. Yancy, MD, FACC, FAHA, FACP Co-Chair Baylor Heart and Vascular Institute Baylor University Medical Center Tracy Y. Wang, MD, MHS, FACC - Co- Chair Duke Clinical Research Institute Hector O. Ventura, MD, FACC Co-Chair National Hispanic Cardiologists Leadership Network Tulane University School of Medicine Paul N. Casale, MD, FACC President, Pennsylvania Chapter, ACC Lancaster General Hospital Elizabeth DeLima Vice President, Cultural Health Initiatives American Heart Association Marshall Chin, MD, MPH Finding Answers: Disparities Research for Change University of Chicago Keith C. Ferdinand, MD, FACC Morehouse School of Medicine Emory University Association of Black Cardiologists, Inc. 5

6 Advisory Group Members, continued Gordon L. Fung, MD, MPH, PhD, FACC UCSF Governor, Northern CA, ACC President, California Chapter, ACC Robert C. Like, MD, MS Center for Healthy Families and Cultural Diversity UMDNJ-Robert Wood Johnson Medical School Ileana L. Piña, MD, FACC, FAHA Case Western Reserve University Louis Stokes VA Medical Center Sarah H. Scholle, DrPH, MPH National Committee for Quality Assurance Kris Vijay, MD, MS, FACC, FACP Chapter President/ACC Governor-Arizona Scottsdale Clinical Research Institute Marcia Jackson, PhD CME by Design Douglas L. Mann, MD, FACC, FACP Heart Failure Society of America Baylor College, Winters Center John S. Rumsfeld, MD, PhD, FACC, FAHA Denver VAMC /NCDR Joanna D. Sikkema, MSN, ARNP University of Miami Whole Health Management President Elect Preventive Cardiology Nurses Association Karol E. Watson, MD, PhD, FACC Geffen School of Medicine 6

7 credo: Why, What and How CVD disparities exist and lead to avoidable, premature morbidity and mortality Trends in general population and cardiology compound CVD disparities Evidence-based approach to reducing disparities available for further testing and implementation

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9 Age-Adjusted High Blood Pressure in Adults 20 Years of Age Lloyd-Jones D et al., Heart Disease and Stroke Statistics 2010 Update: A Report from the American Heart Association, Circulation Feb 23;121(7):

10 Hypertension Death Rates, 2006 Whites 6.5 Blacks 17.7 Hispanics 6.2 Asians 6.1 Native Americans Age-adjusted Death Rate (per 100K), Men and Women National Vital Statistics Report. 2009;57:1-136.

11 Age-Adjusted Death Rates for White and Black Females, 2006 Lloyd-Jones D et al., Heart Disease and Stroke Statistics 2010 Update: A Report from the American Heart Association, Circulation Feb 23;121(7):

12 STEMI Reperfusion by Race/Ethnicity 100% 90% 93% 93% 93% 80% 82% 75% 82.5% 70% 60% 50% Reperfusion DTB <= 90 (Direct) White Black Hispanic ACTION Registry -GWTG 2008 data

13 From Now to 2050: A Much More Diverse Nation Non hispanic, Single race White Black American Indian/Alaska Native 2+ Races Hispanic Asian Native Hawaiian/Other Pacific Islander U.S. Census, 2009.

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16 Rodgers GP et al., ACC 2009 Survey Results and Recommendations: Addressing the Cardiology Workforce Crisis: A Report of the ACC Board of Trustees Workforce Task Force, JACC. 2009;54; Supply and Demand for General Cardiologists

17 Distribution of Hispanic Cardiologists and Population Rodgers GP et al., ACC 2009 Survey Results and Recommendations: Addressing the Cardiology Workforce Crisis: A Report of the ACC Board of Trustees Workforce Task Force, JACC. 2009;54;

18 Rodgers GP et al., ACC 2009 Survey Results and Recommendations: Addressing the Cardiology Workforce Crisis: A Report of the ACC Board of Trustees Workforce Task Force, JACC. 2009;54; Recommendations of Cardiovascular Workforce Report Relevant to Disparities Expand team-based care Recommendation Identify and implement best practices for effective and efficient care to these underserved communities Develop outreach programs to target underrepresented minorities in medical school and internal medicine programs and provide financial support Resources for cultural proficiency education in medical school, residency, and continuing education should be increased

19 Do Clinically Similar Patients Receive Different Care Based on Race/Ethnicity? Web-based survey of 344 cardiologists Lurie N et al., Racial and Ethnic Disparities in Care: The Perspectives of Cardiologists, Circulation. 2005;111:

20 U.S. Physicians Implementing Tools Aimed at Reducing Racial/Ethnic Disparities, 2008 Practice provides interpreter services 55.8% Practice provides patient-education materials in languages other than English 40.1% While nearly half of U. S. physicians identify language or cultural communication barriers as obstacles to providing highquality care, physician adoption of practices to overcome such barriers is modest and Physician received training in minority health 40.3% Physician receives reports on own patients demographic characteristics Information technology to access patients preferred uneven language is available and routinely used Physician receives reports on quality of care for own minority patients 23.2% 7.3% 11.8% HSC 2008 Health Tracking Physician Survey as reported in Reschovsky JD and Boukus ER, Center

21 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 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

22 Information about a patient s race or ethnicity: Should NOT be used to infer information about health-related values or beliefs; Should be used for detecting disparities, optimizing the effectiveness of qualityimprovement, and reaching out to local community March 4, 2010.

23 What Are the Keys to Reducing Disparities? Performance measure-based quality improvement Provider/patient education Team care

24 Proposed credo Pathway to CVD Outcome Equity

25 IOM Recommended Standardized Collection of Race, Ethnicity, and Language Need Institute of Medicine, Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement, 2009.

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27 Acute STEMI-NSTEMI Care by Gender 100% 94% 90% 80% 80% 76% 80% 77% % of Admissions 70% 60% 50% 40% 30% 45% 23% 45% 20% 10% 0% Clopidogrel GP Iib IIIa Inhibitor Reperfusion Time to PCI < 90 min Male Female

28 credo Initiatives: Next Steps Training for NCDR sites on collecting race, ethnicity, and language data Keeping PACE: ACS PI-CME Initiative Dissemination of educational tools and resources to ACC members Development of credo website Development of patient education tools/advisory group Hypertension PI-CME and research initiative

29 Keeping PACE: Patient-centered ACS Care Education

30 Program Support Major independent educational grant support for Keeping PACE provided by Bristol-Myers Squibb/sanofi Pharmaceuticals Partnership Additional independent educational grant support provided by Daiichi Sankyo, Inc. and Lilly USA, LLC, Pfizer, and Schering Corporation

31 credo Arm of Keeping PACE Stage A: Review performance data stratified by race/ethnicity from associated hospital participating in ACTION-GWTG Registry Stage B: Implement Educational Plan Live local meeting reviewing performance measures and tools for improving clinical care and redressing disparities Stage C: Re-examine performance data from associated hospital 31

32 We must not see any person as an abstraction. Instead we must see in every person a universe with its own secrets, with its own treasures, with its own sources of anguish, and with some measure of triumph. Elie Wiesel from The Nazi Doctors and the Nuremberg Code

33 Questions

34 For more information about credo, Contact me: Thanks!!