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Racial Disparities in Cardiac Care (transcript)
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(ANNOUNCER)                   

Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association; an association of independent, locally-operated and community-based Blue Cross and Blue Shield plans, supporting solutions that make quality, affordable healthcare available to all Americans.

 

(MUSIC)

 

(DR. PETER SALGO)          

Welcome to Second Opinion, where each week you get to see firsthand how some of the country’s leading healthcare professionals tackle health issues that are important to you.  Each week our studio guests are put on the spot with medical cases based on real life experiences.  By the end of the program, you’ll learn the outcome of this week’s case and you’ll be better able to take charge of your own healthcare.  I’m your host, Dr. Peter Salgo, and today our panel includes Second Opinion primary care physician Dr. Lisa Harris from the University of Rochester Medical Center, Dr. Mona Fouad from the University of Alabama, Dr. John Stone from Creighton University, and Dr. Gladys Velarde from the University of Rochester Medical Center.  Now that you’ve met everybody, it’s time to get right to work.  Our case today is going to be a little bit unusual; it begins in a restaurant – usually it begins in your office – and it involves not one doctor but two doctors.  These doctors are old friends who went to medical school together.  One is a primary care physician and the other one, named Janice, is a cardiologist.  She has a busy cardiology practice, she’s well-respected by her patients and by her peers, and at lunch, she’s telling her friend that she’s becoming increasingly concerned about cardiac care for her African American patients.  Janice’s lunch companion, who’s a primary care physician, cites his own frustrations in working with patients – and this is a word that he uses now – ‘lifestyle issues’ increase their risk for heart disease.  Now, Lisa, you’re a primary care physician.  What are these lifestyle issues?  Are there lifestyle issues in terms of African American patients and heart disease?

 

(DR. LISA HARRIS)

Well, absolutely. I think there are some traditional types of ethnic food that we tend to indulge in as African Americans that can be concerning and increase your risk with respect to high fat and high cholesterol.

 

(DR. PETER SALGO)

Are there some genetic factors in African Americans for heart disease that they have to know about?

 

(DR. LISA HARRIS)

Well, we know that diabetes, hypertension and cardiovascular disease tend to be in higher incidence in African Americans.

 

(DR. LISA HARRIS)

Why don’t we try to divide these risk factors into things you can change, maybe lifestyle things and things you can’t change, things you’re born with? Are there some things specific to African Americans that they need to consider?

 

(DR. MONA FOUAD)

They need to consider for sure if somebody comes in with a very strong family history of hypertension, heart disease and diabetes.  And they’re starting to have high blood pressure at a younger age so they need to advise African Americans to check their blood pressure at even a younger age than other people.

 

 

(DR. PETER SALGO)

But you do that for anybody, and you do that for everybody – is there something specifics?  These two doctors are talking about the problems in their African American patients; is there something specific to African Americans on the non-modifiable side, the genetic issues?

 

(DR. GLADYS VELARDE)

That’s the issue.  When you say ‘non-modifiable’, that’s where we have a problem because it is modifiable even though it has a genetic background.

 

(DR. PETER SALGO)

Yes, but on a population –

 

(DR. GLADYS VELARDE)

Yes, on a population base, yes.

 

(DR. PETER SALGO)

You can say African Americans seem more pre-disposed to these problems than others and they’re modifiable in the sense that you would like to intervene and reduce their risks to which the genes are making them pre-disposed.

 

(DR. JOHN STONE)

It depends on what you mean by ‘pre-disposed’. If you mean some kind of intrinsic, biological inclination, I think that’s very, very unclear.   We know that they have more hypertension but in terms of the stress hypothesis of multiple years of stress-related to race and negative social circumstances, all these things influence blood pressure through mechanisms that are coming out.

 

(DR. PETER SALGO)

Well, I’ll tell you, Janice is sensitive to this; she knows that lifestyle plays an important role in heart disease, but she’s concerned about something else.  Here’s the phrase that she’s using; she calls it ‘disparities in outcomes’ for African Americans with heart disease.  What is she talking about?

 

(DR. MONA FOUAD)

That’s a different thing.  There is the disparity, you can say higher incidence of hypertension but if you have two people that have high blood pressure but you have a non-African American or people that have access to care versus non-access to care and both of them go to the doctor’s, the person that is an African American, we’re seeing their outcomes as of treatment is going to be different than a non-African American. That’s what she’s talking about.

 

(DR. PETER SALGO)

All right, let’s take genetics out of it; let’s take family history out of it.  We’ll take two people, African American and non-African American with the same problem.  She’s arguing that the African Americans will have different outcomes than the non-African Americans.  What is that about?  Does that happen?

 

(DR. GLADYS VELARDE)

That is absolutely correct.  I think there is undeniable data that can support what Janice is talking about, that unfortunately we have a disparity of outcomes when it comes to cardiovascular disease when it comes to certain racial groups.  And when we talk about African Americans, this is absolutely correct, whether you’re talking about stroke, heart failure, or myocardial infarctions.

 

(DR. PETER SALGO)

Heart attacks.

(DR. GLADYS VELARDE)

Yes, heart attacks.

 

(DR. JOHN STONE)

And survival.

 

(DR. GLADYS VELARDE)

And survival, right.

 

(DR. MONA FOUAD)

When you talk about outcomes, there are several reasons for that.  Some reasons can be due to the person themselves, the patient themselves – that they may not be compliant with their medications or they’re not changing their lifestyle or their eating habits.  But we also have not to forget that it may be the physicians themselves – they’re not explaining or following or not treating the patients equally.  There was also a study where they taped interactions between physicians and African American patients and white patients.  They looked at the interactions of differences of care delivery based on gender and racial, and the worst group was African American women; they did not get equal care compared to the white men, white women, and African American men.

 

(DR. LISA HARRIS)

And then you have to compound that with the Institute of Medicine findings that says there is just a disparity with the way we communicate with patients and that we speak a language that’s totally different.  And regardless of your ethnicity and your educational status, patients don’t understand the instructions that we give them.   So you compound all of that together and you see a huge disparity in outcome.

 

(DR. PETER SALGO)

African American women, for example, die of heart disease at 1.4, 1.5 times the rate that Caucasian women do.

 

(DR. MONA FOUAD)

And what about stroke?  Stroke is even higher.

 

(DR. JOHN STONE)

Yes.

 

(DR. GLADYS VELARDE)

So there’s a gender difference and then on top of that there’s a racial difference.

 

(DR. JOHN STONE)

And I want to add this other point; these same kinds of studies show that minority women, minority patients generally physicians tend to have less dialogue with them.  They tend to listen to them less, they give them more instructions. 

 

(DR. PETER SALGO)

That’s interesting because what Janice says her hospital is doing – I guess this may have been what brought this up at lunch, but her hospital is working on what they’re calling an ‘equity report’.  They’re tracking racial/ethnic disparities in cardiac care.  What is she talking about here?  Is there any reason really to believe race makes any difference in the delivery of cardiac care?  Are doctors doing different things based on this?

 

 

(DR. JOHN STONE)

Well, first of all, we shouldn’t just say doctors because there are all kinds of things in the system that influence care, but we have – back to the Institute of Medicine original report where they looked at lots of studies showing inequalities in care.  This has to do with quality improvement; are we, for example, is somebody with a myocardial infarction if they’re black or white, are they as likely to get beta blockers after a myocardial infarction?

 

(DR. PETER SALGO)

Are they?

 

(DR. JOHN STONE)

No.

 

(DR. GLADYS VELARDE)

No, for African Americans they’re not.   ACE inhibitors they’re not.  Let me go back to the outcomes issue.  First of all, undeniably accepted by the medical community, the outcomes are different – they’re worse.

 

(DR. JOHN STONE)

No question.

 

(DR. GLADYS VELARDE)

But the results – and outcomes are results – are the consequences of steps.  And those steps have to do with access, delivery, personal issues, socioeconomic –

 

(DR. MONA FOUAD)

Health insurance – It’s very complicated and complex.

 

(DR. JOHN STONE)

But if you correct for all those things, large studies – huge studies – you still have these inequalities.  After you adjust for socioeconomic class, insurance, whatever – they’re not getting the medications at the same frequency.

 

(DR. PETER SALGO)

She’s been talking to her colleagues and they’re convinced they’re treating everyone the same.

 

(DR. JOHN STONE)

Can I jump in here?

 

(DR. PETER SALGO)

Please.

 

(DR. JOHN STONE)

Everybody wants to treat everybody equally for their particular problems. We want to know what the data is.

 

(DR. LISA HARRIS)

We don’t teach house staff, we don’t teach medical residents about cultural differences.  If I go into an office or have a medical student sit down with me, they have absolutely no idea what happens Sunday afternoon in most African American households.  It has to do with food and meals, it has to do with love and family and support and changing that modality – when I talk to my patients and say ‘You really have to cut back on the cornbread and the grits and the fried chicken and the neck bones and you can’t cook your greens with salt pork’, they’re like ‘You want me to eat like white people?’  That’s the response you get.

 

(DR. PETER SALGO)

And how do you answer that question?

 

(DR. LISA HARRIS)

Yes.   Yes I do.  

 

(DR. PETER SALGO)

Is that well received?

 

(DR. MONA FOUAD)

I’m glad you brought this up because our medical students and our residents are not trained to work except with people like them. 

 

(DR. GLADYS VELARDE)

When you treat some minority groups - and I think African Americans and the Latino community will fit this mode as I think many Asian families do as well – you treat the patient, you treat the family.   Or you treat the family and you treat the patient.

 

(DR. LISA HARRIS)

That’s right.

 

(DR. GLADYS VELARDE)

It’s so interesting and the fact that we’re involved in medical education and sending that message out to future doctors is so invaluable.   What you’re saying this communication – and that’s cultural sensitivity.

 

(DR. PETER SALGO)

But I’m hearing an unspoken ‘they’.  They don’t eat right, they don’t take their meds right, they aren’t doing this; is there an unconscious, negative stereotype going on here?

 

(DR. MONA FOUAD)

We also said not they, we said that the physicians do not take the time to understand the lifestyle of the patients.  The physicians don’t take the time to ask the questions to probe.  We’re not just saying “they”.  There are groups; the physicians have a role, the patients have a role, and the system has a role.

 

(DR. LISA HARRIS)

There has to be an idea that the community trusts the physicians and there has been a lot of distrust among physicians.  If you look traditionally among African Americans in the United States, during the slavery era and shortly thereafter, we weren’t allowed to see physicians.  You saw the nurse or the midwife or the pharmacist or whatever.  When we were allowed to see physicians, what did you get?  The Tuskegee experiment.  So there’s a lot of mistrust in the community so I’ll listen to what the doctor says but then I’ll ask my family and the rest of my community, is this something I really should be doing? 

 

(DR. PETER SALGO)
Right.  I hear you.

 

(DR. LISA HARRIS)

We have to make sure the patients buy into what we’re saying, and what’s the evidence?  What is the evidence? What do we use for standards, the Framingham study?  Give me a break!  A small Caucasian group of people in Massachusetts and we’re using that to determine cardiovascular risk for African Americans in this country?

 

(DR. PETER SALGO)

Let me turn this over, though.  If you’re saying patients have to trust their doctors, that puts a burden on doctors of course to be worthy of that trust.  But I’m asking, is it subliminally that doctors don’t trust their patients and they don’t trust some patients more than they don’t trust other patients, African Americans in point?

 

(DR. MONA FOUAD)

Yes, for sure.   Because I ask the physicians when I was doing the study for compliance for hypertension in (Acantia) Hospital and they said ‘Good luck.  We’re trying; they’re never going to take their medicine.’  So here’s the doctor already made an assumption that they’re not going to take their medicine and there is no hope –

 

(DR. JOHN STONE)

And if they’re not going to do what they should, we’re absolved of any moral responsibility to do anything else.  It’s their problem, we can be guilt free and then we don’t have to address any of the reasons they may not be taking their medication.

 

(DR. PETER SALGO)

All of this makes very interesting, if you will, lunch discussion, but at the bottom line there’s healthcare delivery to be talking about.  And you guys were all talking about not delivering as conscientiously to African American women perhaps as to others.  Beta blockers, anti-hypertensives, in the hospital on a given day with a given patient; what’s the mechanism that this treatment doesn’t happen?  How does it fail?

 

(DR. MONA FOUAD)

Because I think it’s unintentional that nobody is making an effort to make sure I delivered my instructions the way I should; I made sure that this patient understand the regimen.  It’s just like everybody’s in a hurry, everybody’s going to give them that, and is there no special effort for looking at every human being as a human and a person, that they maybe have a difference than me.

 

(DR. PETER SALGO)

I’m sorry.  Everybody’s in a hurry for every patient – are doctors in more of a hurry for African American patients than Caucasian patients?

 

(DR. JOHN STONE)

I’m not sure, but they may be.

 

(DR. PETER SALGO)

Why?  That’s a terrible thing to say, but –

 

(DR. JOHN STONE)

Yeah, but we do have data, for example, that we physicians tend to dialogue less with minority patients and African American patients.  It takes more time to have a dialogue with patients, to have a sincere in-depth conversation and so then we may fall back on the suggestions that would be beyond our stereotypes and biases – unconsciously, of course; I think everybody wants to give good care.

 

 

(DR. LISA HARRIS)

If you have a patient that says ‘I have a couple of kids, I’m working, my husband or significant other is working, I have to make sure that the kids get to daycare, get to school or wherever and that the house is running and you tell me that I’ve had a mild heart attack and I need to cut back on salt – okay fine.   That goes to the bottom of the burner because everything – life in of itself – takes precedence.

 

(DR. JOHN STONE)

Can I jump in here?  I think the physicians listening to this are going to say ‘Of course we shouldn’t be doing that.  We don’t do that’.  But actually we want to say ‘We might be doing it and we don’t know.’

 

(DR. PETER SALGO)

How about I make it even stronger?  Actually you do.

 

(DR. GLADYS VELARDE)

Exactly.  Exactly.

 

(DR. JOHN STONE)

Well yeah, the data says generally we do.

 

(DR. GLADYS VELARDE)

And that’s what is not accepted and that’s what –

 

(DR. PETER SALGO)

And isn’t that the topic of what – isn’t that what Janice is trying to get at?

 

(DR. LISA HARRIS)

That is what she’s trying to get at.

 

(DR. GLADYS VELARDE)

If you don’t accept you, you can’t move on.

 

(DR. PETER SALGO)

Haven’t we just drilled down into what Janice is talking about?   Doctors think they’re doing something but they’re not getting it done.

 

(DR. LISA HARRIS)

That’s why data is so important.

 

(DR. PETER SALGO)

Janice, by the way, persuaded her colleagues that knowing the facts about how they deliver cardiac care is important and is playing not only a major role in healthcare in the community but in cost-effective healthcare in the community.  Is there a way in which a disparity in healthcare delivery to minorities, to women affects people not in that minority group?  That is to say, pick a 55-year old Caucasian male who’s listening to this and saying ‘Oh my gosh, African American women not getting good health care.  How does that affect me?’

 

(DR. LISA HARRIS)

Is he an employer? Maybe that’s someone that works for him that is now an impact on the workforce.   Is this someone –

 

(DR. MONA FOUAD)

And an impact on the cost of healthcare.

 

(DR. PETER SALGO)

How so?

 

(DR. MONA FOUAD)

This patient is going to come back to the hospital if they were not getting the right medications when they leave.

 

(DR. GLADYS VELARDE)

It affects all of us.

 

(DR. MONA FOUAD)

Yes, the whole community.

 

(DR. LISA HARRIS)

And we’re all connected.

 

(DR. MONA FOUAD)

Yes, a healthy community, a healthy workforce, a healthy economy - it will elevate everybody.

 

(DR. PETER SALGO)

So the rising tide lifts all boats.

 

(DR. LISA HARRIS)

That’s right.

 

(DR. PETER SALGO)

Let’s take a moment here and sum up what we’ve been discussing.  The notion of disparities in healthcare is an uncomfortable subject for most of us.  However, acknowledging that inequities in care may exist is the first step to improving care and achieving the best possible health care for everybody, for an increasingly diverse population.  Delivering healthcare will not just save lives for some people but it’s going to save money - and we’re making this equation of healthcare, lives, money – for everybody and not just the minority populations which are adversely affected.  Is that fair?

 

(ALL VOICES)

That’s fair.

 

(DR. PETER SALGO)

Well, our case today is a bit of departure as you know; we’re not talking about someone who’s sick but we’re meeting Janice at a lunch where she’s meeting another physician and describing her concerns about racial disparities in cardiac care and her hospital’s decision to do something about it.  Several months later now, Janice reports to her friend that her hospital has completed their initial research and planning and they’re planning a program designed to improve cardiac care among minority patients.   They’re going to target providers, patients, and the community.  That sounds pretty good.

 

I want to break it down, if you will.  What can providers do to ensure that patients receive the highest quality cardiac care regardless of racial or ethnic background?  How do you make a plan like that?  Devise this.  What steps do you want to take?

 

(DR. LISA HARRIS)         

Well, one of the things you look at is quality.  If you’re looking at quality across the board for the hospital one of the things you can look at is beta blocker upon discharge.  And that fits for MI’s so every patient should have a beta blocker upon discharge – with congestive heart failure, an ACE inhibitor.   That will meet the criteria for everybody.

 

{crosstalk}

 

(DR. MONA FOUAD)

A study was done that what they did, the system gave feedback to the physicians about their patients after discharge and what happens.   When the physicians got the feedback on a periodic way, they started to improve their prescription to their patients.  Just the physician to get a report card – just a scorecard.

 

(DR. PETER SALGO)

I’m sure that went over really well.

 

(DR. MONA FOUAD)

Actually it went over pretty well because they’re unconsciously doing that; it’s nothing intentional.

 

(DR. GLADYS VELARDE)

Which goes back to having the data that says ‘This is what you’re doing’.   You touch three or four bullet points of this program that Janice is talking about; you said providers and then you said hospital – so in terms of providers or hospital, I think that getting the providers together to form a consensus and acknowledge prior gaps, I think that would be the first move.  And then develop a plan, whether it is a performance measure like applying –in a critical situation, whether it is post MI, heart failure; what are going to be your performance measures? 

 

(DR. JOHN STONE)

As part of the process, you’ve got to have a broad support for these measures because if you’re going to be talking about race and ethnicity, these are volatile issues.  People are very touchy, they’re apprehensive, the risk managers get worried, and if you don’t get community and everyone else involved in doing this, then there are going to be a lot of negative reactions and apprehension.

 

(DR. PETER SALGO)

One of my administrators says ‘You’ve got to find a metric’ –

 

(DR. LISA HARRIS)

Yeah.

 

(DR. GLADYS VELARDE)

Exactly.

 

(DR. PETER SALGO)

I don’t like the word particularly, but I know what that person’s getting at, a measure.

 

(DR. MONA FOUAD)

The other thing too that some hospitals, some systems work on is what we call ‘coordinated care’.  You know, now you have a patient to come and see a primary care physician and then they turn them to a specialist for their heart problem, and then there are never communications between that primary care physician and the specialist and the physician cannot connect those two together.   But if there is a way to do coordinated care, it’s going to be more efficient, it’s going to cut on the time like you were saying, people would know what they got and what they didn’t get, and the patient will have some more continuity when they go back to the primary care physician to continue their care.

 

(DR. LISA HARRIS)

A lot of the data – a lot of our insurance companies do metrics on physicians and give report cards and scorecards, and doing a report card that says ‘Here’s a population of patients that has coronary artery disease that are not on aspirin, that haven’t gotten beta blockers’, and that way you take away the stigma of race and ethnicity and say ‘Look at your patient population and let’s see what you’re doing.’

 

(DR. PETER SALGO)

Is it fair to let the patient off the hook?  It’s one thing to say, look we can all as caregivers and physicians do a better job.  Doesn’t the patient have some responsibility?

 

(DR. LISA HARRIS)

Absolutely.  I had a conversation with a patient two days ago that will just not take her anti-hypertensive.  And I said, ‘You know, when you have the stroke and the heart attack’ – and she just stopped and looked at me.  I said, ‘I’m not joking.  You’re in that population, you’re African American, you’re female, you’re over age 40.  You will have either one if not both.’

 

(DR. MONA FOUAD)

That’s where the community part comes in.  That’s the rest of your plan comes in because community, like we found, that they hear more from their peers and from the lifestyle stories than the physician or the nurse.

 

(DR. LISA HARRIS)

That’s right.

 

(DR. MONA FOUAD)

The physician, oh they don’t live like me and they don’t have my problems and they’re not caring about the grandchildren –

 

(DR. LISA HARRIS)

And it’s hard for them to tell –

 

(DR. MONA FOUAD)

They don’t eat the food I eat, they don’t have problems with transportation.  So what we’ve done in some of our work studies and I think you’ve done some of that, we’re trying to get the community themselves to take ownership and part of these issues.  Show them this is serious, and women or peer support educate their peers because they know the lifestyle.

 

(DR. PETER SALGO)

So help me out on this because the word ‘community’ is kind of amorphous.  Specifically what are you talking about?

 

(DR. GLADYS VELARDE)

What I think is this transferring or where there’s an interaction between the providers.  We talked about the things that providers can do and institutions can do and then, how do we bring that to the community and how can we partner?  Somewhere in the middle because when you have a resistant patient like your patient, Lisa – and I have several of those, unfortunately what you do is ‘Well, let me see what you’re doing.  What is your community?’  And maybe you have community education.

 

(DR. LISA HARRIS)

We have to think non-traditionally and out of the box because everybody’s not impoverished and doesn’t have transportation issues so are you an executive?  Do you work long hours? Is there a group or cohort of people that are like you – is there a fitness club that you go to or gym where we can do blood pressure measurements and talk about screenings and the importance of taking your medications?  The hair dresser, the nail salon, the church, the synagogue – there are lots of things when we say ‘community’, but we have to think non-traditionally.

 

(DR. JOHN STONE)

This isn’t going to take an institutional response; it’s got to be done at the more system level.

 

(DR. PETER SALGO)

All right, let’s stop for a minute and sort of sum up, again, what we’ve been discussing.  Improving cardiovascular care requires coordination, creativity, and it requires commitment by everybody.  It is a partnership among hospitals, providers, communities, families, patients – ultimately you have to play your part to change your life and get the care you deserve, and I would venture to say it’s not just for cardiac care.  It’s for lots of diseases, not just heart disease.  

 

Janice feels, by the way that her hospital is taking meaningful steps to providing the best possible cardiac care.  Is that unusual?

 

(DR. MONA FOUAD)

Every hospital is trying to be the best hospital but it’s based on their knowledge. How much, how many doctors in one hospital have this conversation like Janice?   How many of them are aware about the issue of health disparities and - ? 

 

(DR. GLADYS VELARDE)

Exactly.

 

(DR. MONA FOUAD)

How many go into their clinic that morning and say ‘I’m going to make sure if an African American or a Hispanic or an older woman comes into my office today, I’m going to take more attention’?  It doesn’t happen this way.

 

(DR. GLADYS VELARDE)

That’s the community intervention.   Do we wait for them to be referred to me, a cardiologist, or do I go out there and step out of my box and my comfort zone and say ‘I really want to make a difference here’?

 

(DR. PETER SALGO)

Well, this is an ongoing process.  We’re going to be revisiting it, I’m sure, in future editions of this broadcast.  I want to thank all of you.  We are out of time, but I hope that you continue this conversation on our website where you’ll find a transcript of this show and links to more resources.  The address is www.secondopinion-tv.org.  Again, thank you for watching and thank you all, of course, for being here.  I’m Dr. Peter Salgo, and I’ll see you next time for another Second Opinion.

 

(MUSIC)

 

(ANNOUNCER)                   

Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association, an association of independent, locally-operated and community-based Blue Cross and Blue Shield plans, supporting solutions that make quality, affordable healthcare available to all Americans.

 

(ANNOUNCER)                   

Second Opinion is produced in association with the University of Rochester Medical Center, Rochester, New York.