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Disparities in Cardiac Care for Patients With Complex Cardiovascular Care Needs

Leeper, Barbara MN, RN, CNS M-S, CCRN, FAHA; Centeno, Mae DNP, RN, ACNS-BC, CCRN, CCNS

The Journal of Cardiovascular Nursing: March/April 2012 - Volume 27 - Issue 2 - p 114–119
doi: 10.1097/JCN.0b013e318239f4c1
ARTICLES
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The United States continues to have a prevailing public health problem related to disparities in healthcare. Factors contributing to disparities include ethnicity, gender, socioeconomic status, educational level, geographic location, and hospital characteristics. In cardiovascular care, gaps in care have been associated with lack of conformity to evidence-based therapies known to improve clinical outcomes, including survival, quality of life, and freedom from rehospitalization. Specifically, there are disparities in use of a number of cardiovascular life-saving procedures including cardiac catheterization, percutaneous coronary intervention, coronary artery bypass surgery, and implantation of defibrillators and cardiac resynchronization devices. The purpose of this article was to illustrate the range of disparities that exist in relation to management of patients with acute coronary syndromes, interventional cardiology procedures, cardiac surgery, heart failure, and device implantation. Because the impact on patient outcomes is high, potential interventions to address disparities will be provided.

Barbara Leeper, MN, RN, CNS M-S, CCRN, FAHA Clinical Nurse Specialist, Cardiovascular Services, Baylor University Medical Center, Dallas, Texas.

Mae Centeno, DNP, RN, ACNS-BC, CCRN, CCNS Program Manager/Clinical Nurse Specialist, Heart Failure and Pulmonary Hypertension Outpatient Clinic, Baylor University Medical Center, Dallas, Texas.

The authors have no funding or conflicts of interest to disclose.

Correspondence Barbara Leeper, MN, RN, CNS M-S, CCRN, FAHA, 3500 Gaston Ave, Dallas, TX 75246 (bobbi.leeper@baylorhealth.edu).

Aprevailing public health problem for the United States is disparities in cardiac healthcare. Issues associated with these disparities are wide ranging and include patient factors and hospital characteristics. Patient factors include ethnicity, gender, socioeconomic status, educational level, and geographic location.1 Hospital factors include bed size, geographic location, and capability to perform coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), and cardiac transplantation procedures.1 Although many researchers have identified disparities in cardiovascular care, the reasons for these disparities are not well understood.

In 2006, Mensah and Dunbar2 presented a strategic framework for addressing disparities in cardiovascular health. Their framework incorporated 6 strategic imperatives with 10 focal areas and multiple targeted settings (Table 1).2 Despite this attention to cardiovascular health disparities, there continue to be disparities in healthcare related to use of medication therapies and invasive procedures including cardiac catheterization, PCI, CABG surgery, and implantation of cardiac devices such as implantable defibrillators and cardiac resynchronization devices.3 The purposes of this article were to illustrate the disparities that exist in patients with cardiovascular diseases and to suggest interventions aimed at decreasing gaps in life-saving care delivery.

TABLE 1

TABLE 1

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Acute Coronary Syndrome

Age, gender, and ethnicity are important variables in prehospital delay of people seeking treatments for symptoms of acute coronary syndrome. For example, women delay longer than men when seeking treatment for acute myocardial infarction (AMI)4 and African American women delay longer than white women.5,6 However, gender and race may not be the primary factors in healthcare disparity. Using self-reported data from 509 African American and 500 white women who were interviewed 4 to 6 months after AMI, investigators found no significant differences by race in prehospital delay time, but eligibility for public insurance was a significant predictor for prehospital delay in African American women compared with white women (odds ratio [OR], 2.3).7 When response behaviors to chest pain by American Indian women participating in the Inter-Tribal Heart Project were assessed, differences in response to crushing chest pain lasting longer than 15 minutes were found.8 Sixty-eight percent reported that they would immediately seek healthcare, whereas 32% would take passive action including to sit down and wait until it passed. The latter group was younger (<45 years) and had less than a high school education.8

In addition to prehospital delay disparities, treatment disparities also exist based on race. In a retrospective study of patients experiencing AMI across 81 acute care Veterans Administration hospitals, African American and white patients received β-blockers equally, but African American patients were more likely to receive aspirin (86.8% vs 82.0%; P < .05) and trended to receive angiotensin-converting enzyme (ACE) inhibitors (55.7% vs 49.6%; P = .07) at discharge.9 However, African American patients were less likely to receive fibrinolytic therapy at the time of arrival (32.4% vs 48.2%; P < .01). In this review, there were no differences by race in refusal to receive and rates of percutaneous transluminal coronary angioplasty.9 In the Cardiovascular Cooperative Project, 130 709 white patients were compared with 8286 African American patients admitted with AMI for rates of 6 treatments including reperfusion (fibrinolytics vs PCI) within 6 hours of presentation, aspirin and β-blockers during hospitalization, cardiac catheterization within 30 days of admission, PCI within 30 days of admission, and CABG surgery within 30 days.10 African American patients were less likely to receive all therapies except aspirin. Conversely, African American patients received β-blockers in the hospital more often than white patients did. The authors concluded that clinical variables such as hypertension or diabetes affected treatment decisions equally for whites and African Americans.10

Lipid measurement and cardioprotective medications are important risk factor reduction interventions for patients with cardiovascular disease. Investigators conducted a retrospective review of medical records of 1046 African Americans and 22 077 whites treated for cardiovascular disease in outpatient medical practices across 23 states between January 1995 and March 1998.11 African American patients were younger, more likely to be women, and had more comorbid conditions of heart failure, hypertension, and diabetes. Low-density lipoprotein cholesterol testing rate for white men was 1.3 times higher than the rate for African American men and 1.4 times higher than that for African American women. African Americans were prescribed lipid-lowering agents less than half of the time, whereas almost 60% of white men were prescribed lipid-lowering agents. Thirty-five percent of white men who were tested and treated achieved their low-density lipoprotein cholesterol goal, compared with 21% of African American men. Although researchers concluded that there were racial disparities in lipid management, the rationale for racial disparities was not assessed.11 In another study, racial differences existed in the prescription of cardioprotective medications.12 Investigators queried the Veterans’ Integrated Service Network database for prescription rates for aspirin, β-blockers, statins, and ACE inhibitors. A total of 474 565 patient records (117 071 African Americans and 357 494 whites) were analyzed. African American patients were prescribed β-blockers, statins, and ACE inhibitors less often than their white counterparts were. In addition, African American patients underwent CABG procedures less often than white patients did.12

Finally, patients with acute coronary syndromes may experience disparities in receiving cardiac catheterization and PCI. In a retrospective review using the Pennsylvania Health Care Cost Containment Council database of 16 985 patients who experienced AMI during January 2003 through June 2004, African Americans were less likely than whites to undergo a PCI procedure at any time during their hospitalization (55.8% vs 59.9%, P < .02).13 After adjusting for clinical issues, insurance, and hospital characteristics, African American ethnicity was no longer associated with the rate of PCI procedures (OR, 0.89, 95% confidence interval [CI], 0.76–1.04; P = NS).13 However, after adjustment for clinical issues, insurance, and hospital characteristics, patients in the lowest income quintile had a significantly lower likelihood of PCI procedures (OR, 0.90; 95% CI, 0.82–0.98; P < .02).13

In a review of health disparities affecting outcomes of African American women undergoing PCI procedures, only 56% had private health insurance coverage, and 21% had Medicaid coverage.14 Uninsured African American women were less likely to undergo PCI procedures. Physician bias of the patient’s insurance state was thought to contribute to the PCI disparity. Moreover, hospitals without onsite revascularization capability were less likely to recommend uninsured patients for PCI procedures.14 Health literacy and level of education completed may directly affect the quality of healthcare received because knowledge impacts the ability of individuals to comprehend written materials, numerical instructions, and compliance. Furthermore, authors felt that patients may be unable to make informed choices or even challenge physician providers about available treatment options because of a low self-esteem or a low sense of empowerment.14 Strategies to improve health literacy for providers and patients are outlined in Table 2.

TABLE 2

TABLE 2

In patients treated for acute coronary syndromes, outcomes of treatment differed by factors known to be associated with disparities in care. African American and non–African American patients who had undergone PCI procedures and received drug-eluding stents were followed for 1 year postprocedure for major cardiac events (including AMI, death, and target vessel revascularization).15 During the follow-up period, African Americans had significantly higher rates of cardiac adverse events (17.7% African American vs 12.4% non–African American, P < .001), including higher rates of death, AMI, and target vessel revascularization.15 In addition, in-stent thrombosis was higher in African American patients (2.5% vs 0.7% non–African American, P < .001) in univariate analysis. After multivariate analysis adjusting for socioeconomic status, African American race was not a predictor of major cardiac adverse events; thus, investigators concluded that traditional risk factors and socioeconomic status accounted for racial disparity.15

In 2 studies of door-to-balloon (D2B) times in patients with ST-segment elevation myocardial infarction (STEMI), investigators assessed race and delays in reperfusion.16,17 In the first report, published in 2004, African American patients with STEMI were more likely to have reperfusion delays compared with white patients.16 In a second report of 2875 patients with STEMI who underwent primary PCI, the median D2B time decreased from 101.0 minutes in 2004–2005 to 73 minutes in 2007–2008. Although both white and African American patients experienced clinically significant decreases in the D2B times, the most significant reduction was observed in African American patients.16 Investigators concluded that racial disparities in D2B times significantly narrowed over time.16 These results reflect a capability of hospitals to improve quality of care and, concomitantly, diminish racial disparity.

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Coronary Artery Bypass Surgery

Researchers have demonstrated the presence of disparities related to race and gender in patients receiving CABG surgery. Edwards et al18 reviewed gender differences in coronary artery revascularization between 1993 and 2003. The percentage of women having CABG surgery was unchanged over time, but when age was considered, the percentage of women undergoing CABG surgery significantly declined between 1993 and 2003 (OR, 0.74; 95% CI, 0.52–1.06; P < .02). Investigators also noted that women were more likely to have preoperative comorbidities, including hypertension and heart failure, which increased with age.18 In another study, African American patients were less likely to undergo CABG procedures within 90 days after AMI (6.9% vs 12.5%; P < .001), even when high-risk coronary subgroups were examined. However, there were no differences in the refusal rates between African American and white patients.9

Although the rationale for racial disparities in patients needing CABG surgery is not well understood, access to healthcare providers may play a role.19 When clinical data on Hispanic, African American, and white patients who underwent CABG procedures were analyzed, Hispanics were 3 times more likely to be treated by lower quality surgeons (bottom decile) and African American and white patients were treated similarly by surgeons in the top and bottom quality decile groups.20 Although the reasons for differences are unknown, the authors concluded that there were differences in access to higher quality surgeons by Hispanics.20 Finally, CABG disparities could be related to physician-patient communication.19 African American patients may be more likely to misunderstand the risks and benefits of CABG surgery and less likely to have a friend or a family member who had undergone a CABG procedure.19

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Heart Failure

Many disparities have been found, at the patient and hospital level, in patients being treated for heart failure. Specifically, in one large performance improvement database program, heart failure prescription rates were reduced in older people, even after controlling for other factors associated with drug utilization.21 Despite evidence that quality care has improved over time, persistent disparities in cardiovascular care related to age, gender, race/ethnicity, and hospital characteristics, impact morbidity and mortality rates.22,23

Although the prevalence of heart failure increases with age, age itself should not be a factor in the provision of evidenced-based heart failure therapies. When hospitalization rates were compared among patients 65 years or older in 4 large regions of the United States, they were lowest in the West.24 In another study examining 30-day readmission rates among health referral regions, a similar pattern was found, with parts of Mississippi, River Valley, and segments of Appalachia having the highest readmission rates.25 Such study results provide evidence for the need to reduce geographic differences of heart failure care among older people.

There is evidence demonstrating a lower utilization of evidence-based medical practices in the management of elderly patients with cardiovascular disease. Several investigators have used the Get With The Guidelines–Heart Failure registry to explore adherence to evidence-based heart failure care.26–28 These investigators have found that evidence-based recommendations were frequently used for elderly patients with heart failure, including patients older than 85 years. In addition, in-hospital mortality rates were relatively low in elderly heart failure patients compared with higher in-hospital mortality rates in very old patients hospitalized for acute coronary syndromes. Elderly patients with heart failure were found to have a low use of procedures, including rare use of implantable cardioverter defibrillators (ICD) in patients with left ventricular ejection fractions of 30% or less.21 Elderly heart failure patients with atrial fibrillation were found to have warfarin prescribed less often, indicating nonadherence to the guidelines.26 And finally, the use of the American College of Cardiology/American Heart Association guideline–recommended aldosterone therapy in hospitalized patients was found to be higher in younger patients with heart failure, indicating that evidenced-based practices may not be used in older people, potentially reflecting disparities of care.27 Race/ethnicity in patients with heart failure has been studied to determine if disparities in care exist. Whereas African Americans were more likely to receive a prescription for an aldosterone antagonist at hospital discharge,27 they were less likely to receive warfarin therapy for atrial fibrillation.26 Importantly, race disparities in heart failure care may be decreasing. In 251 hospitals, provision of guideline-based care was comparable among African American, Hispanic, and white patients.27

Heart failure delivery systems may minimize disparities in care. A study by Hebert et al29 examined the impact of standardized care provided through a heart failure disease management program on race/ethnicity and on mortality of patients with heart failure. Mortality did not differ significantly between African Americans and whites; however, white women had significantly lower risk of death than white men did.29 When disparities in access to care were minimized through better patient management from standardized medical follow-up, African American patients had better outcomes.29 This suggests that equal access to care may be useful in reducing racial disparities associated with access to care and mortality.

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Device Therapy

It has been proposed that limited access to healthcare may lead to racial disparity when new technologies become available. Farmer et al30 used data from the National Cardiovascular Data ICD Registry for the purpose of identifying ethnic/racial disparities in the use of cardiac resynchronization therapy–defibrillator (CRT-D). Registry populations included white, African American, and Hispanic patients who received either an ICD or CRT-D from January 2005 to April 2007. Two analyses were conducted: one looking at those patients who received either an ICD or a CRT-D and the second looking at those who may have received a CRT-D outside the published guidelines. A total of 22 205 individuals received 1 of the 2 devices and 27 165 individuals received CRT-D devices. A multivariate analysis revealed that CRT-D–eligible African American patients (OR, 0.84; 95% CI, 0.75–0.95; P < .004) and Hispanic patients (OR, 0.83; 95% CI, 0.71–0.99; P < .033) were less likely to receive a CRT-D than were white patients.30 In addition, African American and Hispanic patients were less likely to receive a device outside the published guidelines when compared with white patients. African American and Hispanic patients were more likely to meet established criteria when compared with white patients.30 The potential impact that socioeconomic and insurance status may have had in this group of patients was not explored.

Several studies have demonstrated that gender and race affect the implantation of ICDs despite a goal of equal availability.7,31–33 MacFadden and colleagues34 studied what influence age and comorbidities might have on gender-specific ICD use. A retrospective analysis of patients hospitalized in Ontario, Canada, between April 1998 through March 2007 examined the use of ICDs in patients after cardiac arrest (secondary prevention) and patients with AMI and heart failure (primary prevention). Implantable cardioverter defibrillators were implanted in 9246 patients for secondary prevention (age, 66.3 ± 14.3 years), with men more likely than women to receive an ICD, with an adjusted hazard ratio (HR) of 1.92 (95% CI, 1.66–2.23).34 There were 105 516 patients in the AMI group (age, 68.3 ± 12.7 years). In this group, men were 3 times more likely to receive ICDs, with an adjusted HR of 3.00 (95% CI, 2.53–3.55). Lastly, there were 62 100 patients with heart failure (age, 76.2 ± 12.0 years), 52% of whom were women. Again, ICDs were implanted more often in men, with an adjusted HR of 3.01 (95% CI, 2.59–3.50).34 Odds of having an ICD implanted increased over time for both genders; however, men continued to have more devices implanted more often than did women. Age and comorbidities did not account for gender differences. It is apparent that gender disparities for primary prevention are greater than disparities for secondary prevention.34

Although evidenced-based care has improved among hospitalized patients, there are interesting disparities that were reported in recent years. Hospitals more likely to supply ICD therapy were also more likely to offer PCI and CABG surgeries and heart transplantation services and to be larger in size,35 suggesting that quality of care for some heart failure therapies may be related to how quickly hospitals adopt more evidence-based heart failure therapies and/or scope of services.

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Conclusions

Collaborative management of patients with coronary artery disease or heart failure may be a contributory factor in improving quality of care and reducing disparities.36 The likelihood of specialty referral for women and patients who are African American, Hispanic, or uninsured or who receive care at community health centers is less.36 Differences have been found in specialty consultation based on demographic characteristics and location of care.37 Women and patients from community centers were less likely to obtain initial and follow-up consultations than male and female patients in hospital-based clinics for coronary artery disease and heart failure care. The relationship between primary care and specialty care is valuable in providing additional monitoring of patients and advice regarding current therapies and guidelines.

In recent years, there has been a targeted effort on the part of a few healthcare systems to implement chronic disease management programs focusing on underserved patient populations. These programs have targeted primarily heart failure and diabetes management, providing access to quality healthcare, effective patient/family education, and close follow-up, which ultimately aims to improve the patients’ self-management of their disease. Peterson et al38 suggest implementing disease management programs using multidisciplinary teams along with critical paths and toolkits to assist with patient education. The use of critical paths standardize the care process, and using standardized order sets also contributes to the reduction in variation among practitioners. Examination of the discharge process represents another opportunity to reduce variation in practice. Developing a transitional care process has been shown to improve the handoff between hospital care and the transition to home with an emphasis on patient family education can contribute to preventing readmissions.38

Disparities in the management of patients with complex cardiac disease continue to exist. The common themes include financial ability, insurance status, and access to quality care by healthcare providers using evidenced-based practices. Health literacy causes many problems ranging from the inability to understand healthcare provider information regarding disease management to challenges reading and understanding patient/family education materials. This limits the patient’s ability to act on the information that is provided. Strategies put forth by Mensah and Dunbar2 and Kamble14 offer actionable solutions that would address many of these issues. Although work done to date reveals some progress, there still are significant opportunities to reduce existing disparities in the management of patients with cardiovascular disease.

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What’s New and Important

  • Disparities in the management of patients with complex cardiac disease continue to exist. Strategies have been suggested to address many of the disparities, but challenges continue to exist. Addressing healthcare illiteracy would break some of the barriers.
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Clinical Pearl

  • Disparities in the management of patients with complex cardiac disease continue to exist. The common themes include financial ability and insurance status and access to quality care by healthcare providers using evidence-based practices. Healthcare illiteracy causes many problems from the inability to understand healthcare provider information regarding their disease management process as well challenges with reading and understanding patient/family education materials. This limits the patient’s ability to act on the information that is provided. Development of appropriate educational level (grade 5–6) patient and family education materials can help address this challenge. The use of multiple media types is also helpful to bridge this gap.
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REFERENCES

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21. Forman DE, Cannon CP, Hernandez AF, et al.. Influence of age on the management of heart failure: findings from Get With the Guidelines–Heart Failure. Am Heart J. 2009; 157 (6): 1010–1017.
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30. Farmer SA, Kirkpatrick JN, Heidenreich PA, et al.. Ethnic and racial disparities in cardiac resynchronization therapy. Heart Rhythm. 2009; 6: 325–331.
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Keywords:

age; cardiovascular disease; disparities; ethnicity; gender

© 2012 Lippincott Williams & Wilkins, Inc.