IMPACT OF DISPARITIES IN CARDIOVASCULAR CARE ON AFRICAN AMERICAN DEATHS Kevin Fiscella, MD, MPH University of Rochester School of Medicine & Dentistry

Background  Burgeoning health care disparities literature  Challenge of prioritizing health care disparities  Need for a common metric for evaluation

Purpose  Population impact - annual deaths  Present a simple model using black- white disparities in CVD  Estimate the number of African American CVD deaths that would be avoided/delayed if disparities in CVD care were eliminated

The Model AA deaths prevented/delayed = absolute disparity x absolute risk reduction

Components of absolute disparity (AD)  Disparity in provision/prescription of intervention  Disparities in use of or adherence to intervention

Estimating AD AD= (EP B x Rx w x Ad w ) - (EP B x Rx B x Ad B ) EP B = Eligible black population i.e. the number who are candidates for the intervention annually Rx w = Provision/prescription of the intervention for whites Ad w = Adherence to the intervention for whites Rx B = Provision/prescription of the intervention for blacks Ad B = Adherence to the intervention for blacks

Common thread: clinician-patient communication  Communication affects patients’ willingness to accept a treatment and clinician’s willingness to provide or prescribe it  Communication affects patients’ adherence

Absolute risk reduction  Baseline mortality in the absence of intervention  Relative risk reduction associated with the intervention  ARR= RRR x base mortality rate

CVD Interventions AMI following hosp discharge – drug treatment AMI – reperfusion and revascularization Chronic angina - drug treatment Chronic heart failure - drug treatment Heart failure following hosp discharge – drug treatment Hyperlipidemia – drug treatment Hypertension - drug treatment Long-term post MI – drug treatment Unstable angina –drug treatment Unstable angina - drug treatment Sudden death prevention – ICD insertion

Population size and mortality rates ConditionSize of population (crude) Base annual Mortality (crude) AMI admits83,49022% HF admits110,00033% UA admits 54,00016% Chronic AMI950,0005% Chronic angina575,002.5% Chronic HF444,00010% Hypertension9.4 million1.6% Hyperipidemia10.4 million0.5% Sudden death13,60015%

Key disparity (black/white ratio) estimates  Drug treatment in the year following hospital discharge ( )  CABG ( )  PTCA ( )  Fibrinolysis ( )  Adherence to treatment for chronic condition – 0.80 ( )

Adjusting summed deaths  Avoiding double counting from hospital readmissions from same year and transfers  Avoiding double counting from comoribidity e.g. AMI and HF, CAD and hypertension  Adjusting for less than additive relative risk

Findings ConditionDisparity Deaths AMI first year following admission1,200 Chronic angina450 Heart failure (> 1 year following admission)1,750 Heart failure first year following admission1,930 Hyperlipidemia430 Hypertension1420 AMI (>1 year following admission)930 Sudden death prevention- ICD200 Unstable angina first year following admission800 TOTAL8,800

Key findings  Common conditions with high mortality requiring daily adherence have the greatest impact on disparities e.g. heart failure and AMI.  Interventions with high reach e.g. cardiac rehabilitation (990) have greater impact than those with smaller reach e.g. reperfusion therapy (740) or ICDs (200).  Disparities in drug adherence is a major driver accounting for 4,980 deaths.

Limitations  Lack of reliable data for many estimates  Assumptions e.g. differential impact, sustained benefit, synergistic effects  No stratification by age or gender  Annual deaths not QALYS

Conclusions  Population impact represents a key (though not the only) metric for prioritizing health care disparities  The population impact model could be adapted by health care organizations that care for defined populations using their own internal data to assess the impact of health care disparities

Acknowledgements Funding: RWJF and NHLBI/NIH Collaborators: Richard Dressler Advice: Simon Capewell

Sensitivity  95% CI - 5,700-11,110  Adherence disparity: , ,290