How Providers Can Ameliorate Disparities in Health Care

DECEMBER 19, 2018
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA

Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: The Association of Black Cardiologists on its website at abcardio.org has a wealth of information on how we as providers can use prior authorization to get these lifesaving newer medicines to our patients.

Another thing we as providers can do is use cardiac rehabilitation, not just for patients who have had a STEMI [ST-elevation myocardial infarction] or non-STEMI, but also now for patients who have heart failure. There is now an estimate that if we apply cardiac rehabilitation appropriately across all populations, we can save hundreds of thousands of lives in the United States.

The Million Hearts program has suggested that cardiac rehabilitation is not applied equally across all populations. For instance, black women have a 60% less likelihood of being referred for cardiac rehabilitation. Therefore, referring our patients for cardiac rehab—again regardless of race, ethnicity, and persons who use English as a second language often do not have appropriate referral to cardiac rehab—will save lives by giving patients a program by which they can exercise, learn how to modify lifestyle, and control risk factors.

One thing that we as providers can do is make sure that we have registries and guidelines applied in the hospital setting. This, of course, will not change the social determinants of health or would suggest that we are going to apply ACE [angiotensin-converting enzyme] inhibitors as needed in higher risk patients; beta-blockers in patients post myocardial infarction or heart failure with reduced ejection fraction; antiplatelet agents, including aspirin and some of the newer agents in patients who have had devices or interventions; and the use of blood pressure control. The pinnacle program, for instance, of the ACC [American College of Cardiology] is able to show that when these guidelines and initiatives are applied in the hospital setting, we can ameliorate or even eliminate some of the disparities in the application of care.

Let’s talk about adherence. Fortunately, the medications save lives. Unfortunately, many patients are unable to afford or don’t understand the need to adhere to their medications. I worked with a working group, including leaders from the FDA and other public sectors, including the CDC’s Division for Heart Disease and Stroke Prevention, that have suggested that adherence is one of the most important things that we should help address in our patients. Why patients do not adhere, there’s a multitude of reasons—poor understanding; lack of an ability to afford medication; feeling a lack of a doctor–patient or provider–patient relationship, such that they can reasonably understand even after feeling better from an acute event why they should maintain medication. These are some of the things that we must address.

And finally, having culturally appropriate, literacy-level appropriate educational materials and videos will help our patients be partners in care so that they can understand why they need to adhere to a certain lifestyle and diet, follow up with care, and take medications as needed.

When I started, I talked about Martin Luther King Jr looking at [President] Lyndon Johnson as he signed the Civil Rights Act in 1964. We’ve come a long way in public accommodations, but, as I’ve suggested to you, we have a long way to go in terms of controlling risk factors and controlling outcomes in cardiovascular disease. Hopefully, we all can dedicate ourselves even more to each individual patient and make sure that they get the best care, evidence-based care, regardless of race, ethnicity, or social class.

It’s important that we talk to our patients, giving culturally appropriate materials, literacy level–appropriate materials, and giving the best one-on-one patient care regardless of race, ethnicity, gender, or social class.

I started with Martin Luther King and I will end with him. He suggested that we were making progress since the Civil Rights Act of 1964 and the Voting Rights Act of 1965. He often said that of one of the most inhumane forms of injustice is injustice in health care.

I’m Dr. Keith C. Ferdinand talking to you about racial, ethnic, and social economic determinants of health.

Transcript edited for clarity.

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