725884
review-article2017
MCRXXX10.1177/1077558717725884Medical Care Research and ReviewDong et al.
Review
Racial/Ethnic Disparities in Quality of Care for Cardiovascular Disease in Ambulatory Settings: A Review
Medical Care Research and Review 1–29 © The Author(s) 2017 Reprints and permissions: sagepub.com/journalsPermissions.nav https://doi.org/10.1177/1077558717725884 DOI: 10.1177/1077558717725884 journals.sagepub.com/home/mcr
Liming Dong1, Oludolapo A. Fakeye2, Garth Graham3, and Darrell J. Gaskin2
Abstract Racial and ethnic disparities in cardiovascular disease (CVD) outcomes are widely reported, but research has largely focused on differences in quality of inpatient and urgent care to explain these disparate outcomes. The objective of this review is to synthesize recent evidence on racial and ethnic disparities in management of CVD in the ambulatory setting. Database searches yielded 550 articles of which 25 studies met the inclusion criteria. Reviewed studies were categorized into non-interventional studies examining the association between race and receipt of ambulatory CVD services with observational designs, and interventional studies evaluating specific clinical courses of action intended to ameliorate disparities. Based on the Donabedian framework, this review demonstrates that significant racial/ethnic disparities persist in process and outcome measures of quality of ambulatory CVD care. Multimodal interventions were most effective in reducing disparities in CVD outcomes. Keywords cardiovascular disease, hypertension, quality of care, ambulatory care, racial and ethnic disparity This article, submitted to Medical Care Research and Review on August 11, 2016, was revised and accepted for publication on July 17, 2017. 1University
of Michigan School of Public Health, Ann Arbor, MI, USA Hopkins Bloomberg School of Public Health, Baltimore, MD, USA 3Aetna Foundation, Hartford, CT, USA 2Johns
Corresponding Author: Darrell J. Gaskin, Department of Health Policy and Management, Hopkins Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Suite #441, Baltimore, MD 21205, USA. Email: [email protected]
2
Medical Care Research and Review 00(0)
Introduction The Institute of Medicine’s (IOM) 2002 report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care documented the pervasiveness of racial and ethnic disparities in quality of medical care (Nelson, Smedley, & Stith, 2002). The IOM concluded that racial and ethnic differences in quality of care were not due solely to patients’ preferences or to socioeconomic barriers encountered in accessing care. Rather, disparities observed were attributed to a complex function of clinical, administrative, health professional, patient, organizational, legal, and regulatory factors operative in the health system. The evidence for racial and ethnic disparities in treatment and management of cardiovascular disease (CVD) was among the “strongest and most consistent” among health conditions (Nelson et al., 2002, p. 39). Several studies cited in the report demonstrated that Black patients were less likely than White counterparts to receive potentially beneficial cardiac therapies, even after controlling for disease severity, comorbidities, insurance status, and other potential confounders (Ayanian, Udvarhelyi, Gatsonis, Pashos, & Epstein, 1993; Canto et al., 2000; Hannan et al., 1999; Johnson, Lee, Cook, Rouan, & Goldman, 1993). Disparities were reported for use of diagnostic and interventional procedures, medications for secondary prevention of cardiac events, and surgical procedures. Disparities persisted even in contexts where individuals enjoyed universal access to a health care system without financial barriers, such as within the Veteran’s Administration (VA) health services delivery system (Mirvis, Burns, Gaschen, Cloar, & Graney, 1994; Mirvis & Graney, 1998; Peterson, Wright, Daley, & Thibault, 1994; Petersen, Wright, Peterson, & Daley, 2002; Sedlis et al., 1997; Whittle, Conigliaro, Good, & Lofgren, 1993). The report advocated for further research to identify the relative contributions of patient-, provider-, and system-level factors to disparities and to assess promising intervention strategies intended to address these gaps. To effectively address racial and ethnic disparities in health care, it was suggested that solutions combine awareness, education, and aligned incentives targeted to the spectrum of stakeholders at the various levels of the health system. Finally, the IOM indicated the need for research that explores disparities between Whites and racial and ethnic minority groups other than African American and Hispanic populations. Specifically, the IOM encouraged research that documents, explains and addresses disparities for Asian Americans, Alaskan natives, Hispanics, Native Americans, and Pacific Islanders. More than a decade after the publication of Unequal Treatment, racial and ethnic disparities in the burden, management, and outcomes of CVD persist. Increased prevalence and inadequate control of cardiovascular risk factors among non-Whites, their lack of access to diagnostic and corrective cardiac procedures, provider stereotyping, and bias remain important contributory factors (Lewey & Choudhry, 2014). Over this period, research on racial and ethnic disparities in cardiovascular care has focused largely on invasive surgical therapies and on medication administered in the inpatient setting. For example, numerous studies have examined disparities in the receipt of the following: drug-eluting stents (Hannan et al., 2007; Sabatine et al., 2005); cardiac
Dong et al.
3
catheterization (Barnato, Lucas, Staiger, Wennberg, & Chandra, 2005; Sonel et al., 2005); revascularization, including both primary percutaneous coronary interventions and coronary artery bypass graft surgery (Bradley et al., 2004; Cohen et al., 2010; Popescu, Vaughan-Sarrazin, & Rosenthal, 2007; Sonel et al., 2005); fibrinolytic therapy (Bradley et al., 2004); aspirin (Vaccarino et al., 2005); clopidogrel and glycoprotein inhibitors (Sonel et al., 2005). These studies rely primarily on data from administrative databases and have critical limitations including the inability to observe patients’ severity and the clinical necessity of the care rendered, the inability to control for treatment options offered to patients, and the lack of socioeconomic data on patients beyond insurance status. The body of research on racial and ethnic disparities in ambulatory management of CVD is relatively slimmer and centered on physician referral behavior for surgical procedures. The health care delivery system has, however, evolved since the publication of the IOM report and there is now increased emphasis on reducing unnecessary hospitalizations through improvements in community-based care. The Centers for Medicare and Medicaid Services and private payers are encouraging hospitals to reduce inpatient admissions by providing better outpatient care and partnering with community-based physicians through arrangements such as accountable care organizations (Berwick, 2011). This transition underscores the need to evaluate whether racial and ethnic minority populations receive comparable or lower quality of care for CVD in the ambulatory setting. If they do, it is necessary to identify determinants of these disparities that can inform actionable policy interventions. This article reviews the literature on racial and ethnic disparities in the quality of ambulatory care provided to patients with CVD. For the purpose of this literature review, we define CVD as conditions that affect the heart valves, heart muscles, or that involve narrowed or blocked blood vessels in the heart. These conditions include coronary artery diseases (CADs), myocardial infarction, arrhythmia, heart failure (HF), heart valve diseases, congenital heart diseases, cardiomyopathy, pericardial diseases, aortal diseases, and vascular diseases. In addition, we included hypertension and hyperlipidemia under this categorization because they are considered important risk factors for heart disease and because there is a plethora of studies on disparities in care for these conditions. We identified the quality measures currently used to quantify physician, health plan, and health system performance in the ambulatory care setting with respect to CVD care. We also identified gaps in the literature and suggest directions for future studies of racial and ethnic disparities in quality of ambulatory care for cardiovascular conditions.
Conceptual Framework The structure-process-outcome conceptual framework propounded by Avedis Donabedian (1988) is ubiquitously applied in evaluations of quality and effectiveness of health care delivery. From this perspective, health care is viewed as a composite of the following: physical, technological, manpower-related, and organizational aspects of the settings in which care is delivered (structure); therapies and procedures of care
4
Medical Care Research and Review 00(0)
delivered to patients (process); and, the short- and long-term effects of care delivered as well as patient and population experiences (outcome). We employ the Donabedian framework to categorize the measures of quality assessed in the articles included in this review and to describe how the structures, processes, and outcomes of care for CVD vary by race and ethnicity.
New Contributions To the best of our knowledge, this is the most comprehensive review summarizing the evidence on racial and ethnic disparities in management of CVD in the ambulatory care setting. Previous, notable reviews have focused on disparities within a particular racial group or comparisons of that single group with others (Hutchinson & Shin, 2014), risk factors but not CVD conditions (Kurian & Cardarelli, 2007), disparities within a single type of health system (Saha et al., 2008), or on interventions to address disparities (Davis, Vinci, Okwuosa, Chase, & Huang, 2007). Our study adopts a wider ranging definition of CVD that includes select risk factors as well as advanced conditions. Our inclusion criteria allowed us to draw on studies ranging in scope from groups of primary care practices to national evaluations. Furthermore, we consider all racial and ethnic comparisons available in our included studies without limiting to a particular group of interest. The studies in our review assess and/or address disparities in care for CVD. Our review builds on the comprehensive 2002 report by the IOM, Unequal Treatment (Nelson et al., 2002), which compiled evidence on racial differences in quality of cardiovascular care but focused on disparities related to clinical inpatient care and procedures. This review is complementary to Unequal Treatment in that we adopt a similar, multilevel conceptual framework that views quality of care as a composite of structural, process-related, and outcome-related components. We operationalized a broad definition for the patient profile of interest by including a variety of cardiac and vascular conditions and risk factors—particularly hypertension and hyperlipidemia—to capture variation in use of screening, preventive as well as interventional procedures for CVD in the ambulatory setting. This review synthesizes results from randomized controlled trials (RCTs), quasi-experimental, and descriptive studies conducted in single practices, local and regional health systems, and using data collected nationally. Inferences drawn in this review derive from very diverse populations with respect to age, gender, race, location, medical condition, disease severity, and health insurance category receiving care for CVD in a variety of clinical settings with different organizational structures. The heterogeneity of these populations did not permit meta-analyses of results from the individual studies. Based on study design, we have divided included studies into non-interventional or descriptive studies, and interventional studies that evaluate therapeutic procedures to ameliorate racial/ethnic disparities in ambulatory management of CVD. Finally, we present important critiques of the design and analyses of the studies included and proffer suggestions to enhance the internal and external validity of this domain of research.
5
Dong et al. Table 1. Inclusion and Exclusion Criteria for Study Selection. Inclusion criteria
Exclusion criteria
Population
Patient sample includes at least two racial/ethnic groups with cardiovascular diseases in the United States
Settings
Ambulatory care settings
Study objectives
Type of publication
To document disparities, identify causes of disparities, or evaluate solutions or interventions that address or impact disparities Racial/ethnic disparities in quality of care Original research
Patients from a single racial/ethnic group; patients with diseases other than cardiovascular diseases, such as diabetes; patients not in the United States Other settings, including emergency rooms Studies not focusing on racial/ethnic disparities
Publication date
January 2003 to January 2016
Availability of study
Full text in English
Outcome
Studies not focusing on quality of care Other manuscript types such as reviews, editorials, and non-peer-reviewed publications Studies published or conducted before 2003 Abstract only
Method Search Strategy We conducted a literature search in PubMed and Embase to identify peer-reviewed articles published in the English language between January 2003 and January 2016 on racial and ethnic disparities in quality of health care for CVD in ambulatory care settings (Supplemental Table S1, all supplementary tables are available online at http://mcrr.sagepub.com/content/by/supplemental-data). The year 2003 was selected as starting point because a comprehensive review of disparities in cardiovascular care was featured in the IOM’s report Unequal Treatment published in 2002 (Nelson et al., 2002). Controlled vocabularies, text words, and keywords were used for developing search strategies for the following five general concepts: (a) health care and health insurance, (b) quality of care, (c) CVD, (d) racial/ethnic disparities, and (e) ambulatory care settings. Studies were identified by combining the five concepts with the “AND” Boolean term. The search terms were adapted according to the specific database interface. Additional articles were sourced from the reference lists of papers identified using the search terms.
Eligibility Criteria Table 1 presents inclusion and exclusion criteria applied in the screening process to identify relevant articles for this review. We included original research studies that
6
Medical Care Research and Review 00(0)
examined racial and ethnic disparities in the quality of ambulatory care for adults with CVD in the United States. Articles examining quality of inpatient care exclusively or medical conditions other than CVD were excluded. We included only studies that contrasted quality of ambulatory care for CVD between samples from at least two racial/ethnic groups. Because this review was focused on pathological risk factors for CVD rather than behavioral or lifestyle-related risk factors, we excluded studies on racial/ethnic disparities in provision of behavior modification services in the ambulatory setting. Such services included, but were not limited to, counseling on smoking cessation, diet and nutrition, exercise, and weight reduction counseling. Studies comprised exclusively of children (
review-article2017
MCRXXX10.1177/1077558717725884Medical Care Research and ReviewDong et al.
Review
Racial/Ethnic Disparities in Quality of Care for Cardiovascular Disease in Ambulatory Settings: A Review
Medical Care Research and Review 1–29 © The Author(s) 2017 Reprints and permissions: sagepub.com/journalsPermissions.nav https://doi.org/10.1177/1077558717725884 DOI: 10.1177/1077558717725884 journals.sagepub.com/home/mcr
Liming Dong1, Oludolapo A. Fakeye2, Garth Graham3, and Darrell J. Gaskin2
Abstract Racial and ethnic disparities in cardiovascular disease (CVD) outcomes are widely reported, but research has largely focused on differences in quality of inpatient and urgent care to explain these disparate outcomes. The objective of this review is to synthesize recent evidence on racial and ethnic disparities in management of CVD in the ambulatory setting. Database searches yielded 550 articles of which 25 studies met the inclusion criteria. Reviewed studies were categorized into non-interventional studies examining the association between race and receipt of ambulatory CVD services with observational designs, and interventional studies evaluating specific clinical courses of action intended to ameliorate disparities. Based on the Donabedian framework, this review demonstrates that significant racial/ethnic disparities persist in process and outcome measures of quality of ambulatory CVD care. Multimodal interventions were most effective in reducing disparities in CVD outcomes. Keywords cardiovascular disease, hypertension, quality of care, ambulatory care, racial and ethnic disparity This article, submitted to Medical Care Research and Review on August 11, 2016, was revised and accepted for publication on July 17, 2017. 1University
of Michigan School of Public Health, Ann Arbor, MI, USA Hopkins Bloomberg School of Public Health, Baltimore, MD, USA 3Aetna Foundation, Hartford, CT, USA 2Johns
Corresponding Author: Darrell J. Gaskin, Department of Health Policy and Management, Hopkins Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Suite #441, Baltimore, MD 21205, USA. Email: [email protected]
2
Medical Care Research and Review 00(0)
Introduction The Institute of Medicine’s (IOM) 2002 report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care documented the pervasiveness of racial and ethnic disparities in quality of medical care (Nelson, Smedley, & Stith, 2002). The IOM concluded that racial and ethnic differences in quality of care were not due solely to patients’ preferences or to socioeconomic barriers encountered in accessing care. Rather, disparities observed were attributed to a complex function of clinical, administrative, health professional, patient, organizational, legal, and regulatory factors operative in the health system. The evidence for racial and ethnic disparities in treatment and management of cardiovascular disease (CVD) was among the “strongest and most consistent” among health conditions (Nelson et al., 2002, p. 39). Several studies cited in the report demonstrated that Black patients were less likely than White counterparts to receive potentially beneficial cardiac therapies, even after controlling for disease severity, comorbidities, insurance status, and other potential confounders (Ayanian, Udvarhelyi, Gatsonis, Pashos, & Epstein, 1993; Canto et al., 2000; Hannan et al., 1999; Johnson, Lee, Cook, Rouan, & Goldman, 1993). Disparities were reported for use of diagnostic and interventional procedures, medications for secondary prevention of cardiac events, and surgical procedures. Disparities persisted even in contexts where individuals enjoyed universal access to a health care system without financial barriers, such as within the Veteran’s Administration (VA) health services delivery system (Mirvis, Burns, Gaschen, Cloar, & Graney, 1994; Mirvis & Graney, 1998; Peterson, Wright, Daley, & Thibault, 1994; Petersen, Wright, Peterson, & Daley, 2002; Sedlis et al., 1997; Whittle, Conigliaro, Good, & Lofgren, 1993). The report advocated for further research to identify the relative contributions of patient-, provider-, and system-level factors to disparities and to assess promising intervention strategies intended to address these gaps. To effectively address racial and ethnic disparities in health care, it was suggested that solutions combine awareness, education, and aligned incentives targeted to the spectrum of stakeholders at the various levels of the health system. Finally, the IOM indicated the need for research that explores disparities between Whites and racial and ethnic minority groups other than African American and Hispanic populations. Specifically, the IOM encouraged research that documents, explains and addresses disparities for Asian Americans, Alaskan natives, Hispanics, Native Americans, and Pacific Islanders. More than a decade after the publication of Unequal Treatment, racial and ethnic disparities in the burden, management, and outcomes of CVD persist. Increased prevalence and inadequate control of cardiovascular risk factors among non-Whites, their lack of access to diagnostic and corrective cardiac procedures, provider stereotyping, and bias remain important contributory factors (Lewey & Choudhry, 2014). Over this period, research on racial and ethnic disparities in cardiovascular care has focused largely on invasive surgical therapies and on medication administered in the inpatient setting. For example, numerous studies have examined disparities in the receipt of the following: drug-eluting stents (Hannan et al., 2007; Sabatine et al., 2005); cardiac
Dong et al.
3
catheterization (Barnato, Lucas, Staiger, Wennberg, & Chandra, 2005; Sonel et al., 2005); revascularization, including both primary percutaneous coronary interventions and coronary artery bypass graft surgery (Bradley et al., 2004; Cohen et al., 2010; Popescu, Vaughan-Sarrazin, & Rosenthal, 2007; Sonel et al., 2005); fibrinolytic therapy (Bradley et al., 2004); aspirin (Vaccarino et al., 2005); clopidogrel and glycoprotein inhibitors (Sonel et al., 2005). These studies rely primarily on data from administrative databases and have critical limitations including the inability to observe patients’ severity and the clinical necessity of the care rendered, the inability to control for treatment options offered to patients, and the lack of socioeconomic data on patients beyond insurance status. The body of research on racial and ethnic disparities in ambulatory management of CVD is relatively slimmer and centered on physician referral behavior for surgical procedures. The health care delivery system has, however, evolved since the publication of the IOM report and there is now increased emphasis on reducing unnecessary hospitalizations through improvements in community-based care. The Centers for Medicare and Medicaid Services and private payers are encouraging hospitals to reduce inpatient admissions by providing better outpatient care and partnering with community-based physicians through arrangements such as accountable care organizations (Berwick, 2011). This transition underscores the need to evaluate whether racial and ethnic minority populations receive comparable or lower quality of care for CVD in the ambulatory setting. If they do, it is necessary to identify determinants of these disparities that can inform actionable policy interventions. This article reviews the literature on racial and ethnic disparities in the quality of ambulatory care provided to patients with CVD. For the purpose of this literature review, we define CVD as conditions that affect the heart valves, heart muscles, or that involve narrowed or blocked blood vessels in the heart. These conditions include coronary artery diseases (CADs), myocardial infarction, arrhythmia, heart failure (HF), heart valve diseases, congenital heart diseases, cardiomyopathy, pericardial diseases, aortal diseases, and vascular diseases. In addition, we included hypertension and hyperlipidemia under this categorization because they are considered important risk factors for heart disease and because there is a plethora of studies on disparities in care for these conditions. We identified the quality measures currently used to quantify physician, health plan, and health system performance in the ambulatory care setting with respect to CVD care. We also identified gaps in the literature and suggest directions for future studies of racial and ethnic disparities in quality of ambulatory care for cardiovascular conditions.
Conceptual Framework The structure-process-outcome conceptual framework propounded by Avedis Donabedian (1988) is ubiquitously applied in evaluations of quality and effectiveness of health care delivery. From this perspective, health care is viewed as a composite of the following: physical, technological, manpower-related, and organizational aspects of the settings in which care is delivered (structure); therapies and procedures of care
4
Medical Care Research and Review 00(0)
delivered to patients (process); and, the short- and long-term effects of care delivered as well as patient and population experiences (outcome). We employ the Donabedian framework to categorize the measures of quality assessed in the articles included in this review and to describe how the structures, processes, and outcomes of care for CVD vary by race and ethnicity.
New Contributions To the best of our knowledge, this is the most comprehensive review summarizing the evidence on racial and ethnic disparities in management of CVD in the ambulatory care setting. Previous, notable reviews have focused on disparities within a particular racial group or comparisons of that single group with others (Hutchinson & Shin, 2014), risk factors but not CVD conditions (Kurian & Cardarelli, 2007), disparities within a single type of health system (Saha et al., 2008), or on interventions to address disparities (Davis, Vinci, Okwuosa, Chase, & Huang, 2007). Our study adopts a wider ranging definition of CVD that includes select risk factors as well as advanced conditions. Our inclusion criteria allowed us to draw on studies ranging in scope from groups of primary care practices to national evaluations. Furthermore, we consider all racial and ethnic comparisons available in our included studies without limiting to a particular group of interest. The studies in our review assess and/or address disparities in care for CVD. Our review builds on the comprehensive 2002 report by the IOM, Unequal Treatment (Nelson et al., 2002), which compiled evidence on racial differences in quality of cardiovascular care but focused on disparities related to clinical inpatient care and procedures. This review is complementary to Unequal Treatment in that we adopt a similar, multilevel conceptual framework that views quality of care as a composite of structural, process-related, and outcome-related components. We operationalized a broad definition for the patient profile of interest by including a variety of cardiac and vascular conditions and risk factors—particularly hypertension and hyperlipidemia—to capture variation in use of screening, preventive as well as interventional procedures for CVD in the ambulatory setting. This review synthesizes results from randomized controlled trials (RCTs), quasi-experimental, and descriptive studies conducted in single practices, local and regional health systems, and using data collected nationally. Inferences drawn in this review derive from very diverse populations with respect to age, gender, race, location, medical condition, disease severity, and health insurance category receiving care for CVD in a variety of clinical settings with different organizational structures. The heterogeneity of these populations did not permit meta-analyses of results from the individual studies. Based on study design, we have divided included studies into non-interventional or descriptive studies, and interventional studies that evaluate therapeutic procedures to ameliorate racial/ethnic disparities in ambulatory management of CVD. Finally, we present important critiques of the design and analyses of the studies included and proffer suggestions to enhance the internal and external validity of this domain of research.
5
Dong et al. Table 1. Inclusion and Exclusion Criteria for Study Selection. Inclusion criteria
Exclusion criteria
Population
Patient sample includes at least two racial/ethnic groups with cardiovascular diseases in the United States
Settings
Ambulatory care settings
Study objectives
Type of publication
To document disparities, identify causes of disparities, or evaluate solutions or interventions that address or impact disparities Racial/ethnic disparities in quality of care Original research
Patients from a single racial/ethnic group; patients with diseases other than cardiovascular diseases, such as diabetes; patients not in the United States Other settings, including emergency rooms Studies not focusing on racial/ethnic disparities
Publication date
January 2003 to January 2016
Availability of study
Full text in English
Outcome
Studies not focusing on quality of care Other manuscript types such as reviews, editorials, and non-peer-reviewed publications Studies published or conducted before 2003 Abstract only
Method Search Strategy We conducted a literature search in PubMed and Embase to identify peer-reviewed articles published in the English language between January 2003 and January 2016 on racial and ethnic disparities in quality of health care for CVD in ambulatory care settings (Supplemental Table S1, all supplementary tables are available online at http://mcrr.sagepub.com/content/by/supplemental-data). The year 2003 was selected as starting point because a comprehensive review of disparities in cardiovascular care was featured in the IOM’s report Unequal Treatment published in 2002 (Nelson et al., 2002). Controlled vocabularies, text words, and keywords were used for developing search strategies for the following five general concepts: (a) health care and health insurance, (b) quality of care, (c) CVD, (d) racial/ethnic disparities, and (e) ambulatory care settings. Studies were identified by combining the five concepts with the “AND” Boolean term. The search terms were adapted according to the specific database interface. Additional articles were sourced from the reference lists of papers identified using the search terms.
Eligibility Criteria Table 1 presents inclusion and exclusion criteria applied in the screening process to identify relevant articles for this review. We included original research studies that
6
Medical Care Research and Review 00(0)
examined racial and ethnic disparities in the quality of ambulatory care for adults with CVD in the United States. Articles examining quality of inpatient care exclusively or medical conditions other than CVD were excluded. We included only studies that contrasted quality of ambulatory care for CVD between samples from at least two racial/ethnic groups. Because this review was focused on pathological risk factors for CVD rather than behavioral or lifestyle-related risk factors, we excluded studies on racial/ethnic disparities in provision of behavior modification services in the ambulatory setting. Such services included, but were not limited to, counseling on smoking cessation, diet and nutrition, exercise, and weight reduction counseling. Studies comprised exclusively of children (
