Previous research has shown that there appears to be disparate care among different racial and ethnic populations, especially in the treatment of coronary artery disease (CAD). Clinical studies also suggest that there are differences in the use of evidence-based medicine among these different racial and ethnic groups. According to published data, minorities with acute coronary syndromes are more likely to receive sub-standard care. It has been shown throughout the medical literature that racial and ethnic minorities often receive evidence-based treatments less frequently than Caucasians. Other studies show that minorities are often treated at facilities that are not as adept at adhering to composite performance measures.
The Get With the Guidelines-CAD (GWTG-CAD) quality improvement program, provided by the American Heart Association and American Stroke Association, is designed to enhance hospital adherence to guidelines when managing CAD patients. The program employs a set of performance, quality, and reporting measures to track the quality of care at an institution, and it has been proven to improve adherence to evidence-based care of patients hospitalized with CAD. A part of the GWTG-CAD program is directed toward improving ethnic and racial disparities among CAD patients to the point where care is defect-free. The concept of defect-free care is a critical component in the GWTG-CAD program. At its core, defect-free care is intended to ensure that every patient receives all of the interventions for which they’re eligible. These interventions are also known as performance measures because their use in CAD patients is supported by well-grounded scientific evidence. Therefore, performance measures are well-suited for public reporting to compare hospitals and pay-for-performance initiatives.
Quality Improvement Programs Work
In the May 2010 issue of Circulation, my colleagues and I had a study published in which we followed 443 hospitals that engaged in the GWTG-CAD program over a 5-year period. At the onset of our study, significant gaps in defect-free care for patients with heart attacks existed between racial and ethnic groups; 68% of Caucasian patients received this defect-free care, compared with a 58% rate for African-American patients and a 65% rate for Hispanics. The most notable finding was that as the GWTG-CAD quality improvement program was implemented, the differences between different racial and ethnic groups greatly improved, as did the number of patients receiving defect-free care. By the second half of the study, differences in defect-free care were no longer significant; eventually, they were completely eliminated. By the time the study ended, 95% of Hispanics were receiving defect-free care and 93% of Caucasians and African Americans were treated at the same benchmark.
It’s important to note that the increase in quality of care for heart attack patients was observed across all hospitals in the investigation, including those that cared disproportionately for African Americans and Hispanics. This is a unique finding because other data have suggested that the chief reason for disparate care among minorities is that these individuals were more likely to be treated at facilities that provided inferior care. Our findings demonstrated that this does not appear to be a mitigating factor when hospitals participate in quality improvement programs like GWTG-CAD.
Patients who are socioeconomically disadvantaged will likely benefit significantly by being treated in facilities that participate in GWTG-CAD. Over time, the hope is that the disparities between lower- and higher-class hospitals can be eliminated. Ideally, all patients should be receiving defect-free care; what our study demonstrated is that quality improvement programs have the capability to be substantially effective at reducing disparities in care for CAD. Our work is part of a larger solution for improving the quality of care for patients regardless of their socioeconomic status and the color of their skin. The availability of appropriate follow-up and preventive care after patients are discharged and efforts to ensure patient compliance are paramount to continuing the progress that has begun with GWTG-CAD. As these efforts continue, there is optimism that we’ll be able to further reduce any remaining gaps in disparate care.
Readings & Resources (click to view)
Cohen M, Fonarow G, Peterson E, et al. Racial and ethnic differences in the treatment of acute myocardial infarction: findings from the Get With The Guidelines—Coronary Artery Disease program.Circulation. 2010;121:2294-2301. An abstract is available at:http://circ.ahajournals.org/cgi/content/short/121/21/2294.
Cook N. Disparities in cardiovascular care: does a rising tide lift all boats? Circulation.2010;121:2253-2254.
Mayberry R, Mili F, Ofili E. Racial and ethnic differences in access to medical care. Med Car Res Rev. 2000;57:108-145.
Peterson E, Yancy C. Eliminating racial and ethnic disparities in cardiac care. N Engl J Med. 2009;360:1172-1174.
Chin M, Walters A, Cook S, Huang E. Interventions to reduce racial and ethnic disparaties in health care. Med Care Res Rev. 2008;64:7S-28S.