Heart care program leads to system-wide advances

By Jeni Baker

It’s been well documented: When it comes to heart disease, patients of different races and ethnicities often experience different risk factors, different disease progression, and different medical care.

For instance, high blood pressure, a key risk factor for cardiovascular disease, is several times more prevalent among African Americans than it is among Caucasians -- yet black and Hispanic people are less likely than whites to be properly evaluated and treated for it, as well as for obesity and poor cholesterol levels. And black patients are less likely than white ones to receive proven medical treatments after hospitalization for heart attack, heart failure, and stroke.

In 2006, Duke University Health System launched a formal effort to identify and improve these issues -- with the goal of delivering better, more culturally appropriate care.

It all started when Duke University Hospital was chosen -- along with nine other U.S. medical centers -- to participate in the “Expecting Success: Excellence in Cardiac Care” program, funded by the Robert Wood Johnson Foundation.

The program’s goals were to identify and analyze care disparities among African American and Hispanic inpatients and community members seen by Duke clinicians for cardiac issues -- and to develop and share tools to better serve those populations.

The good news is that most performance measures Duke University Hospital uses for treating inpatients for heart attacks (acute myocardial infarction, or AMI) and heart failure (HF) showed no inequality in care across race, ethnicity, or language. Black and white patients received the same treatment as other patients for these conditions (see charts).

According to the report for the 29-month initiative, released in November 2008, Duke Hospital “maintained AMI and HF core measures at or above state and national averages throughout the project” in its care of black and Hispanic patients.

“Duke already provided outstanding care to our heart patients, and throughout the course of ‘Expecting Success,’ we continued to improve incrementally in all categories,” says cardiologist and principal investigator Eric Velazquez, MD. There was, for example, a decrease in readmission rates among African American heart-failure patients.

Duke’s participation in the program also led to efforts that include:

• Changes to Duke Heart Center discharge educational materials and documents, such as writing them at a lower reading level and providing Spanish versions  
• The delivery of advanced heart-care services to disadvantaged patients of Durham’s federally designated Lincoln Community Health Center
• Creating a new intake system to accurately capture race, ethnicity, and primary language data of heart patients

Even better, says Velazquez, the initiative served as a springboard for a larger effort to improve the care Duke University Health System delivers to all patients.

“We saw this as a great opportunity to reevaluate and redesign how the health system overall collects race and ethnicity data and uses that information in care delivery,” he says. “Instead of a small focused effort on cardiovascular health, Duke took a comprehensive, health system-wide approach.”

Using Heart Services as a model, Duke launched the health system-wide Get REAL (Race, Language, and Ethnicity) campaign, led by the “Expecting Success” project team, in late 2006 to comprehensively and accurately capture this information while also focusing on reducing disparities in national quality measures.

In addition to asking all patients to identify their race, ethnicity, and primary language, Get REAL involved upgrading many information systems and training intake staff about new patient data-collection procedures.

“Figuring out why disparities exist depends on having consistent, reliable data about the populations we serve, on understanding their culturally specific needs, and on identifying patterns in care,” Velazquez says. “So having this system in place is a huge step forward for the health system as a whole.”

The next steps, he says, will be to establish why differences in care can exist and how the health system can modify variables to reduce inequities, such as improving care access to outpatients and underserved community members.

“We’re leading an evolutionary change in the health system,” Velazquez says.

For more information about Duke’s efforts to eliminate disparities in care, contact the Office of Institutional Equity at 919-684-8222 or visit duke.edu/web/equity.

The graphs below illustrate how Duke's focus on results and highly reliable processes decreases the opportunity for disparity in treatment for patients of different races.