30 Oct Racial Disparities Persist in Access to Specialized Heart Failure Hospital Services

MedicalResearch.com Interview with:

Dr. Morse

Michelle Morse, MD, MPH
Founding Co-Director, EqualHealth
Soros Equality Fellow
Assistant Professor, Harvard Medical School
Co-Founder, Social Medicine Consortium 

MedicalResearch.com: What is the background for this study?

• Response: Frontline clinicians have a unique vantage point to identify and characterize inequities in care. This study was inspired by internal medicine residents’ first-hand clinical experiences of black and Latinx patients who were frequently admitted to the general medicine service, as opposed to the cardiology service, with an ultimate diagnosis of HF.
• Research has shown that structural inequities are pervasive throughout healthcare delivery systems and across many services, within both the inpatient and outpatient arenas. We hope other institutions and clinicians will be equally committed to addressing inequities in their own contexts, systems, and care settings and that patients will identify opportunities for self-advocacy in their care.

MedicalResearch.com: What are the main findings?

Response: We found that the race, gender, and age of patients with heart failure influence admission to either a specialized cardiology service or general medicine service for hospitalized heart failure (HF) patients. Specifically, patients who were black, Latinx, female and over the age of 75 were less likely to be admitted to the cardiology service, even after adjusting for demographic and clinical factors.

These findings are an example of the pervasiveness and the detriment of structural racism, which we define as differential access to goods, services, and opportunities of society by race, often evident as inaction in the face of needs (Jones, Am J Public Health 2000). Biology is often erroneously blamed for disparate outcomes because clinicians, administrators, researchers, etc., are uncomfortable naming racism as the true culprit, and because race is often erroneously defined as a biological risk factor rather than a risk marker. We believe that race is a social construct, that phenotypic racial features have meaning due to societal rather than biological factors. With this work, we wanted to encourage other researchers, clinicians, administrators to see the societal and structural forces (like racism) that define race and make it relevant, but also understand how such forces can lead to differential access to care and disparate outcomes.

We believe there are a multitude of interrelated structural drivers that are pervasive across our health care system and consequently in our institution. Black and Latinx patients likely have barriers to accessing outpatient cardiology care as they were less likely to have an outpatient cardiologist at our institution, which was the strongest predictor of admission to the inpatient cardiology service. 

MedicalResearch.com: What should readers take away from your report?

• Response: We expect that communities, patients, and patient advocacy groups will have access to these results and will work with us on the projects which seek to remedy these inequities and ensure accountability and institutional change around issues of equity from the systems that serve them.
• These findings also highlight other structural inequities that exist, such as barriers to accessing outpatient cardiology care for our black and Latinx patients, leading to decreased admission to cardiology service and subsequent worse HF outcomes. We urge healthcare policy makers to recognize how our current healthcare systems promote the interests of dominant group members, and recommend that care delivery be designed to prioritize the care of our most marginalized patients. 

MedicalResearch.com: Is there anything else you would like to add?

Response: Like at many institutions, it is often easier for patients to be accepted to an inpatient cardiology service with limited beds if they are known to an institutional cardiologist or if their cardiologist can advocate for them for appropriate admission.

Levels of perceived discrimination and mistrust in the healthcare system may also lead to differential self-advocacy for admission to a specialized service by patients from different backgrounds. While structural drivers are likely the prevailing forces, implicit bias is ubiquitous and probably contributes as well. It is plausible that patients with less financial resources, lower health literacy are in some cases seen as “too psychosocially complex” to be admitted to a cardiology service.

MedicalResearch.com: What recommendations do you have for future research as a result of this work? 

Response:   Identifying inequities is the first step in a process. With significant institutional support and leadership commitment, we have begun the work to address these demonstrated inequities through two pilot projects.

In one project, are conducting real-time surveys of the physicians involved in the admissions process, as well as the patients being admitted, to better understand what drives the decision regarding which service a patient is admitted to. The results of these surveys will inform the creation of objective admission service guidelines for patients with HF.

Additionally, to improve care for patients with HF on the general medicine service we have developed a standardized clinical assessment management plan that ensures patients receive guideline-directed medical therapy and are provided with a package of services we believe will improve care. These services include more streamlined and systematic follow-up with outpatient cardiology providers once the patient is discharged; guidelines for cardiology consultation, involvement, and transfer; support for attending post-discharge appointments; provision of weight scales at no cost to patient who cannot afford them; verification of medications affordability; and post-discharge follow-up calls to address any issues in the post-discharge period.

It has been pivotal to work in an institution that is willing to both reflect on inequities and to invest in addressing them. At a macrolevel, recognizing that inequities like those we identified are pervasive, we believe that collaboration across services and provider roles, shared definitions and analysis of structural drivers of inequity, and a collective commitment to improvement are essential to minimizing these gaps.

Citation: 

Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center

Lauren A. Eberly, Aaron Richterman, Anne G. Beckett, Bram Wispelwey, Regan H. Marsh, Emily C.Cleveland Manchanda, Cindy Y. Chang, Robert J. Glynn, Katherine C. Brooks Originally published29 Oct 2019 https://doi.org/10.1161/CIRCHEARTFAILURE.119.006214Circulation: Heart Failure. 2019;12:e006214

https://ahajournals.org/doi/full/10.1161/CIRCHEARTFAILURE.119.006214

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Last Updated on October 30, 2019 by Marie Benz MD FAAD