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Quality, Patient Safety and Clinical Affairs
NJHA Institute for Quality and Patient Safety
Expecting Success: Excellence in Cardiac Care Learning Network - Disparities in Cardiac Care
Contents: Introduction | Distribution of N.J. Residents by Race and Ethnicity | New Jersey Patients Hospitalized for Heart Failure | Distribution of African Americans and Hispanics/Latinos in Selected N.J. Counties | Race and Ethnicity Distribution of Cities and Towns with One or More of the Ten Expecting Success Hospitals | Footnotes
IntroductionThe overwhelming evidence of racial and ethnic disparity in healthcare is described in a plethora of reports and articles in the literature. The reasons for disparities are complex and multidimensional; contributing factors exist within the design of U.S. healthcare services, the social milieu of communities and states across the nation and economic conditions of minority populations. All of these factors combine ultimately to produce disparities in health status, access, service utilization and outcomes. The summary of core measures of quality in the 2005 National Healthcare Disparities Report concluded that, for a large number of measures, minority populations receive a lower quality of care than whites. For African Americans, quality of care was poorer than for whites for 20 out of 46 measures (43 percent). Among measures for Hispanics/Latinos, 20 of the 38 measures (53 percent) showed that they received a lower quality of care than whites.1
The 2002 Institute of Medicine's report, Unequal Treatment, provided a significant amount of evidence of the disparities in the diagnosis and treatment of cardiac disease.2 Cardiovascular disease remains the leading cause of death in the United States, accounting for 37.3 percent of all deaths in the nation in 2003.3 The burden of heart disease is higher for African-American and Hispanic/Latino minorities than for whites. Premature death among individuals with cardiovascular disease is more common for blacks (31.5 percent) and Hispanics/Latinos (23.5 percent) than for whites (14.3 percent).4
In 2005, the Robert Wood Johnson Foundation partnered with George Washington University to establish the national program, Expecting Success: Excellence in Cardiac Care. This program has 10 sites nationally to address the issue of disparities in care for African American and Hispanic/Latino patients with heart failure and acute myocardial infarction. These deficiencies in care are expected to have significant effects throughout our nation, as it is estimated that by 2050 one-half of our population will be considered "minority."5 The rapid growth in minority populations underscores the growing importance of ending disparities to provide one equal standard of care to all patients, irrespective of their race and/or ethnicity.
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Snapshot: Distribution of New Jersey Residents by Race and Ethnicity
New Jersey is comprised of citizens and communities rich in ethic, racial and cultural diversity. Approximately 28 percent of New Jersey citizens are either African-American or Hispanic/Latino, and the Asian and Pacific Islander population has approached 7.5 percent. Twenty six percent of New Jersey's residents (more than 2 million residents) speak a language other than English at home, and 11 percent of the population has limited English proficiency.6 In 2004, under Public Law 2004, c. 137, the New Jersey Legislature authorized the Commissioner of Health of the N.J. Department of Health and Senior Services to establish the "Eliminating Health Disparities Initiative" in the Office on Minority and Multicultural Health (OMMH).7
African-American and Hispanic/Latino Populations in New Jersey
NJ Hispanic/Latinos represent 14.2% of New Jersey's residents.
African Americans represent 14% of New Jersey's residents.
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Table 1. Demographic Trends in New Jersey vs. USA
New Jersey's demographic trends closely mirror the national trends in respect to race and ethnicity.
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Snapshot: New Jersey Patients Hospitalized for Heart Failure (DRG 127) by Race and Ethnicity
One major area of emphasis within the Initiative's plan is cardiovascular disease. Cardiovascular disease is the leading cause of death in New Jersey, and, although coronary artery disease is declining, stroke remains the leading cause of death in New Jersey. The death rate for African-Americans is much higher in the 45- to 64-year-old age group than for whites of the same age group. Numerous outreach and educational efforts, established within the plan, are specifically targeted to reduce the number of deaths due to cardiac disease.8
In concert with these efforts, the Robert Wood Johnson Foundation funded the New Jersey Health Initiatives' Expecting Success: Excellence in Cardiac Care program to specifically address the care of African-Americans and Hispanic/Latinos with heart failure.9 Inpatient discharge data from 2006 identified a total of 33,923 patients with a primary diagnosis of heart failure (DRG 127) with information noted on ethnicity and race. Seven percent of these patients were coded to be of Hispanic/Latino origin, and 20.8 percent were identified as African-American by race. It is of interest to note that the third largest category of patients by race was "other," representing 3.3 percent of the inpatients, in support of the noted trend toward increasing "minority" populations as a result of racial and ethnic blending. Despite the known issues regarding the proper classifying and coding of race and ethnicity 10, this information can be used to establish patterns of healthcare delivery for heart failure in the inpatient population of New Jersey hospitals.
Expecting Success Hospitals within New Jersey CommunitiesTen hospitals have been selected into the program following an application and on-site review process. In addition to other selection criterion, hospitals were selected based on the numbers of African-Americans and Hispanics/Latinos in the geographic areas proximate to where the hospitals are located. The following illustrates the number and percentages of African Americans and Hispanics/Latinos by counties and cities for each of the 10 Expecting Success hospitals.
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Distribution of African Americans and Hispanics/Latinos in Selected New Jersey Counties
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Race and Ethnicity Distribution of Cities and Towns with One or More of the Ten Expecting Success Hospitals
Review of the census data identifies the numbers and percentages of African-Americans and Hispanics/Latinos in the cities where the 10 Expecting Success Hospitals are located. The combined total of African-Americans and Hispanics/Latinos for each of the cities ranges from 45 percent to 97.9 percent, a median percentage of 88.5 percent and a mean percentage of 78.8 percent. These population distributions identify the significant opportunities that the 10 Expecting Success hospitals will have to improve the care of individuals, families and communities they serve.
Data trends for distribution of inpatients by race and ethnicity, specifically with a primary diagnosis of HF (DRG 127) is useful for the general assessment of the mix and distribution of each hospital's target populations. Since each hospital will be required to refine, implement and evaluate performance improvement plans for the program, baseline data was obtained by all of the applicant hospitals.
Baseline data for each of the 10 New Jersey Expecting Success hospitals will be reported to each hospital for comparative blinded baseline performance measurement of heart failure process and outcome measures. Data analysis will help construct the individual performance improvement plans, which will be unique to each hospital and their patient population.
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Footnotes
1. National Healthcare Disparities Report; 2005 [Internet]. Agency for Healthcare Research and Quality, Rockville (MD). Available from: http://www.ahrq.gov/qual/nhdr05/nhdr05.htm
2. Institute of Medicine. Smedley, B.D., Stith, A.Y., and Nelson, A.R., editors. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health care; 2002. Washington (DC): National Academies Press; ©2003. Available from: http://www.iom.edu/?id=4475&redirect=0
3. American Heart Association. Heart Disease and Stroke Statistics: 2006 Update. A Report from the American Heart Association’s Statistics Committee and Stroke Statistics Subcommittee Update. Circulation [Internet]. 2006 Feb 14;113(6):e85-151. Available from: http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.105.171600v1
4. Centers for Disease Control and Prevention. Heart Disease Fact Sheet [Internet]. Atlanta (GA): Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion; 2005. Available from: http://www.cdc.gov/DHDSP/library/fs_heart_disease.htm
5. American Heart Association. Statistical Fact Sheet: Hispanics/Latinos and Cardiovascular Disease; 2005 [Internet]. Dallas (TX). Available from: http://www.americanheart.org/presenter.jhtml?identifier=2011
6. State of New Jersey. Healthy New Jersey 2010: Update 2005 [Internet]. Trenton (NJ): New Jersey Department of Health and Senior Services. Center for Health Statistics; 2005. Available from http://www.state.nj.us/health/chs/hnj2010u05/index.shtml/
7. State of New Jersey. Strategic Plan to Eliminate Health Disparities in New Jersey 2007 [Internet]. Trenton (NJ): New Jersey Department of Health and Senior Services; 2007. Available from www.nj.gov/health
8. Ibid.
9. Regenstein, M., Mead, H., Lara, A. The Heart of the Matter: The Relationship Between Communities, Cardiovascular Services, and Racial and Ethnic Gaps in Care [Internet]. Washington (DC): The George Washington University School of Public Health and Health Services, Department of Health Policy; 2006. Available from: http://www.expectingsuccess.org/uploads/HeartoftheMatterfinalreport.pdf
10. Wynia, M., Matiasek, J. Promising Practices for Patient Centered Communication with Vulnerable Populations: Examples from Eight Hospitals [Internet]. New York (NY): The Commonwealth Fund; 2006. Available from: http://www.cmwf.org/publications/publications_show.htm?doc_id=397067&
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