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DITORIAL COMMENT

are Disparitiesoving From Gray to Black and White*

ohn S. Rumsfeld, MD, PHD, FACC,†ric D. Peterson, MD, MPH, FACC‡enver, Colorado; and Durham, North Carolina

quity in the delivery of health care is one of the principalomains of health care quality as defined by the Institute ofedicine (IOM) (1). Despite this, more than 100 studies

ave demonstrated racial differences in cardiovascular caren the U.S. These pervasive findings have prompted theOM, the Agency for Healthcare Research and QualityAHRQ), and the major cardiovascular societies to launchational campaigns designed to increase awareness of racialisparities in care as well as to stimulate efforts to overcomeare inequities (2,3).

See page 72

In this issue of the Journal, Groeneveld et al. (4) add tour understanding of racial differences in cardiovascular carehrough their investigation of the use of implantable cardiacefibrillators (ICDs). Studying a national sample, the in-estigators found that African American patients hospital-zed with ventricular tachycardia, ventricular fibrillation, orardiac arrest were only about half as likely as Caucasians toeceive an ICD. Examining these differences over a 10-yeareriod, however, the investigators noted a significant nar-owing of the “racial gap” in ICD use, due in part to regionaliffusion of the technology. More specifically, areas of theountry with a higher proportion of African Americanse.g., the South) tended to be slower at adopting ICD usemong sudden cardiac death survivors. Over time, however,here was some “geographic equalization” of ICD availabil-ty, resulting in greater use of the technology among Africanmericans. In particular, expanded use of ICDs at non-

cademic hospitals was associated with a narrowing of racialifferences at these types of hospitals. Despite this, Africanmericans remained 30% less likely than Caucasians to

eceive an ICD at the end of the study period.This study, or more generally, any report of care disparity,

hould trigger three questions in readers’ minds. First, arehe observed differences in care real (i.e., not due to

*Editorials published in the Journal of the American College of Cardiology reflect theiews of the authors and do not necessarily represent the views of JACC or themerican College of Cardiology.From the †Denver Veterans Affairs Medical Center/University of Colorado Health

ciences Center, Denver, Colorado; and the ‡Duke Clinical Research Institute, Dukeniversity Medical Center, Durham, North Carolina. Dr. Rumsfeld is supported byVA Health Services Research Advanced Research Career Development Award. The

eiews expressed in this article are those of the authors and do not necessarily representhe views of the Department of Veterans Affairs.

onfounding clinical factors)? Second, are these differencesmportant (i.e., do they measurably affect patients’ healthnd well being)? And third, if the disparities are real andmportant, what can be done to minimize or eliminatehem?

The short answer to whether racial disparities exist inCD implantation is “probably.” Certainly, the study byroeneveld et al. (4) demonstrates that the rate of ICD

mplantation differs between African Americans and Cau-asians. However, the study, based on administrative claimsata, lacks potentially important clinical details that couldontribute to observed treatment patterns. Without suchata, it remains possible to challenge the notion that lowerse in African Americans constitutes “underuse.” For exam-le, African-American patients were more likely to havelectrolyte disturbances, a potentially reversible cause ofentricular dysrhythmias not mandating ICD implantation.frican Americans were also more likely to suffer anoxicrain injury with cardiac arrest, and it is possible that ICDmplantation was not deemed appropriate for patients withignificant impairment. Although these possibilities exist, its difficult to imagine that they fully explain the markedacial variability in implantation found in this study.

The next question is whether the observed differences inCD implantation affect patient outcomes. Unfortunately,he current study did not include downstream patient eventr survival rates. However, there is strong evidence fromandomized trials that patients surviving sudden cardiaceath live significantly longer with ICD implantation com-ared with patients without ICDs (5). Given the high riskf the study population, it is certainly possible that racialisparities in implantation could translate into higher mor-ality for African Americans.

Under the reasonable assumption that racial disparities inCD implantation exist and can affect patient outcomes, theey issue becomes how to eliminate these differences. Thetudy by Groeneveld et al. (4) provides one interestingead—the diffusion of technology. By highlighting signifi-ant geographic and institutional variation in the diffusionf ICD devices into routine clinical practice, this studyuggests that reducing this variation may reduce racialisparity.In this regard, it is helpful to place the issue of racial

isparity in cardiac care within a more general model of thedoption of evidence-based care in clinical practice (6).doption of new treatment should ideally be initiated afterell-executed clinical trials and observational studies definehich patient populations benefit from the therapy. Thesendings should then be rapidly summarized into clearractice guideline recommendations. Finally, quality assess-ent and performance improvement initiatives should be

tilized to promote broad-based adoption of these newecommendations in general clinical practice. Because thispproach emphasizes the standardization of care where

vidence supports that a given therapy be provided to all

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80 Rumsfeld and Peterson JACC Vol. 45, No. 1, 2005Editorial Comment January 4, 2005:79–81

ligible patients, one byproduct may be the reduction ofacial disparities.

Although this model is well supported in theory, realedicine presents multiple challenges to its application.

trong evidence may not be available to guide a givenreatment decision. Even when clinical trials have beenone, key patient subgroups (co-morbid illness, advancedge, women, minorities) may be underrepresented (7).hus, clinicians often are placed in a gray zone in whichedical decisions are made without clinical certainty. These

ray areas of medicine allow more subjective factors to enterhe decision-making process and have the potential to leado racial disparity.

Patients also face uncertainty when asked to consideredical treatments. In the case of ICD implantation, it

akes a great deal of trust in one’s caregivers and inechnologic science in general to permit implantation of ashock-box” into one’s chest. This may be coupled withoncern about the potential economic implications of im-lantation. The clinician-patient relationship therefore as-umes a critical role. Clinicians should clearly convey toatients the potential risks, benefits, and alternative treat-ent options in a manner that will stimulate informed

ecision-making. However, surveys have found that racialinorities are more likely to report poor communicationith their physicians, which may contribute to a reluctance

o undergo cardiac procedures compared with Caucasianatients (8–10).Finally, we have inadequate systems of care to support

apid and complete implementation in clinical practice evenhen the evidence is compelling (1). In the study byroeneveld et al. (4), only about 10% of the overall sudden

ardiac death survivors received an ICD, even after a decader more of strong and expanding randomized trials. Thus,he “equality issue” is dwarfed by a more general failure todopt evidence-based care in all patients.

To advance the model of adoption of evidence-based cares a means of reducing racial disparities, several thingshould be done:

Reduce the “grayness” of medicine through better evidence: Asevidence for the effectiveness of a given therapy mounts,care decisions become more clear-cut. In such “black andwhite” situations, the impact of patient’s skin color shouldbe minimized. Ongoing support of both clinical research(emphasizing studies with more representative patientpopulations and ensuring the inclusion of minorities) andhealth services/outcomes research (emphasizing studies ofthe best methods to implement evidence-based care inpractice) by government agencies and foundations areessential.Promote a better patient-clinician interface: Patient activa-tion, whereby patients are empowered through educationinitiatives to have a better understanding of their diseaseand the treatments available to modify its course, can help

patients be more proactive about the care they receive m

(11). Cultural sensitivity and communication training forhealth professionals may promote a better environment inwhich the need for invasive procedures such as ICDplacement can be discussed (8).Provide up-to-date and explicit clinical guidelines: Becauseguidelines have, in many ways, replaced textbooks as theprimary source of clinical reference, and because qualityindicators and performance measures are derived fromguidelines, it is essential that they stay up to date. TheAmerican College of Cardiology (ACC) and other majorcardiovascular professional societies, as well as appropriategovernmental and regulatory agencies, should maintain acommitment to the ongoing development, frequent up-dating, and dissemination of evidence-based guidelines.Promote quality improvement programs: Quality improve-ment programs should specifically promote the imple-mentation of guideline-based care for all eligible patients,and thereby should help reduce inappropriate variation incare including racial disparities. Multidisciplinary collab-orative care programs are most likely to promote highestquality of care, and advances in information technology(e.g., electronic medical record, clinical reminders,e-health solutions) are likely to bolster these efforts (12).National quality improvement programs, such as theACC-National Cardiovascular Data Registry, can provideclinicians with comprehensive feedback on their carepractices, benchmarked with their peers (13). Althoughcontroversial, programs that link payment incentives toquality initiatives (so called pay-for-quality programs)may serve to intensify interest in meeting quality-of-carestandards.Finally, ensure that performance measurement considersequity: National efforts to measure and improve careshould provide clinicians with feedback on care stratifiedby age, gender, race, and other historically underservedpopulations. As in public education, we may need a “nopatient left behind” policy for evidence-based care.

By definition, the provision of high-quality care includeshe delivery of equitable care. The study by Groeneveld et al.4) helps us take a step forward in our understanding ofacial disparities, not just by highlighting a gap in care betweenfrican American and Caucasian patients, but by calling

ttention to a potential avenue for resolution through improvediffusion of technology. Promoting the adoption of evidence-ased care in practice, the cornerstone of quality improvement,ay be the best avenue to reduce variation in the diffusion of

echnology. It is hoped that better evidence, timely guidelines,nd both local and national quality initiatives will provide thelight” necessary to remove the grayness of medicine that hasupported racial disparities to this point.

eprint requests and correspondence: Dr. John S. Rumsfeld,enver VA Medical Center, Cardiology (111B), 1055 Clermont

treet, Denver, Colorado 80220-3808. E-mail: John.Rumsfeld@

ed.va.gov.

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81JACC Vol. 45, No. 1, 2005 Rumsfeld and PetersonJanuary 4, 2005:79–81 Editorial Comment

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1. Institute of Medicine, Committee on Quality Health Care in America.Improving the 21st-century health care system. In: Crossing theQuality Chasm: A New Health System for the 21st Century. Wash-ington, DC: National Academies Press, 2001:39–60.

2. Agency for Healthcare Research and Quality. National Health CareDisparities Report. Washington, DC: Department of Health andHuman Services, 2003.

3. Institute of Medicine. Unequal Treatment: Confronting Racial andEthnic Disparities in Health Care. Washington, DC: National Acad-emies Press, 2003.

4. Groeneveld PW, Heidenreich PA, Garber AM. Trends in implantablecardioverter-defibrillator racial disparity: the importance of geography.J Am Coll Cardiol 2005;45:72–8.

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6. Califf RM, Peterson ED, Gibbons RJ, et al. Integrating quality into

the cycle of therapeutic development. J Am Coll Cardiol 2002;40:1895–901.

7. Krumholz HM, Gross CP, Peterson ED, et al. Is there evidence ofimplicit exclusion criteria for the elderly in randomized trials? Evi-dence from the GUSTO-1 Study. Am Heart J 2003;146:839–47.

8. Kressin NR, Petersen LA. Racial differences in the use of invasivecardiovascular procedures: review of the literature and prescription forfuture research. Ann Intern Med 2001;135:352–66.

9. Whittle J, Conigliaro J, Good CB, Joswiak M. Do patient preferencescontribute to racial differences in cardiovascular procedure use? J GenIntern Med 1997;12:267–73.

0. Ferguson JA, Weinberger M, Westmoreland GR, et al. Racialdisparity in cardiac decision making: results from patient focus groups.Arch Intern Med 1998;158:1450–3.

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