Recognizing Disparities inHealthcare intheU.S.andFindingSolutions"

ClydeW.Yancy,MD,MScProfessor ofMedicine,Professor,MedicalSocialScienceChief,CardiologyAssociate Director, BluhmCVInstitute&Vice-Dean, Diversity &InclusionNorthwestern University, FSM&DeputyEditor, JAMACardiology

Whatisahealthcaredisparity? Gettingtheglossary correct

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Disparitycondition or fact of being unequal. This is what we

wish to avoid

Diversitynoticeable heterogeneityThis is what we must embrace

Cultureshared, learned, symbolic system of values, beliefs and attitudes that shapes and influencesperception and behavior

This is what we wish to enhance

A relevant glossary:

INCLUSION

IOM Report: Differences, Disparities, and Discrimination

Disparities-racial or ethnic differences in healthcare that are not dueTo access related factors, clinical needs, patient preferences or the Appropriateness of the intervention.

Non-

Min

ority

Min

ority

Difference

Clinical Appropriatenessand Need, PatientPreferences

The Operation ofHealthcare Systems and

the Legal and Regulatory Climate

Discrimination: Biases andPrejudice, Stereotyping,and Uncertainty

Disparity

Populations with Equal Access to Health Care

Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. The Institute of Medicine, National Academies Press, Washington, DC. 2002

Istherecontemporaryevidenceofdisparities inCardiovascularMedicine?

Whoexactlyisaminority?

•TheBiologyofBias•Howdoyouseetheworld?•CulturalCompetence•Strategies toovercomebiasinCardiovascularMedicine

Whatdoyousee?

Frog or Horse?

A young woman with A distant gaze OR An older coarse woman?

TheHermanGrid

TheHermanGrid

• Doyouseegraydotsatthewhite intersections?• AretheGrayspots really there?• This isanexample ofhowwesometimes seethings thatarenot really there.Discussion:• Haveyoueverhadawrong first impression of someone whohadadifferentbackground orcamefrom another culture?

• Hassomeone from adifferent back-ground oranother culture everhad thewrong first impression ofyou?

ConnectTheDots

Connect allofthedots with four straight lines.•DoNOTlift yourpencil off thepaper.•DoNOTretraceanyline. Linesmaycross ifnecessary.

ConnectTheDots

Discussion:

•Whyisitthatmostofusdonotthinkaboutgoingoutoftheboundaries?Wehadtodrawoutsideofthelines.Thisiswhatisrequiredofuswhenweinteractwithothersaseveryonethinksdifferently (outsideofourboundariesor"box").•Whyisitsohardtoseeothers'pointofviews?Weoftenaresobusythinkingaboutourpointofview,thatwefailtoseeothers'pointofviews.•Thisactivitydemonstrates thatweoftenlimitourperspectiveandchoices.

UnconsciousBias

•https://www.youtube.com/watch?v=0veDFGo666s

•https://www.youtube.com/watch?v=vytOEbWvVjc

Understanding Diversity&Inclusion andmanagingsubconscious bias:Take-away #1

•Consideradifferentperspective

•Recognize thatmorecontent/depth/substancemaybepresentthanisinitially acknowledged

•Bewilling tothinkunconventionally

Implicit Bias

•Apreferenceforasocial groupthatisbothunconscious andautomatic.

• Itisubiquitous insociety; allpersonsareaffected• Itisinformedbyanindividual’s experiences andperceptions ofothers

• InaUSsample population, therewasanimplicitpreferenceof68%forwhitepersons

Haider, Sexton, Sriram et al. JAMA, vol 306(9); 942-51

Strategiestoovercomebias

•Uniquecohortspecific initiatives andclinicaltrials

•Addressing CulturalCompetency• EnhancingDiversity intheWorkforce, especiallyinDiscovery Science

• Enriching thepipelineoftalentedunder-representedminorities andwomen

• Increasing Diversity inClinicalTrials• Transitioning toPrecisionMedicine insteadofStereotyping inClinicalDecisionMaking

Arewebiased?

Alongitudinal survey; NorthwesternUniversity, FeinbergSchoolofMedicine

Cultural Competence; ameans toanend;asolution?

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AddressingDiversity inClinical Trials

• TheFDAandpayers should consider economic incentives (or penalties) thatwould enable greater inclusion inclinical trials.

• Industry partners should commit tothiseffort, examining thedesign oftheirtrials, andselection of investigators andsites, both inandoutside of theU.S.

• Sitediversity, coordinator diversity andinvestigator diversity offer immediatesolutions, but incentives should becreated tofacilitate thisclinical trialconduct.

• “Enhanced cohort” recruitment inphase IVorpostapproval studies shouldbecome astandard.

• Novel ITstrategies, including theuseofsocial media, gamification andotherdigital health technologies mayprovide unique solutions andshould continuetobeexplored.

• Additional effort should beput towards theinformed consent process,assuring that language isconcordant andconsent isculturally sensitive.

• Educational efforts should beaimed atincreasing society’s overall “researchI.Q.”sothatweareallbetter able tounderstand thenature, purpose andimportance ofresearch participation.

Inpress…Ortega,R,YancyC,MehranR,BatchelorW

Jameson JL,LongoDL.NEngl JMed2015;372:2229-2234.

Implementation of Precision Medicine.

EpigeneticMechanisms

Overarching hypothesis:Disparities inHF&CKDemanate fromthebuiltenvironment

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“Ihavebeenimpressedwiththeurgencyofdoing.Knowingisnotenough;wemustapply.Beingwilling isnotenough;wemustdo.”―LeonardodaVinci

“The roomwhere ithappens…”…