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CME / ABIM MOC

Confronting Racial and Ethnic Disparities in Cardioprevention: Actionable Insights to Enhance Patient Care

  • Authors: Karol E. Watson, MD, PhD; Modele O. Ogunniyi, MD, MPH
  • CME / ABIM MOC Released: 11/21/2022
  • Valid for credit through: 11/21/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for primary care physicians, cardiologists, and diabetologists/endocrinologists.

The goal of this program is for learners to be better able to understand how social determinants of health manifest as health inequities and contribute to CVD-related morbidity and mortality.

Upon completion of this activity, participants will:

  • Have increased knowledge regarding the
    • Role that social determinants of health have on CVD risk and cardioprevention in the community


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Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.


Faculty

  • Karol E. Watson, MD, PhD

    Professor of Medicine/Cardiology
    David Geffen School of Medicine
    Director, UCLA Barbra Streisand Women’s Heart Health Program
    University of California, Los Angeles
    Los Angeles, California

    Disclosures

    Karol E. Watson, MD, PhD, has the following relevant financial relationships:
    Consultant or advisor for: Amgen; AstraZeneca; Boehringer Ingelheim; Novartis
    Speaker or member of speakers bureau for: Boehringer Ingelheim

  • Modele O. Ogunniyi, MD, MPH

    Associate Professor of Medicine and Master Physician
    Associate Medical Director, Grady Heart Failure Program
    Emory University School of Medicine, Division of Cardiology
    Atlanta, Georgia

    Disclosures

    Modele O. Ogunniyi, MD, MPH, has the following relevant financial relationships:
    Speaker or member of speakers bureau for: Pfizer
    Research funding from: AstraZeneca; Boehringer Ingelheim; LabCorp Drug Development; Zoll

Editor

  • Anne M. Sendaydiego, PharmD

    Medical Education Director, WebMD Global, LLC

    Disclosures

    Anne M. Sendaydiego, PharmD, has no relevant financial relationships.

Compliance Reviewer

  • Yaisanet Oyola, MD

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Yaisanet Oyola, MD, has no relevant financial relationships.


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Developed through a collaboration between Association of Black Cardiologists and Medscape Education.



In support of improving patient care, Medscape, LLC is jointly accredited with commendation by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Aggregate participant data will be shared with commercial supporters of this activity.

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CME / ABIM MOC

Confronting Racial and Ethnic Disparities in Cardioprevention: Actionable Insights to Enhance Patient Care

Authors: Karol E. Watson, MD, PhD; Modele O. Ogunniyi, MD, MPHFaculty and Disclosures

CME / ABIM MOC Released: 11/21/2022

Valid for credit through: 11/21/2023

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Activity Transcript

Karol E. Watson, MD, PhD. Hello, I'm Karol Watson, professor of Medicine and Cardiology at the David Geffen School of Medicine at UCLA. I'm also director of the UCLA-Barbra Streisand Women's Heart Health Program in Los Angeles, California. Welcome to this program titled, “Confronting Racial and Ethnic Disparities in Cardioprevention: Actionable Insights to Enhance Patient Care”. Joining me today is my good friend and colleague Modele Ogunniyi. She's associate professor of Medicine and Master Physician. She's also the associate medical director of the Grady Heart Failure Program at Emory University School of Medicine in Atlanta, Georgia. Welcome, Modele.

Modele O. Ogunniyi, MD, MPH: Thank you, Karol, for having me.

Dr Watson: Multiple organizations have called for a reduction in health inequities, and they recommend consideration of social determinants of health (SDOH) in order to achieve this. In this program, we will discuss how SDOH manifest as health inequities and contribute to cardiovascular disease (CVD)-related morbidity and mortality, and how clinicians can help to reduce these health inequities within their own practices. Modele, can you begin by briefly describing what are SDOH?

Dr Ogunniyi: Thank you, Karol. I think that it is very good to lay a foundation for an interesting discussion today. SDOH, briefly put, are the conditions in the environment where people are born, live, learn, work, play and worship. These SDOH affect a range of health functioning and quality of life outcome and risk.

I particularly like this schematic and definition by the US Department of Health and Human Services has outlined in the Healthy People 2030 goals, which is a set of national data-driven objectives to guide the health of the nation. SDOH can be grouped into 5 domains: education access and quality, healthcare access and quality, economic stability, social and community context, and neighborhood and built environment. Simply put, SDOH affect people where they spend majority of their life.

Dr Watson: How do these various social determinants of health contribute to health inequities in CVD risk and outcomes?

Dr Ogunniyi: That is a very important question. We know from the REGARD study, a cohort study that looked at differences in outcomes among patients from underrepresented race and ethnicity, that there's an increase in risk of fatal coronary heart disease (CHD), as well as non-fatal myocardial infarction (MI), as the number of SDOH factors increased. In fact, individuals with 3 or more SDOH had more than double the risk of fatal CHD when compared to individuals without.

We can look at other SDOH, such as social isolation. We know that in Black women SDOH are associated with an increased risk of CHD mortality. When we look at the neighborhood and built environment, talking about rural and urban areas, when you compare Black and White women of lower socioeconomic status, Black women have almost 3-fold odds of having worse cardiovascular (CV) health compared to their Black counterparts.

I'll close by saying that we know that when we look at hypertension prevention, detection and control, Black men and women tend to have worse outcomes. In fact, when we look at incident hypertension, that is those who do not have hypertension, lifetime discrimination has been identified as a risk factor for developing incident hypertension.

Dr Watson: Yes, that always something that worries me. We can name all the SDOH, like income, education, neighborhood, et cetera, but racism is a social determinant of health and that's very hard to measure, very hard to capture, but it's definitely something that impacts outcomes.

Dr Ogunniyi: That's a very important point that you bring up. As we go through this discussion, I hope that our viewers are thinking about ways that we can address racism, because, in fact, people long have described race as a risk factor. However, as you eloquently mentioned, racism is really that adverse social determinant of health that is leading to worse CV outcomes.

Now I'll turn to you, Karol. How do you think that this various SDOH contribute to health inequities in CV risk and outcomes? Could you tell us briefly the impact of SDOH?

Dr Watson: We think of how our patients do and what their outcomes are as being based on the medications we prescribe, the procedures we perform, those things that we do. But when you look in reality, the actual provision of healthcare is a minor part of how patients will do. When we look at outcomes, the things that impact a patient's outcomes are more their social determinants; things like socioeconomic factors, how much money they have, can they afford their foods? How much education they have, can they understand the complexities of their illness? How much social support they have, things like that. The physical environment, that plays a role as well. Our neighborhoods are where we congregate, how we live and many studies have shown that diseases congregate in neighborhoods, how your neighbor's health is will impact how your health is. How healthy your physical environment is will impact your health. Do you have healthy places to exercise? Healthy places to buy food? Do you have grocery stores that are accessible and affordable?

There are healthy behaviors, also. We have personal responsibility. We need to not smoke, we need to watch our blood pressure, we need to get our labs checked, we need to see our doctors. That matters as well. Then again, the healthcare that we, as physicians and clinicians, provide is a part of how well people do. But as you look at the whole mix of what goes into making a person healthy, you see that these social and socioeconomic factors have probably the greatest impact.

Dr Ogunniyi: Well said.

Dr Watson: When we think about the social determinants and their impact on CVD, we have to think about socioeconomic position. I really like to think about this in every encounter with every patient. You have to remember, they come with their own set of values, beliefs, identity, and we have to respect that. A lot of that really is informed by their socioeconomic position. If they've grown up without access to healthy food or healthy behaviors, if they grew up in areas where there's deprivation, that's going to impact everything.

We like to think about race and its impact and ethnicity and its impact on health, but really what we need to be thinking about is racism. We've been shown time and time again that all people are 99.99999% alike regardless of their race or their ethnicity. What is different is the racism.

Social support matters enormously. Culture and language, can they understand what we are asking them to do? Access to care. Then again, as I mentioned, the residential environment is so important because where we live impacts so much. We tend to adopt the habits that are around us. They've shown that obesity tends to cluster, that if you have a first-degree relative who's obese, you're more likely to be obese. If you have a neighbor who's obese, you're more likely to be obese. A lot of that has to do with the residential environment, but also the culture and the practices and what you learn and adopt.

Now, Modele, it's recommended that clinicians evaluate SDOH on an individual basis to inform treatment decisions for CVD prevention efforts. How do you assess SDOH in your practice?

Dr Ogunniyi: I like to think of myself as a public health physician because of my interest in public health and because I work in a safety net hospital where most of my clinical practice is heavily influenced by patients who are struggling with really multiple adverse SDOH. Being a busy practice, this is where the importance of a multidisciplinary team comes in.

I'll take an example of food insecurity. We know that most of our patients that we see at Grady Memorial Hospital are likely to be food insecure. If we look at the national data, people from the Black race or Hispanic race, and really underrepresented races and ethnicities, have a higher incidence or prevalence of food insecurity compared to the general population.

In my practice, when a patient checks in, it's actually the medical assistant or the nurse that addresses SDOH. Increasingly we see, in this era of electronic medical records, a number of tools to assess SDOH have incorporated into the electronic medical records. In my practice, a medical assistant or a liscensed practical nurse (LPN) is checking in the patient, they're assessing vital signs. They're also asking about SDOH. In fact, the famous wheel of the domains of SDOH populates in a medical record so that by the time I'm getting to see the patient, I can identify the SDOH domain that they are facing problems with, for example, food insecurity. That is already populated in the medical record and as I see the patient, even before I see the patient, the intervention to address that has already been set into motion.

For our colleagues, I'll refer you to the UCSF website. They have a network called Social Interventions Research and Evaluation Network, called SIREN. On that website, they have a list of validated SDOH assessment tool that can be printed on paper or incorporated into electronic medical records.

Dr Watson: That's excellent.

Dr Ogunniyi: Karol, as we think about SDOH and the inequities in CVD, you eloquently have discussed how SDOH negatively influence CV health. We know that this relationship is complex and interrelated. To address them, it requires not only a multilevel approach but a multidisciplinary approach. Can you tell us what can clinicians do in their everyday practice that can help reduce and ultimately eliminate some of these disparities that we discussed?

Dr Watson: That's a critical question. One of the most important things we can do is recognize that SDOH are important and that every patient comes with their own social determinants. We have to think about that when we encounter them. I give an example of a patient I saw about a year ago who had just had an uncomplicated non-ST-elevation MI, did very well, got appropriate therapy released from the hospital with all the right things, the right medications, the right prescription to cardiac rehab, the right dietary advice, everything. And when I saw him in follow up, he sort of sheepishly told me, even though we gave him these generic, life-saving medications, he really couldn't afford them. Even though we gave him a prescription for cardiac rehab, he works 2 jobs and can't take off time to do it. All of the things that we know patients need to do and mostly they want to do, we can't always get to them because of social determinants.

We have to recognize that every time we look at a patient, we have to understand their access to care. If they are able to understand their medications, if they're able to attend their cardiac rehab, if they have a grocery store in their neighborhood where they can find fresh fruits and vegetables.

We also have to address any communication barriers. That's very true, especially of our non-native English speakers. We can't always assume that the information we put out is the same information they receive. That will definitely impact their quality of care.

There are a number of things we can do. We have wonderful, wonderful social workers at UCLA that can help with all this. There's a website I like, it's called findhelp.org. You can actually just put in your zip code, and they can find help for housing assistance, monetary assistance, food assistance, things like that. I do whatever I can to help my patients.

Dr Ogunniyi: I think that as you discuss these strategies, what readily comes to my mind is our practice at Grady Memorial Hospital. We have what we call a food pharmacy, or a program called Grady Food Prescription Program where, like I mentioned earlier, a patient that is identified as being food insecure, can walk out of the hospital to that food pharmacy right outside the hospital. In fact, it used to be a fast-food joint when I was a resident, but now through community partnership with the Atlanta Food Community Bank, and other community banks and other community resources, patients can actually go in and receive a serving of fresh fruits and vegetables for family of 4. The important thing is that we are being able to tie it to improvement in CV outcomes – a reduction in glycated hemoglobin (A1C), control of blood pressure. Patients and their families are offered healthy food cooking classes, cooking demonstrations, which during COVID we were able to do in the world of Zoom.

I think that to address these adverse SDOH, as clinicians, (1) we need a multidisciplinary team; and (2) we have to think outside the box, because as we both discussed today, SDOH have an impact on CV outcomes. To put everything together, our whole purpose today is to make sure we deliver equitable CV care for all.

I will leave you with this summary comments. As a healthcare system, because really this is not only the work of the clinician, we have to understand, and like Karol said, recognize and respond to the needs of our patients. We also said, routine assessment of SDOH should be incorporated into our care system. We cannot do it all. Collaborate with community partners, leaders that our patients trust and as we have heard Karol beautifully explain, a multidisciplinary team-based approach. Providing culturally tailored and competent care to our patients is very important. We cannot underestimate the role of the nontraditional healthcare team workers such as social workers care coordinators, pharmacists and community health workers. Finally, thinking outside the box. Innovation is really important. Innovative programs specifically tailored to address these barriers to care, and programmatic challenges will lead us to achieve that goal of delivering equitable CV care for all, and ultimately reducing CV disparity.

Dr Watson: That was so beautifully said, Dr. Ogunniyi. We have to work from the system level, from the provider level, from the patient level, from the community level. It's going to require all of that.

Dr Ogunniyi: Thank you. It's been an honor and privilege to have this great discussion with you and learning from you because I've known you to be a champion for health equity and really thinking outside the box to improve the care of your patients.

And thank you all, honestly, for participating in this activity. We appreciate your participation, and we know that together we all can achieve health equity for all people regardless of the color of their skin. So please continue on to answer the questions that follow and complete our evaluation.

This transcript has not been copyedited.

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