Duke University Hospital (DUH) has joined nine other U.S. hospitals in a new national effort that officials believe will help improve heart care for African-Americans and Hispanics. The Robert Wood Johnson Foundation (RWJF) is funding the new program.

More than 120 hospitals and health systems in the U.S. applied to be pilot sites for the “Expecting Success: Excellence in Cardiac Care” program. The 10 hospitals selected all have large minority patient populations, treat many cardiac patients, and have demonstrated an ability to design programs to develop and test best practices to reduce disparities in cardiac care, according to RWJF officials.
“It has been well documented by many studies that this country has troubling racial and ethnic disparities in the treatments patients receive and how they fare,” says William J. Fulkerson, M.D., CEO of Duke Hospital. Fulkerson is the executive sponsor for Duke’s participation in the RWJF program.

“In 2002 the Institute of Medicine issued a groundbreaking report entitled ‘Unequal Treatment,’ which showed that racial and ethnic minorities were more likely to receive lower-quality health care than whites,” says Fulkerson. “Three years later, many studies, including some done by our own Duke Clinical Research Institute, show that the gap persists.”

Fulkerson believes this program can help close the gap, both in Durham and nationally. He points out that Durham is approximately 40 percent African-American and another 12 percent Hispanic. “This program should not only help us reduce disparities in our own community, but hopefully what we learn will allow us to participate in the national solution,” he says.

The 10 participating hospitals will develop a “learning network” to test new ideas, quantify results and share lessons learned. “The types of hospitals chosen and where they are located represent a real-life slice of what is happening in cardiac care in African-American and Hispanic communities across the country,” says Eric Velazquez, M.D., a cardiologist who will serve as program director at Duke. “When the project is complete, the consortium will share relevant lessons with health care providers and policy makers nationwide.”

Capturing Correct Patient Data
A critical way to address and reduce racial and ethnic gaps in treatment is to improve the collection and tracking of patient data by race, ethnicity and spoken language. To this end, DUH will attempt to improve the accuracy of race, ethnicity and language information on patients being admitted.

“We want to move more toward asking patients to self-report on their race or ethnicity, rather than making assumptions,” says Amy Kessenich, R.N., director of the Duke Heart Center’s Center for Excellence. She is the co-project leader with Velazquez. To discover if there is a hidden gap at Duke, the project also will closely monitor balanced scorecards for the heart center and DUH. “We will report each balanced scorecard performance measure by race,” says Kessenich.

Focusing on Discharge
Research has shown that inpatients are increasingly receiving care that clinical trials and studies have shown to be effective in saving lives. However, there is less data on the challenges faced by patients after discharge.

“Our data don’t show any obvious discrepancies at Duke in the care given to minorities while they are in the hospital,” Velazquez says. “But the data do show that African-Americans and Hispanics are more likely to be readmitted or to come back to the emergency department after discharge. Factors ranging from barriers to out-patient appointments to follow-up care to an inability to afford medications to travel difficulties can all play a role, so one area we are focusing on is ensuring that the discharge process is working properly.”

Strategies for this will include:
• Using technology to prompt the scheduling of follow-up appointments at the time of admission
• Implementing culturally sensitive patient education materials
• Finding a way to ensure that all heart failure patients are evaluated for the appropriateness for outpatient disease management
• Making sure that discharge prescription medications are appropriate to the situation -- for example, if the patient is likely to be seen at Lincoln Community Health Center (LHCC), ensure that the medications prescribed are on the LCHC formulary.

Partnering with the Community
Velazquez is also working with LCHC to improve their patients’ access to follow-up cardiac care. “Several Duke cardiologists, including myself, are volunteering our services once a week at Lincoln, to provide consultative services for their patients with heart failure,” says Velazquez. “LCHC sees an enormous number of patients who have been treated for or are at high risk for heart failure. But they haven’t had the resources to provide advanced consultative services. We will be able to help by seeing patients that the LCHC refers to us and providing them with a plan for appropriate follow-up care that providers at LCHC can provide.”

Evelyn Schmidt, M.D., executive director of LCHC, believes bringing this service to patients’ “home ground” will be extraordinarily helpful. “Lincoln serves a large proportion of low-income patients who will be much more comfortable interacting with physicians and planning for follow-up in a familiar setting that is easy for them to access,” says Schmidt. “In addition, our primary care physicians will be able to learn from the knowledge the Duke clinicians share.”

According to Velazquez, the Tuesday evening clinics will benefit the Duke clinicians as well as the patients. “We will learn more about the issues faced by community clinics and by the patients in our community. That understanding is a key to improving health.”