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Ann Thorac Surg 2003;76:S1346-S1347
© 2003 The Society of Thoracic Surgeons
a Department of Cardiovascular and Thoracic Surgery, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois, USA
* Address reprint requests to Dr Higgins, Department of Cardiovascular and Thoracic Surgery, Rush University, 1653 W. Congress Parkway, Chicago, IL 60612-3833, USA
e-mail: robert_higgins{at}rush.edu
Presented at the symposium on Understanding Disparities in Cardiovascular and Thoracic Surgical Outcomes in African Americans, San Diego, CA, Jan 30, 2003.
Our society has struggled for centuries with racial and ethnic disparities in all sectors of American life. African Americans, Hispanics, American Indians, and Pacific Islanders are all disproportionately represented in lower socioeconomic ranks, in lower quality schools, and in lower paying jobs [1]. These disparities can be traced to historic patterns of discrimination and legalized segregation. Evidence of these racial and ethnic disparities is also found in modern healthcare systems across the country.
The medical literature is replete with a large number of studies demonstrating disparities in cardiovascular care, cancer, treatment of HIV infection, transplantation, and a host of other disease areas [2–6]. Recent emphasis in this regard has refocused individual and national attention on the topic of health disparities. These are not new revelations because members of the minority community have often understood these historical trends to be true throughout the trials and tribulations of their life and death on the outside of the world's most progressive medical infrastructure. Associations such as the National Medical Association and other minority physician groups have worked extensively over the years "to create a force for parity and justice in medicine and the elimination of disparities in health" [7]. In 1986 this topic gained national attention with the release of the report of the Secretary's Task Force on Black and Minority Health by the Department of Health and Human Services [8]. The most recent body of evidence of health disparities was underscored by the National Institute of Medicine's report, "Unequal Treatment," which concluded that "ethnic minorities were more likely than whites to receive a lower quality of health care even among the insured and higher income minority populations" [9]. Although the substance of this work from the Institute of Medicine will be addressed by our keynote speaker, Dr. Alan Nelson, who is the chair of the Institute of Medicine committee on Health Disparities, my comments here serve only as an introduction to the topic and lead us to the very substantive presentations to be highlighted in today's program.
As part of a strategic planning initiative by the Association of Black Cardiovascular and Thoracic Surgeons (ABCTS) in the Spring 2002, this group of roughly 175 African American and minority cardiothoracic surgeons has worked diligently to address the issues of health disparities in cardiovascular and thoracic outcomes through its mission to lower mortality rates for cardiovascular disease among African Americans by increasing access to effective treatment modalities, providing training for cardiovascular and thoracic surgeons, and promoting the prevention of cardiovascular disease. With this primary mission as a focus, a small group of committed members chartered a course to extend its message beyond the membership by creating an external focus in the surgical community at academic and scientific meetings. This symposium is the culmination of many months of effort by the leadership of the ABCTS and represents a focal point for membership, both new and old, to extend its message and work. We are indebted to Dr. William Baumgartner, President of The Society of Thoracic Surgeons, and his staff for their encouragement and support in making this symposium possible. We also are appreciative of Dr. L. Henry Edmunds, Jr., for his support in creating an opportunity to publish the proceedings of this meeting in a supplement to The Annals of Thoracic Surgery.
As we move on to the substance of this meeting, I would like to point out a few very important facts. The Centers for Disease Control and Prevention have reported that of the 15 leading causes of death for African Americans in 1999, heart disease, malignant neoplasms, and cerebrovascular accidents account for the top three causes of death [10]. Coincidentally, sustaining an intentional injury (homicide) and diabetes round out the top five killers of African Americans. Heart disease is the leading cause of death for all racial and ethnic groups, and African Americans were 30% more likely to die of heart disease than whites when differences in age distributions are taken into account [11]. The medical literature is extensive on this topic and confirms differences in cardiac care because African Americans are less likely to undergo invasive diagnostic tests [12], revascularization [13], and thrombolytic therapy [14]. And as these diagnostic and therapeutic modalities are related to outcome, it is evident that long-term survival rates for African Americans with cardiovascular disease is poor as well [15].
In those patients with the diagnosis of thoracic malignancies, particularly nonsmall cell lung cancer, which is potentially curable by surgical resection, there is a body of evidence that suggests that African Americans are less likely to receive surgical treatment and that they are likely to die sooner than whites from their cancer [16]. African-American women were more likely to die of breast and colon cancers than women in any other racial or ethnic group, although they have approximately the same lung cancer death rates as white women [17].
Of critical importance in any discussion about disparities in healthcare among populations is not only the documentation of the occurrence, but rather a more in-depth look at the causes of disparities in healthcare. There is a complex interaction of patient, provider, and healthcare system factors that all contribute to the observations noted above. Issues such as access to quality care and affordable insurance, differences in disease presentation, socioeconomic factors, differences in regional utilization, and patient and physician behaviors all impact disparities in healthcare particularly in cardiovascular and thoracic malignancies in African Americans. Recent literature evaluating the impact of comorbidities highlights the contribution of major diseases to disparities in mortality. In a recent article, published in the New England Journal of Medicine, evaluating the cause specific risks of death from data from the National Health Interview Survey, the study calculated potential years of life lost and potential gains in life expectancy related to specific causes with stratification according to education level and race [18]. The report concluded that although many conditions contribute to socioeconomic and racial disparities and potential life years lost, a few conditions such as smoking related diseases, fewer years of education, hypertension, HIV, diabetes mellitus, and trauma contributed to higher mortality rates among African Americans. In this analysis hypertension and HIV disease contributed as much as ischemic heart disease, stroke, and cancer to the disparity between African Americans and whites.
The Department of Health and Human Services, led by Secretary Tommy Thompson, has identified health disparities in minority communities as a major health emphasis and has embarked upon a number of initiatives to eliminate this disparity. "Take a loved one to the doctor day," a nationwide event developed to help racial and ethnic minority populations improve primary access to health professionals, and "Closing the Gap," a consumer-friendly website providing information and statistics regarding a variety of healthcare services and conditions, have been conceived to eliminate these health disparities [19]. The ABCTS applauds the efforts of members of the health community whether they be of the majority or minority population in working to eliminate disparities in healthcare in this country. We believe that systematic reviews of healthcare delivery systems are necessary, and a proactive implementation program with initiatives designed to address these issues are paramount to achieving the goal of a healthier society for all Americans.
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