Racial and ethnic disparities in cardiovascular medication use among older adults in the United States
This US-based investigation surveyed racial and ethnic disparities in the use of statins and aspirin among 3005 older community-dwelling adults (aged 57–85 years) at low (n=812), moderate (n=977), and high risk (n=1066) for cardiovascular disease (CVD) between June 2005 and March 2006. The paper reports the highest rates of use among respondents at high cardiovascular risk. Racial differences were highest among respondents at high risk, with Blacks less likely than Whites to use statins (38% vs 50%) and aspirin (29% vs 44%). Racial/ethnic disparities persisted after controlling for confounding factors.
Importantly, although the authors talk about disparities in ‘participant use of medication’, on closer reading of the paper it appears that the researchers looked at ‘presence of medication’ in the home. This suggests that disparities in ‘adults use’ are in fact due to lower rates in ‘prescriptions’ for African Americans with high CVD risk. The fact that disparities increased with CVD risk is also alarming. Strategies to consider in our own practice may include clinical audits (to monitor prescribing practice) and health literacy interventions that empower patients/whānau.
Reference: Pharmacoepidemiol Drug Saf. 2010;19(8):834-42.
General practitioners’ views about diagnosing and treating depression in Māori and non-Māori patients
Findings are reported from semi-structured interviews with 23 general practitioners (GPs) in the Auckland region, including both Māori and non-Māori GPs, that elicited their views about risk factors for depression, recognising depression and circumstances in which GPs would prescribe medication or recommend other treatments for depression. The interviewers hoped to establish possible reasons for reported lower levels of diagnosis and treatment of depression among Māori compared to non-Māori patients. Reasons reported by GPs as most likely to lead to ethnic differences in diagnosing depression were greater stigma relating to admitting depression among Māori patients, Māori patients being less likely to talk about being depressed, and the need for patients to have effective communication with their GP. Effective communication, where Māori patients felt free to talk about personal feelings, was more likely when there was an established relationship between the GP and patient.
This study aims to understand why Māori with depression are less likely to have a correct diagnosis and appropriate management. Increasingly, we are seeing literature that describes the ‘provider’s perspective’ in an attempt to explain ethnic disparities. This paper goes further to consider skills that could be taught to GPs in order to improve their practice.
Reference: J Prim Health Care. 2010;2(3):208-16.
A community-based model of care improves blood pressure control and delays progression of proteinuria, left ventricular hypertrophy and diastolic dysfunction in Māori and Pacific patients with type 2 diabetes and chronic kidney disease: a randomized controlled trial
The efficacy of a novel, integrated, community-based model of care using culturally appropriate health-care assistants to manage hypertension in Māori and Pacific patients with diabetes and chronic kidney disease (CKD) was compared with that of conventional care in achieving blood pressure (BP) targets and delaying progression of cardiac and renal end-organ damage. The study cohort consisted of 65 Māori and Pacific patients (aged 47–75 years) with type 2 diabetes, moderate CKD (>0.5 g proteinuria/day, serum creatinine 130–300 μmol/L) and hypertension, who were randomised to usual care (n=32) or community/ intervention care (n=33) for 12 months. Community care patients were visited monthly by a nurse-led health care assistant for BP measurement. By 12 months, the community care patients had achieved a significantly greater reduction in office systolic BP (−21 mmHg vs −12 mmHg; p=0.04) and in 24h urine protein (−1.4 g vs +0.1 g; p=0.04). The number of prescribed antihypertensives was greater in these patients at 12 months (3.4 vs 2.3; p<0.01). Left ventricular mass and left atrial volume progressed in the usual care group, but not in the intervention group.
I think key factors in the success of this ‘intervention’ are (1) the Māori and Pacific health worker (referred to as a health care assistant in the paper); (2) the health care assistants working closely with nurse leaders; (3) integrated care across primary and secondary services including communication between providers; (4) the ‘education package’ about hypertension and reasons for medication and; (5) regular contact.
Reference: Nephrol Dial Transplant. 2010;25(10):3260-6.
Impact of the community’s socioeconomic status on characteristics and outcomes of patients undergoing percutaneous coronary intervention
These Israeli researchers sought to determine whether the socioeconomic status of a community influences the characteristics and outcome of patients treated with percutaneous coronary intervention (PCI), using data from the Israel Central Bureau of Statistics, which assigns a socioeconomic index (SI) to communities based on demographic, economic and educational parameters. The SI was determined for 1397 patients who underwent PCI between April 2004 and October 2006; patients were divided into low, intermediate or high SI. Compared with an intermediate or high SI, a low SI community socioeconomic level was associated with a significantly younger age, significantly higher rates of diabetes and of smoking, a significantly lower rate of drug-eluting stent implantation, lower adherence to aspirin and clopidogrel therapy, a significantly higher rate of repeat revascularisation and a higher rate of recurrent myocardial infarction. A lower SI was an independent predictor of major adverse cardiac events during follow-up (HR, 1.52).
PCI may not be appropriate treatment for coronary artery disease in smokers or people with diabetes. In these cases, CABG (coronary artery bypass grafts) should be considered for the microvascular and multi-vessel nature of the disease. Given the poor outcomes associated with PCI in people with low SI, perhaps guidelines should be revised to ensure that a ‘high level of deprivation associated with DM and smoking’ is considered in or contributes to a lower threshold for recommending CABG.
Reference: Int J Cardiol. 2010;144(3):379-82.
Targeting dental resources to reduce inequalities in oral health in the North East of England – a health equity audit methodology to evaluate the effects of practice location, practice population and deprivation
Outcomes are reported from a health equity audit undertaken in County Durham, England, to support the targeting of resources to meet the needs of patients from deprived communities, in areas where levels of poor oral health remain higher than the rest of the population as a whole. The researchers matched postcodes of 224,107 patients in County Durham to Lower Super Output Areas (LSOA) for each practice. Deprivation scores were identified for each LSOA. The postcode of 59 dental practices was matched to the LSOA and the practice population divided into quintiles from the most to the least deprived areas. The more deprived the area in which a dental practice was located, the greater the proportion of the practice population accessing care from the most deprived quintile. The size of the practice alone was not directly related to meeting the needs of a more deprived population.
This paper supports the notion of an ‘inverse care law’ operating in dental care in North England, whereby dental practices have set up in areas of high demand rather than high need. As the authors suggest, targeted investment to meet local need is required to address dental health inequities; many Māori providers have already established Orange Niho care on site and perhaps Whānau Ora centres should also consider investing into oral health services.
Reference: Br Dent J. 2010;209, E3.
Is bowel cancer screening important for Māori?
This paper discusses the evidence in support of the importance of bowel cancer screening in Māori New Zealanders. Currently, Māori have lower incidence of colorectal cancer compared with NZ Europeans, but the rates are increasing more rapidly among Māori. Moreover, despite this lower incidence, the colorectal cancer mortality burden is similar for Māori and NZ Europeans. Notably, colorectal cancer mortality rates have generally increased since the early 1980s among Māori, yet have remained stable or declined among NZ Europeans. In addition, survival among Māori with colorectal cancer is lower than that for non-Māori. There is evidence of poorer access and quality of care contributing to poorer colorectal cancer survival in Māori compared with non-Māori patients. A pilot bowel cancer screening programme is planned; the authors of this paper stress that attention must be paid to the effectiveness of this programme for Māori as well as European New Zealanders. Its introduction has the potential to reduce ethnic disparities in colorectal cancer survival, if screening is accompanied by investment in diagnostic and treatment services (such as colonoscopy).
With the roll-out of bowel cancer screening, and potential for further cancer screening programmes to be developed/implemented with advancing technologies, it’s timely to consider the place of such initiatives for Māori. This opinion piece provides a description of the issues that is both comprehensive and relevant so that when faced with a similar question – is this important for Māori – we can respond appropriately.
Reference: N Z Med J. 2010;123(1320):9-12.
Incidence and management of high grade glioma in Māori and non-Māori patients
These researchers retrospectively analysed data from 301 patients undergoing surgery for high-grade glioma (HGG) in New Zealand between 1993 and 2003. The study aimed to determine the relationship of ethnicity with incidence, treatment and survival. Age standardised incidence rates for HGG did not differ between Māori and non-Māori patients (4.2 vs 4.1 per 100,000 person years). Māori were more likely to have complete tumour resection (OR, 3.59) but waited 1.32 times longer for radiotherapy. Median survival was 29 weeks, with poorer survival in Māori compared to non-Māori (HR, 1.55).
An example of researching the health care pathway – and that it’s not enough to stop at incidence rates when they appear ‘equal’. As the researchers have shown, despite equal rates in occurrence and initial treatment, the disparities in long-term treatment appear to contribute to poo
Reference: J Clin Neurosci. 2010;17(9):1144-7.
Pōwhiri process in mental health research
Māori value the traditional Pōwhiri process of engagement and participation in mental health; the practices and protocols of this process are founded on the notion of respect and positive relationships between the tangata whenua (hosts or research participants) and manuwhiri (guests or researchers). The paper’s authors suggest that the Pōwhiri process may be a model applicable to research with other indigenous cultures.
A great example of a Kaupapa Māori methodology being presented in an international forum. The authors have not only described the process so that others may consider utilising it in their research methods, they have also provided an informative critique.
Reference: Int J Soc Psychiatry. 2010 Nov 18. [Epub ahead of print]
