The Problem: Almost half of the residents in Durham County, N.C., are African American (40%) or Latino (8%). Duke University Hospital, the 811-bed, not-for-profit flagship hospital of the Duke University Health System, had identified disparities in cardiac health in this population:
- Although 28 percent of all patients admitted to the hospital were African American, more than 35 percent of the heart attack or heart failure patients were African American.
- African-American patients were more likely than Whites to return to the emergency department within seven days of being discharged from the hospital (12% for African Americans, compared to 4% for Whites).
- African-American patients were more likely than Whites to be readmitted to the hospital within 30 days of their discharge (25% for African-Americans, compared to 18% for Whites).
The Duke University Health System, comprised of Duke University Hospital, Duke Raleigh Hospital and Durham Regional Hospital, is the primary provider of health services in Durham County.
Background: Duke University Hospital had already met or exceeded state and national standards in providing care for heart attack or heart failure patients. It also had a number of initiatives dedicated to improving care for the county's underserved African-American and Latino populations. For example, the hospital provided in-home primary care case management to Latino immigrants and low-cost health services to medically fragile older people living in subsidized housing, most of whom are African-Americans.
Nonetheless, there was work to do. Before participating in the Robert Wood Johnson Foundation's (RWJF) Expecting Success: Excellence in Cardiac Care program, the hospital's intake forms asked about patient race, ethnicity and language, but there were no clear guidelines for ensuring the data were actually collected. "When we saw an outcome that indicated a disparity, we weren't confident that it was accurate," said Catherine McCarver, MBA, MHA, director of the Center of Excellence and administrative lead of Duke's Expecting Success project.
Duke had also developed a monthly scorecard to track key performance metrics, and were working towards that tool being fully reflective of the hospital's diversity goals, as well as being an accountability tool for those goals.
The Project: Duke University Hospital and the health system wanted to improve cardiac care for African-American and Latino populations by identifying and analyzing disparities and developing tools that would better serve them. RWJF supported this work through Expecting Success.
The project team developed and implemented the Get REAL (Race, Language, and Ethnicity) campaign throughout the health care system requiring registration staff to ask all patients to identify their race, ethnicity and primary language. Staff training, upgraded information systems, and efforts to inform patients and families about the purpose of collecting this information were part of the initiative.
"Figuring out why disparities exist depends on having consistent, reliable data about the populations we serve, on understanding their culturally specific needs, and on identifying patterns in care," said Eric Velazquez, MD, the cardiologist who was the principal investigator for Expecting Success.
The project team also refined the performance scorecard, setting goals for employees, departments and the overall health system that focused on quality and patient safety, customer service, finance and work culture. Examples of performances measures include patient satisfaction and, for heart attack patients, angioplasty within 90 minutes of hospital arrival.
"The scorecard provides a simple yet comprehensive view of performance metrics at all levels of our hospital. This helps us to focus on the key hospital goals and direct quality improvement efforts," said McCarver.
To improve outpatient care for heart failure patients, the project team established a clinic in partnership with Lincoln Community Health Center, a federally qualified health center. Primary care doctors at Lincoln screened patients and referred them to Duke cardiologists, either on-site or at a Duke outpatient clinic.
Results: Project staff reported the following results:
- Throughout the Duke health system, the patient population for whom data about race and language was "unavailable" decreased from 20 percent to 8 percent from November 2006 to March 2008.
- Duke University Hospital maintained core measures of heart failure and heart attack care at or above state and national averages throughout the project. The same percentage of African-American and White patients received appropriate heart failure and heart attack care.
- The hospital made incremental improvements in meeting state and national cardiac standards of care during the project period. For example, the percentage of patients who received all of the Centers for Medicare & Medicaid Services' core measures of high-quality care:
- Heart attacks: increased to 98 percent in 2008, compared to 95 percent in 2006 (the statewide figures for North Carolina were 94% in 2008, compared to 82% in 2006).
- Heart failure: increased to 98 percent in 2008, compared to 82 percent in 2006 (in North Carolina, 82% in 2008 and 63% in 2006).
- The hospital revised its discharge process—by improving staff training, revising patient education materials to a lower reading level and translating them into Spanish—to support patients in better managing their care and reducing readmissions.
- The heart failure clinic improved access to outpatient specialty care for patients at Lincoln Community Health Center.
RWJF Perspective: RWJF is committed to ensuring that all Americans receive quality health care. Racial and ethnic disparities were especially likely to occur in treating heart disease, according to the Institute of Medicine. RWJF's Expecting Success national program engaged 10 acute-care hospitals in identifying cardiac care disparities and developing and sharing tools to improve care for African-American and Latino patients. RWJF focused Expecting Success on cardiac care because disparities are well documented and the recommended standard of care is widely accepted and easily measured.
"These hospitals courageously led the way in using data to discover and correct their own racial and ethnic gaps in care. Their hard work demonstrates that we cannot have high quality of care for all until providers see eliminating disparities in care as an essential function of mainstream quality improvement," said Pamela S. Dickson, MBA, assistant vice president for RWJF's Health Care Group.