Cardiovascular Disease and Determinants of Health

by Charles Vega, MD

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    00:01 Let's talk about cardiovascular disease differences.

    00:03 Another form of health disparities.

    00:05 I do applaud the cardiovascular community because they've dig in a really hard look at particularly race based differences on outcomes.

    00:15 While men continue to have higher rates of cardiovascular disease compared with women, the risk of cardiovascular disease continues to be underrecognized among women.

    00:24 Women and men die of cardiovascular disease at roughly similar rates.

    00:28 Comparing black versus white adults.

    00:30 Higher cardiovascular disease prevalence and a higher cardiovascular disease mortality.

    00:35 Now, given that information, we know that percutaneous interventions for acute myocardial events so just acute myocardial infarction have become a lot more commonly used.

    00:50 Now, they're part of guidelines.

    00:51 It's better care.

    00:52 Patients do better with early PCI within a month of their myocardial infarction.

    00:58 But at the same time despite knowing that this is now considered a standard of care, we see that there's still a lot of folks who are left out from that model.

    01:09 And the disparities that were there in 1992-1993 which are in the green, remain in 2009-2010.

    01:17 While everybody has more access now to PCI.

    01:20 And hospitals have certainly improve their access it may have more of a model of care.

    01:24 You can see that, you know, back in '92-'93, the rates of using PCI were about double in white men compared with black women.

    01:34 And now it's slightly less than double.

    01:36 So these disparities continue despite the broader use of this technology.

    01:41 And that's the thing is that study after study showed, even when these balance out things like socio-economic status and geographical location, insurance status, black patients are less likely to get things like PCI versus white patients.

    02:00 So it really does come down to appearances and an inherent racism within medicine.

    02:06 It does certainly have a factor, and social determinants of health as well that some of the things I just mentioned.

    02:13 I'm just gonna go through what are the major social determinants of health.

    02:16 This list is not comprehensive.

    02:17 But these are the major causes that I see in my practice.

    02:20 It is also recommended by Federal Commission to consider as the major social determinants.

    02:25 So there's income, educational level, unemployment, job security, employment and working conditions in particular.

    02:33 I have a fair number of patients who are at risk for poor health outcomes because of the type of work that they do.

    02:38 Early childhood development.

    02:40 Food insecurity in being in a food desert.

    02:43 The housing situation.

    02:45 Social exclusion and having a social safety network, very, very important.

    02:50 The access to health services of course.

    02:53 Aboriginal status, gender, race and disability.

    02:57 All importance social determinants of health.

    02:59 As I said, the list is incomprehensive but something to consider as you're going through patient care to think about where your patients may have gaps in these areas.

    03:08 Or where they maybe in a group that suffers disparities.

    03:11 And then trying to address that as you move forward with their care.

    03:14 How do you do that? You know, what are some of the keys to cross cultural communication? Because certainly not every patient is gonna share your background, and you know, your values necessarily.

    03:27 That's natural, and I think that's actually a really rich and positive part of medicine.

    03:31 It's being able to communicate with people whose backgrounds aren't your own.

    03:35 It starts of course with good listening skills.

    03:38 So we talked about communication, listening with empathy, and respect at all times.

    03:43 Next is you do get a chance to explain your perspective.

    03:47 Even if a patient really values some kind of care that you don't necessarily provide or even believe in, they're still come into you, it's your job to explain, Well, this is the way my training and what we would normally recommend using these treatment algorithms.

    04:03 Here's what we would recommend to work for you.

    04:07 You're gonna acknowledge the differences and the similarities there.

    04:10 And so that's a great starting point.

    04:12 Where do you have agreement with the patient, and that's a good place to start in negotiating a plan of care.

    04:19 Because you're gonna recommend treatment.

    04:21 The patient did come to see you to get the care that you can provide.

    04:25 So it doesn't, so respecting a person's beliefs and their values and what they wanna do with their own health, doesn't mean that you have to be completely silent.

    04:34 You still got to recommend a treatment but you're not going to mandate the treatment.

    04:38 They're gonna negotiate a plan of care.

    04:40 So I really believed in this LEARN model that the L, and the N are... they're critical parts that negotiation is very, very important.

    04:49 A couple of things about negotiating a plan of care.

    04:52 It leads to greater adherence.

    04:55 So therefore, because your patients more body in and they understand that you heard them and their needs and their limitations.

    05:03 Therefore, I think you're gonna find that they're more likely to follow through.

    05:07 That leads to better outcomes and certainly more satisfaction.

    05:10 Also when I'm negotiating a plan of care, I also document in the chart that they were shared decision making going on.

    05:17 And that's particularly important in cases where patients refuse good evidence base care.

    05:22 I'll make a special note to that.

    05:24 Make sure it's clear on the chart, the electronic record that we use.

    05:28 That way if any other provider sees the patient it instantly recognizable to them.

    05:34 And also just as a note to myself.

    05:36 Because some patients maybe they go away due to family crisis and don't come for two years, I'll still have that front and center on their chart.

    05:44 So it helps me to maintain that respectful relationship and with their values in mind.

    About the Lecture

    The lecture Cardiovascular Disease and Determinants of Health by Charles Vega, MD is from the course Introduction to Family Medicine. It contains the following chapters:

    • Cardiovascular Disease Differences
    • Determinants of Health

    Included Quiz Questions

    1. Negotiating a plan of care
    2. Mandating treatments because they do not have the medical training you do
    3. Making sure they know you are more educated than they are
    4. Assuring that they are only using traditional western medicine that you are familiar with
    5. Avoiding documenting the treatment plan in the patients record if they decline your recommendations
    1. Blacks
    2. Asians
    3. Non-Hispanic Whites
    4. Hispanic Whites
    1. Black women
    2. Black men
    3. White women
    4. White men
    1. Genetics
    2. Income
    3. Education
    4. Gender
    5. Race

    Author of lecture Cardiovascular Disease and Determinants of Health

     Charles Vega, MD

    Charles Vega, MD

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