Under Pressure Episode #5: Shared Decision Making in Cardiovascular Patient Care to Address Cardiovascular Disease Disparities

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Instructions

Friday, May 13, 2022, 12:00 PM - Tuesday, April 15, 2025, 12:00 PM

What is shared decision making?
Shared decision making is a collaborative process in which the clinician and patient come to a mutual agreement on the patient’s plan of care. It takes into consideration the patient’s values, preferences and social context and aims to improve the therapeutic relationship.

What are some of the disparities in cardiovascular care between white and non-white patients?

• Patients of African descent are three times more likely to die of cardiovascular disease.
• Black patients have higher risk-adjusted mortality after myocardial infarction, especially when they are treated at hospitals that disproportionately serve Black patients.
• Race-based calculators/adjustments can cause over or under diagnosis of certain conditions. Examples include the eGFR calculator, which can lead to the under diagnosis of chronic kidney disease in Black patients. Another example are risk calculators used by cardiac surgeons to predict a patient’s risk of death from cardiothoracic surgery. Using these calculators, Black patients have up to 20% higher predicted risk of death and poor outcomes. As a result, they may not be offered lifesaving interventions.

What is the difference between race and racism?

Race is a social construct. It is a label placed on persons because of physical characteristics (i.e. skin color), ancestral heritage, culture, etc. There is growing evidence that race is not a reliable proxy for genetic differences or physiologic/biologic processes. Racism is a system that assigns values, structures, and opportunities based on a patient’s race.

How should we be assessing social determinants of health (SDH) in our visits?

Social determinants of health involve the conditions in which people are born, live, work, grow, learn, and play that impact their health and health outcomes. Assessing social determinants should be a routine part of clinical workflow. Given the time constraints of a normal primary care visit, Ruth-Alma suggests using a pre-visit screening questionnaire. Some questions may also be asked during the history, such as:

• “What are your goals for your health?”
• “Do you ever have to skip meals at the end of the month to make ends meet?
• “Do you have trouble affording your prescriptions?”

Do you have an example of how screening for SDH has improved patient outcomes?

Ruth-Alma provides example of a 48 year-old male with history of hyperlipidemia found to have elevated blood pressure during office visit. He says that he does not typically have high blood pressure at home/outside of the office. In reviewing his records, you see that he has intermittently missed appointments in the past and his blood pressure was elevated at his last visit. In screening for SDH, he admits that he sometimes is not able to afford his medications. In this case, the first thing to assess is what his goals are for his healthcare. From there, you can discuss the diagnosis of hypertension, lifestyle modifications that fit his goals, and programs to help manage co-pays, and affordable ways to allow him to monitor his blood pressure outside of the office setting.

It can be daunting for physicians to ask about SDH, as we fear we do not have the resources to address some of the issues our patients face. How do you manage this?

Utilize social workers, case managers, community resource specialists, and other members of healthcare team/clinic staff. Look for resources in the community i.e., food banks. If patients are having difficulty paying for prescriptions, consider switching to a different medication within the same class or helping patients obtain manufacturer coupons or pharmacy-based co-pay assistance.

Ruth-Alma’s final clinical pearl: With shared decision making, we have to value patients as partners in their healthcare. Interactions with patients are critical to achieving desired outcomes based on the patient’s desired outcomes and health goals. This will lead to more equitable treatment of cardiovascular conditions.

References:

Berger, R. The Effect of Race on Estimating Glomerular Filtration Rate. NEJM Resident 360. 01 Dec 2021. Accessed on 3/15/22. https://resident360.nejm.org/from-pages-to-practice/the-effect-of-race-on-estimating-glomerular-filtration-rate.

Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361-1367. doi:10.1007/s11606-012-2077-6

1. Describe some of the disparities in cardiovascular care between white and non-white patients.
2. Define social determinants of health.
3. Describe how screening for social determinants of health can improve patient outcomes.

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