Partnership Programs for Reducing Cardiovascular Disparities in Native Hawaiians

BACKGROUND:

While there has been great progress in reducing CVD morbidity and mortality in the U.S. over
the past 40 years, some minority groups have not benefitted from this progress, and continue
to have lower life expectancy and higher CVD morbidity. On average, minorities have more
limited access to medical care, receive less aggressive care, and receive fewer diagnostic
and therapeutic cardiac procedures than non-minority populations. Additionally, most
minority groups adhere poorly to prescribed medical regimens and often present to emergency
departments rather than primary care physicians for complications of advanced chronic CVD
conditions. Thus, research to reduce health disparities by improving CVD outcomes in
minorities offers potential for a substantial positive impact on public health. Academic
medical centers and institutions that are capable of carrying out such research, however,
often lack access to minority patients and have difficulty gaining the trust of those they
are able to treat. Minority communities often report greater satisfaction when receiving
care from minority providers and are reluctant to receive treatment outside their minority
healthcare serving systems.

In general, minorities have high rates of elevated cholesterol, hypertension, cigarette
smoking, obesity, metabolic syndrome, and diabetes. Other behavioral, environmental, and
occupational risk factors for cardiovascular diseases, such as sleep problems are also
common among minorties. These risk factors all contribute to excess CVD morbidity and
mortality. Heart failure (HF) is also a major public health problem. The impact of HF on
minority populations, such as Native Hawaiians and other Pacific peoples, is unknown. Native
Hawaiians are known to have high rates of risk factors for HF and one of the highest rates
of CVD mortality in the U.S. The causes of minority health disparities are complex and are
not understood completely. Although evidence of genetic, biologic, and environmental factors
is well documented, poor outcomes are also attributed to incomplete treatment. Such
treatment may be due to limited access to health care or, in some cases, break-down of the
medical system or failure of the physician and/or patient to allow for optimal health care,
even when access is not impaired. The complex interactions of behavior, socio-economic
status (SES), culture, and ethnicity are important predictors of health outcomes and sources
of health disparities. Despite efforts to elucidate genetic and environmental risk factors
and to promote cardiovascular health in high-risk populations, trends in CVD outcomes
suggest that CVD health disparities continue to widen.

The Partnerships Program to Reduce Cardiovascular Health Disparities involves collaboration
between research-intensive medical centers (RIMCs) that have a track record of NIH-supported
research and patient care and minority healthcare serving systems (MSSs) that lack a strong
research program. Each Partnership Program will design and carry out multiple
interdisciplinary research projects that investigate complex biologic, behavioral, and
societal factors that contribute to CVD health disparities and facilitate clinical research
within the MSS. The aim will be to improve CVD outcomes and reduce health disparities.
Additionally, each program will provide reciprocal educational and skills development
programs to train investigators to conduct research that is aimed at reducing cardiovascular
disparities, thereby enhancing research opportunities and enriching cultural sensitivity and
cardiovascular research capabilities at both institutions.

The Request for Applications for Partnership Programs to Reduce Cardiovascular Disparities
was released in September, 2003. The awards were made in September, 2004.

DESIGN NARRATIVE:

To address heart failure disparities among native Hawaiians and Pacific peoples, a
partnership program, the HF Disparities Program (HFD), will be established between the Queen
Emma Clinic (QEC) and the Department of Native Hawaiian Health. Partners of the HFD Program
include tha following: MedStar Research Institute, Oahu-based Community Health Centers
(CHCs), and the Hawaii EXPORT Center, an NIH-funded initiative addressing
diabetes-associated disparities in native Hawaiians and Pacific peoples. The HFD Program
will address the following aims: determine the reliability and validity of echocardiograms
performed by community-based health workers compared to a professionally trained sonographer
as the "gold standard"; determine if a culturally competent educational program for heart
failure reduces HF hospitalizations and mortality compared to usual care; characterize
ethnic differences in the HF syndrome in hospitalized native Hawaiians and Pacific peoples
compared to Caucasians; construct HF pedigrees using probands identified at the Queen Emma
Clinic for a future HF linkage study in native Hawaiians and Pacific peoples; educate
community-based health workers to perform echocardiography scans for the detection of HF in
a high risk population of native Hawaiians and Pacific peoples; and train new investigators
to conduct research focused on CVD disparities in general, and HF in particular. By
achieving these aims, the HFD Program will improve access to HF care at Community Health
Centers that serve native Hawaiians and Pacific peoples, fill a gap in knowledge of CVD
disparities in native Hawaiians and Pacific peoples, and provide a foundation for future
studies on genetic determinants of HF.

Inclusion Criteria:

- Clinical symptoms and signs of heart failure AND

1. Left ventricular systolic ejection fraction of less than 40% OR

2. Left ventricular systolic ejection fraction of less than 60% AND evidence of
abnormal diastolic function confirmed by echocardiogram and documented in the
patient's medical record

- Discharged from a hospital admission for heart failure as a primary or secondary
discharge diagnosis within 6 weeks of study entry

- Self-identified ethnicity/race as Native Hawaiian or Pacific Islander (e.g., Samoan,
Tongan, Tahitian, Maori, Marshallese, etc.)

Exclusion criteria

- Heart failure caused by high-output states (i.e., sepsis, etc.) or transient
non-cardiac disease

- Terminal illnesses in addition to heart failure (e.g., cancer with projected survival
of less than 6 months)

- Currently living in a nursing home

- Currently undergoing hemodialysis or peritoneal dialysis