Author + information
- Richard J. Kovacs, MD∗ ()
- Krannert Institute of Cardiology, Indiana University School of Medicine/Indiana University Health, Indianapolis, Indiana
- ↵∗Reprint requests and correspondence:
Dr. Richard J. Kovacs, Krannert Institute of Cardiology, Indiana University School of Medicine/Indiana University Health, 1801 North Senate Boulevard, MPC-2 Suite 4000, Indianapolis, Indiana 46202.
Clinicians face many questions in daily practice; among the most important are: Does the evidence upon which I base my practice produce the desired results in the patients I care for? Am I doing my part to reduce racial and ethnic disparities in care?
The Institute of Medicine, in a report on the “Learning Healthcare System,” has called attention to the virtuous cycle of an evidence-based practice that in turn generates practice-based evidence of patient outcomes (1). Clinicians need more opportunities to look at their own practice-based evidence, reflect on the evidence, and improve care. This is the essence of the learning health care system. Electronic medical records and other sources of “big data” now allow for the analysis of such practice level data, including outcomes of patients treated according to different pathways. These data hold promise to not only confirm guideline adherence in real-world care, but also identify gaps in care and generate new hypotheses for testing in randomized trials. The sheer volume of practice-based evidence that can be accumulated automatically should allow for a rapid cycle of improvement in care and the acquisition of new knowledge. The practice of medicine and the pursuit of new knowledge will merge in ways not possible prior to electronic health records and big data (2,3) (Figure 1).
The under-representation of racial and ethnic minorities in clinical trials has continued to challenge clinicians when they apply the results of randomized trials in 1 population to the patients they care for who may not “look like” the trial participants. In cardiovascular medicine, these racial and ethnic differences must be dealt with every day when treating common diseases, such as hypertension and heart failure (HF). It has been more than 5 years since the American College of Cardiology called for a Coalition to Reduce Racial and Ethnic Disparities in Cardiovascular Disease Outcomes (CREDO) (4). CREDO promoted strategies of performance measure–based quality improvement, provider cultural competence training, team-based care, and patient education. Perhaps we can add 1 more strategy: the effective use of electronic records and big data.
In this issue of the Journal, Ogedegbe et al. (5) address both of the previously mentioned questions in an analysis of real-world clinical data on the treatment of hypertensive black patients served by New York City’s Health and Hospital Corporation. The data come from a broad sample of care sites: acute care hospitals, long-term care facilities, home care services, and neighborhood clinics. More than 43,000 patient records were analyzed to answer a crucial question of comparative effectiveness: Did black hypertensive patients receiving angiotensin-converting enzyme (ACE) inhibitors in this health care system fare worse than white hypertensive patients receiving ACE inhibitors?
They determined that ACE inhibitor use in blacks was associated with poorer outcomes: more strokes, myocardial infarctions, and HF. Comparing the effectiveness and safety of antihypertensive drugs in real-world practice empowers a large system of care to make changes that will prevent adverse events. The opportunity to improve outcomes is staggering. In this study, 12,937 blacks in the health care system were treated with ACE inhibitors and nearly 84% were on monotherapy. Presumably, these patients’ blood pressure could be controlled with 1 to 2 alternative antihypertensive agents after simple education of the front-line providers about the results of this trial. Using the number of events reported in the paper, 13 strokes, 3 heart attacks, and 25 cases of HF might be prevented over a period of about 5 years at little or no cost to the system. The long-term sequelae of those events also could be avoided. In addition to the health benefits to the patients, significant savings to the health care system should follow. Demonstrating such a reduction in stroke, myocardial infarction, and HF would seem to be a logical next step for this health care system.
The results may be generalizable and applied to reduce risk in other health care systems. The authors point out that the racial and ethnic mix of New York City is similar to many cities across the United States; consequently, if the data here were applied in similar health care systems, we could rapidly close a gap in care with minimal resource consumption. The evidence generated by this practice enables the virtuous cycle envisioned by the Institute of Medicine to go forward another turn. We look forward to data demonstrating that outcomes can be improved if the care team applies the results of this important analysis to treatment of black patients cared for by the New York City’s Health and Hospital Corporation, a learning health care system.
↵∗ Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.
Dr. Kovacs has reported that he has no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
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