Cardiologists Seek Equity in the Improvement of their Field

To the naked eye, cardiology does not look to be a field in need of improvement—more so just one which has already made great improvements.

If the most accepted metric of a specialty’s status is patient outcomes, and if the greatest outcome is survival, cardiology looks like a field which spent this last decade in a new stratus. After reporting nearly 530,000 deaths due to ischemic heart disease in 1999, the field decreased its mean annual count by approximately 30% in the 2010s

All this speaks to new therapies, robust patient outcome data, and greater marriage between drug development and regulation in that time frame.

But as European Society of Cardiology (ESC) President Barbara Casadei, MD, DPhil, would say: this isn’t quality data. Quality data would show in that great drop in mortalities a far lesser one (if any) among minority groups.

It would show heart failure, hypertension, obesity rates, and diabetes—comorbid events better tied to preventive health—have not similarly decreased.

It would show heart disease remains, significantly so, the greatest killer of women in the US—and that just half of all women know that fact.

Quality data shows a great health inequity in cardiology, a challenge which institutions aim to combat through the 2020s.

Earlier this year, the American College of Cardiology (ACC) launched a task force aimed at improving health equity. Current task force chair and ACC Vice President Dipti Itchhaporia, MD, told HCPLive® the new committee represents the college’s effort to move from aspiration to actual action.

“We've had health equity as a goal on our strategic plan for a very long time,” she said. “We’ve always felt strongly about it, but we haven't really actualized it.”

Itchhaporia, who takes over as ACC President in March 2021, sees the committee aligning with current national movements addressing racism and social injustices in the US—just in the capacity and proficiency of a world-leading cardiology institution.

The systemic and structural barriers that have driven heart disease disparity and socioeconomic determinants of health could be tackled by a triplet of focuses: education, science and quality, and advocacy. From those 3 pillars, Itchhaporia hopes to set a roadmap to 2030 which results in improvement of cardiac mortality across all patient populations.

“Even if we do have a strategic plan or a roadmap within this, it's going to take many, many years of work to actually to have some of the big deliverables that we can envision,” she said. “We have to think, ultimately, about resources and all of that. But all this stuff starts with baby steps, and then we can get accelerated.”

Luckily, the great past successes in cardiology—in bolstered collaboration, in a plethora of new drug classes, in droves of patient-level data, in an embrace of technological advances—has given institutions a leg up in tackling inequity.

Itchhaporia cited “major, robust databases” responsible for optimal benefit of therapy options—advances toward the greatly sought-after precision care.

“Now, can it help to address these issues in social-driven outcomes?” she asked.

Casadei would counter that it’s the responsibility of the specialist, not the data itself, to drive that pursuit. She told HCPLive that the field needs to begin educating a generation of “militant cardiologists”: young clinicians who are fixed on the field’s inequality, and who are savvy with health economics, care cost-effectiveness, and data overall.

The 2020s should see an introduction to cardiologists that are aware their field of care is a “societal problem of a huge dimension,” she said—and that as a result, cardiovascular deaths are causally linked to an element of waste.

“There are a number of nations who have an enormous expenditure in cardiovascular disease that does not reflect in a better outcome or better cardiovascular mortality,” Casadei said. “I think that the use of data is the killer of prejudice.”

Both Itchhaporia and Casadei pondered at what level of education should the issue of cardiac inequity be addressed. Itchhaporia considered the idea of new training models, or collaboration with more social health-facing organizations to create resources. Such materials could be introduced at either the medical school or fellowship levels.

Casadei suggested it begin in medical school. She imagined scenarios where interns and residents are introduced to electronic health records with a better valuation for patient-level data and how it could influence their path of care. Clinicians could become better providers of precision care; researchers could provide more quality observational data.

The ESC and the University of Oxford recently began to offer a Master’s degree in Clinical Trials, in part to emphasize the importance of informed research; a new generation of cardiologists equipped with an understanding of evidence-based care could help break the barrier into health equity.

Beyond the need for better education tools, both institutions see an issue in their field’s representation. Data show nearly half of all US medical school students are women; just 20% of cardiology fellows and 12% of board-certified cardiologists are women.

“We need to generate an environment where female medical students want to be cardiologists, and female trainees and cardiologists are happy to work in cardiology,” Casadei said. “I think it will also make a big difference to the future of our profession and our patients.”

At the ACC task force’s launch meeting, one member asked Itchhaporia, “How big should we think?” She told them to think boldly, and toward what the goal is, regardless of the currently reality about reaching it.

She thought back to the launch of another of the college’s tasks forces: the Task Force on Diversity, in 2017. Within 3 years, it’s become a part of the ACC’s culture and fabric. Its agenda is included without effort in every plan the college puts forth.

“And if we can do that in health equity, how great would that be?” she said.

In 21 years, cardiology medicine has improved greatly—just not for all. The next 10 years may become a time when the needs of the most at-risk patients are finally met.

Cardiologists have high hopes for their field by 2030, scoring a mean 8.3/10 on optimism that the specialty will improve over the next decade.