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Comment & Response
March 4, 2020

Improving Racial and Ethnic Minority Representation in Cardiovascular Disease Trials to Advance Health Equity—Reply

Author Affiliations
  • 1Faculty of Medical Science, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
  • 2ICES, Toronto, Ontario, Canada
  • 3Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  • 4Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
  • 5Cardiovascular Division, Women’s College Hospital, Toronto, Ontario, Canada
JAMA Cardiol. Published online March 4, 2020. doi:10.1001/jamacardio.2020.0146

In Reply We appreciate Ifidon and colleagues’ letter regarding infrequent reporting of racial and ethnic minority groups among the included studies in our systematic review.1 The issue of racial disparities in the treatment of hypercholesterolemia has been well documented. Notably, rates of statin use are often lower in African American populations considered at highest risk of cardiovascular disease compared with white populations at equal risk.2 In secondary prevention, racial minority groups with coronary heart disease often have worse long-term cardiovascular outcomes and higher rates of mortality.3 Given these disparities, novel interventions that are effective among populations experiencing the greatest inequity in cardiovascular care—be they racial or ethnic minority groups, individuals with low socioeconomic status, women, or the intersection of multiple social categorizations—are critically important.4

The existing literature regarding statin prescribing interventions is still in its infancy, and significant research is needed to confirm the types of interventions most likely to be effective. It is important for future pragmatic studies to consider the racial/ethnic, socioeconomic, and sex makeup of their populations and tailor their setting, recruitment tactics, interventions, and follow-up accordingly. The first step in this process is collecting and reporting data on the racial/ethnic makeup of the study populations, which, as Ifidon and colleagues thoughtfully noted, unfortunately was often not done by the studies included in our review.1 A robust understanding of the racial/ethnic makeup of these patients would have improved the review’s external validity to real-life clinical practice.

Another major finding from our review was that patient-focused interventions are more likely to be effective than those that are physician oriented.1 This finding highlights the significant impact of empowering patients in their health. Such a focus also aligns with patient-oriented research and engagement in health care and policy, particularly with an emphasis on including those traditionally underrepresented in these areas. The importance and benefit of engaging patients in health care improvement projects cannot be understated, especially as a means to authentically reflect the needs of diverse racial and ethnic minority groups. To assist clinicians and researchers in integrating patient engagement in their intervention-based trials, both the Patient-Centered Outcomes Research Institute5 in the United States and Strategy for Patient-Oriented Research6 in Canada have resources available to support this work.

The goal of research exploring ways to improve statin prescribing is to ultimately reduce the burden of cardiovascular disease in high-risk populations. It is vital that improvements in cardiovascular disease management be equally enjoyed by individuals from all racial and ethnic groups. The letter by Ifdon et al highlights the importance of discussing and reflecting on how medical research can be improved to help reach this goal.

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Article Information

Corresponding Author: Jacob A. Udell, MD, MPH, Cardiovascular Division, Women’s College Hospital, 76 Grenville St, Toronto, ON M5S 1B1, Canada (jay.udell@utoronto.ca).

Published Online: March 4, 2020. doi:10.1001/jamacardio.2020.0146

Conflict of Interest Disclosures: Ms Ferreira-Legere reports receiving grants to her institution from the Ontario Ministry of Health and Long-Term Care. Dr Udell reports receiving a Heart and Stroke Foundation of Canada National New Investigator–Ontario Clinician Scientist Award and an Ontario Ministry of Research Innovation and Science Early Researcher Award; grants from AstraZeneca, Novartis, and Sanofi; and personal fees for consulting or honoraria from Amgen, AstraZeneca, Boehringer Ingelheim, Janssen Pharmaceutical, Merck, Novartis, and Sanofi. No other disclosures were reported.

References
1.
Sparrow  RT, Khan  AM, Ferreira-Legere  LE,  et al.  Effectiveness of interventions aimed at increasing statin-prescribing rates in primary cardiovascular disease prevention: a systematic review of randomized clinical trials.  JAMA Cardiol. 2019;4(11):1160-1169. doi:10.1001/jamacardio.2019.3066PubMedGoogle ScholarCrossref
2.
Qato  DM, Lindau  ST, Conti  RM, Schumm  LP, Alexander  GC.  Racial and ethnic disparities in cardiovascular medication use among older adults in the United States.  Pharmacoepidemiol Drug Saf. 2010;19(8):834-842. doi:10.1002/pds.1974PubMedGoogle ScholarCrossref
3.
Mochari-Greenberger  H, Mosca  L.  Differential outcomes by race and ethnicity in patients with coronary heart disease: a contemporary review.  Curr Cardiovasc Risk Rep. 2015;9(5):9. doi:10.1007/s12170-015-0447-4PubMedGoogle ScholarCrossref
4.
Taber  DJ, Gebregziabher  M, Posadas  A, Schaffner  C, Egede  LE, Baliga  PK.  Pharmacist-led, technology-assisted study to improve medication safety, cardiovascular risk factor control, and racial disparities in kidney transplant recipients.  J Am Coll Clin Pharm. 2018;1(2):81-88. doi:10.1002/jac5.1024PubMedGoogle ScholarCrossref
5.
Patient-Centered Outcomes Research Institute. Engagement tool and resource repository. https://www.pcori.org/engagement/engagement-resources/Engagement-Tool-Resource-Repository. Accessed December 12, 2019.
6.
Canadian Institutes of Health Research. Strategy for Patient-Oriented Research—patient engagement framework. https://cihr-irsc.gc.ca/e/48413.html. Accessed December 12, 2019.
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