Charles Modlin

The Cleveland Clinic Foundation: 

The Cleveland Clinic Foundation 1921 “Better care for the sick, investigation of their problems and further education of those who serve” Mission Statement

Minority Men’s Health CenterMMHC: 

Minority Men’s Health Center MMHC A New Initiative Charles Modlin, MD, FACS

Minority Men’s Health Center: 

Minority Men’s Health Center Why?

Minorities Increasing in Numbers: 

Minorities Increasing in Numbers 1970: All U.S. Minorities 12.3% population 2003: All U.S. Minorities 25% 2050: Projected 50% Minorities: AA, H, Asian, Native American, Pacific Islander

Special Problems in African American Men: 

Special Problems in African American Men Charles S. Modlin, MD, FACS Glickman Urological Institute Cleveland Clinic Foundation

Health Disparities: 

Health Disparities Measurable differences in disease incidence, morbidity and mortality Disproportionate Burden of disease and illness borne by African Americans Disparate health of AA’s documented in shorter life expectancies Health of the Nation differs by Race

Why Healthcare Disparities?: 

Why Healthcare Disparities? Reasons for healthcare disparities Multifactorial Patient and Provider Factors Impact of Culture Education Historical Factors and Racism Economic Lack of health insurance Lack of access

African Americans and History: 

African Americans and History Historical Distrust by AA’s of white health providers Important barrier for health care Distrust and skepticism of white providers and researchers How did the distrust develop?

Abbreviated Chronology of African Americans in America: 

Abbreviated Chronology of African Americans in America 1857—Dred Scott Decision- US Supreme Court declares Americans of African Descent noncitizens 1863—Emancipation Proclamation freeing slaves in Rebel States 1865—Ku Klux Klan founded 1877—Reign of Terror—arbitrary lynching of black men, women and children in South Beginning of Jim Crow Laws

Abbreviated Chronology of African Americans in America: 

Abbreviated Chronology of African Americans in America 1896—Supreme Court rules segregated schools constitutional 1919—81 Black Troops lynched after WWI 1931—increased pace in lynching 1941-1945—Black returning WWII troops experience more violence in North & South

Tuskegee: 

Tuskegee Tuskegee Study of Untreated Syphilis, 1932-1972 US Public Health Service study, 399 black men, Macon County, Georgia, with Syphilis Deliberately denied treatment, observed to autopsy to study Syphilis natural history President Clinton, May 16, 1997 apologized Link made between Tuskegee, AIDS and Genocide National Research Act of 1974 protection of human subjects

Emory University Fractured Bone Study: 

Emory University Fractured Bone Study Todd KH: Racial Disparity in utilization of pain medication. Annals of Emergency Medicine 35: 11-16, 2000 Black patients 127, White 90, 40-month period Black patients 2/3 as likely as White to receive pain medication for a fractured arm or leg, comparable long bone fractures in urban ER, similar pain complaints Conclusion: patient ethnicity affects decision-making, independent of objective clinical criteria

Examples of Health Disparities: 

Examples of Health Disparities

African Americans Life Expectancies: 

African Americans Life Expectancies AA’s 6 years shorter life expectancy at birth than whites. Average Life Expectancy of Black Americans is 71.8 years, >5 yrs. Shorter than Whites (ave. 77.4 yrs.) AA’s have not benefited equally from medical advances (not even affluent AA’s).

Cardiovascular Disease and Heart Failure in AA’s: 

Cardiovascular Disease and Heart Failure in AA’s CVD leading cause of death in all U.S. pts. Greater incidence in AA’s Major risk factors: tob, HTN, cholesterol, diet, physical inactivity (related to hyperinsulinemia and obesity) AA 13% less likely to have coronary angiography, 1/3 less to have bypass

Cerebrovascular Disease: 

Cerebrovascular Disease Blacks have a higher incidence of stroke than whites Blacks more have hemorrhagic vs. ischemic Are less likely than whites to receive invasive procedures to diagnose and treat Blacks have greater mortality from strokes

Mental Health: 

Mental Health 25% AA develop clinical depression As a result of childhood physical/emotional problems. Suicide 3rd leading cause of death among young AA youth, aged 15-24.

Smoking in African Americans: 

Smoking in African Americans AA tend to start smoking later in life Smoke fewer cigarettes per day than Whites. More likely to smoke Tar and Nicotine brands, 55% AA use only mentholated form. AA are less likely than Whites to quit AA have 30% higher Nicotine intake per cigarette and differ in metabolism.

Slide19: 

Total Population, 1997 Overall Cases of Diagnosed Diabetes Rate per 1,000 Total 40 Race and ethnicity Black or African American 74 White 36

Slide20: 

Persons With Diabetes, 1997 Lower Extremity Amputations

Slide21: 

Total Population, 1997 Diabetes Deaths Rate per 100,000 Total 75 Race and ethnicity Black or African American 130 White 70

HypertensionAfrican Americans: 

Hypertension African Americans HTN risk factor Kidney, eye, heart, vascular disease 20% U.S. Adults 7.5 million Blacks: 33% Blacks have HTN High salt diets, urban living, poverty, psychosocial factors: stress/ anger, genetic predisposition Greater likelihood of being untreated

Response to Medications African Americans: 

Response to Medications African Americans Differences in genetics, environmental and cultural factors may lead to racial differences in response to medications.

Cancer in African Americans: 

Cancer in African Americans Cancer is the 2nd leading cause of U.S. deaths AA’s have the highest death rates in U.S. Contributing factors: Tob, occupations, diet, knowledge, attitudes and practices, health/medical resources, biological factors, and socioeconomic status.

Cancer: 

Cancer By race, AA more likely to develop and die of the 4 most common cancers (breast, prostate, colon, and lung—ACS 2002.

Slide26: 

Total Population, 1998 Lung Cancer Deaths Rate per 100,000 Total 57.6 Race and ethnicity American Indian or Alaska Native 38.2 Asian or Pacific Islander 29.3 Black or African American 66.7 White 57.5 Hispanic or Latino 22.7

Slide27: 

Total Population, 1998 Colorectal Cancer Deaths Rate per 100,000 Total 21.2 Race and ethnicity American Indian or Alaska Native 13.3 Asian or Pacific Islander 13.7 Black or African American 28.2 White 20.8

Prostate Cancer in Blacks: 

Prostate Cancer in Blacks Black men, on average, 3-yrs younger than whites at time of diagnosis Risk Factors: Strong familial disposition 5-10% cases or > 1, 2 or 3 First Degree Relatives with CAP Relative risk increase 2, 5, 11% respectively Hormonal High Fat Diet Molecular Epidemiology (chromosomal alterations) High Grade PIN

Slide29: 

Males, 1998 Prostate Cancer Deaths Rate per 100,000 Total 32.0 Race and ethnicity American Indian or Alaska Native 15.9 Asian or Pacific Islander 12.4 Black or African American 68.7 White 29.4 Hispanic or Latino 20.9

AA and ESRD: 

AA and ESRD Growing Burden of chronic renal disease. Rate of ESRD from HTN 6x higher in AA. 319 cases/million AA vs. 52 cases/million W. ESRD from DM 4x higher in AA than W. AA mean age of ESRD 5 yrs. Earlier In AA each level of SBP, AA more likely to develop ESRD. AA 56% less likely to receive peritoneal dialysis.

Racial Disparities in Renal Transplantation: 

Racial Disparities in Renal Transplantation

Source of Allograft:Racial Disparities: 

Source of Allograft: Racial Disparities AA W p=0.0003 CAD 70% 53% LR 24% 35% LUR 6.0% 12% DUAL 6.0% 4.4% p=0.4

Cadaveric Renal TXMedian Waiting Time: 

Cadaveric Renal TX Median Waiting Time Whites 734 Days Blacks 1335 Days

Pre-TX Wait List and Dialysis Durations: 

Pre-TX Wait List and Dialysis Durations Days P<.0001

Slide35: 

P=.0003

Race: 

Race * P<.0001

Slide37: 

P=.002

Dialysis 1st Week Post-TX: 

Dialysis 1st Week Post-TX *P<.0001 *

Organ Allocation System Unfair?: 

Organ Allocation System Unfair? Current HLA allocation system favors whites More white cadaver and living donors Need more organ donation in black community Reasons for refusal of donation are religious myths and misperceptions, distrust of medical community, racism

What does the Minority Community Want?: 

What does the Minority Community Want? The African American Community wants a long-term, regular on-going relationship. Connection with provider who engages him/her for the long haul. Demonstrated support for the community.

Elimination of Minority Health Disparities: 

Elimination of Minority Health Disparities

MMHC A New Approach to Combat Health Disparities: 

MMHC A New Approach to Combat Health Disparities Initial Target Group: AA Men Initial Focus of clinical and research efforts: Prostate cancer (detection, treatment) Renal Failure (Transplantation Access) Facilitated and Coordinated Care Resource for AA complete patient care HTN, Cholesterol, Diabetes, Colon Cancer, Nutrition, Physical Fitness, Smoking Cessation, Sexual Dysfunction, etc. (Clinical Research Database will track outcomes)