Why Diversity Matters in ICH Research and Clinical Care

Roy Hamilton, MD, MS, FAANAssistant Professor of Neurology and Physical Medicine & RehabilitationAssistant Dean for Diversity and InclusionPerelman School of MedicineUniversity of Pennsylvania

Image from Johns Hopkins School of Medicine, Diversity Leadership Council website

Why talk about diversity in a meeting on ICH?• Different incidence,

prevalence, and impact in different populations (Disparity)

• Access and treatment are distributed unevenly(Health equity)

• More diverse clinical and research teams enhance care and discovery(Pipeline issues)

?

ICH Impacts Different Populations Differently in the US

Higher growth rates in US ICH admissions in nonwhites than whites from 1979-2008

Disposition and mortality trends of ICH admissions in from 1979 to 2008

Rincon & Mayer, 2013

High rates of uncontrolled hypertension in black and Hispanic

populations my contribute. (Safford, 2016)

Higher in-hospital mortality: • Whites• Women• Black women <

45 years• Middle-aged

black men

• Compared to white patients, black, Hispanic, and Asian patients:– Younger– More severe stroke (higher median NIHSS)

• Black patients: less likely to have door to CT time ≤25 minutes

• All-cause mortality lower for blacks, Hispanics, and Asians than for white patients.

• All minority groups: lower odds of death, comfort measures only, or discharged to hospice; longer hospital stays.

>120K patients with ICH hospitalized at “Get With The Guidelines-Stroke” hospitals (2003 and 2012)

Xian et al., 2014

ICH Impacts Different Populations Differently in the US

Global differences in ICH burden• Incidence of ICH in Asian

populations near double other ethnicities

• Higher % of stroke is ICH in Asian countries– 17-33% Hong Kong, Taiwan,

South Korea, Singapore, Malaysia, Thailand, Philippines and Indonesia

– 30% in the South-East Asian Region (SEAR) and Western Pacific Region (WPR).

• Limited data in African populations suggests proportion of ICH of 26-33% in stroke

Truelsen et al., 2000

Disparities in Access

Figure courtesy ofMichael Stitzer, MD

Disparities in Access

Figure courtesy ofMichael Stitzer, MD

Disparities in Access

Figure courtesy ofMichael Stitzer, MD

Disparities in Access

Figure courtesy ofMichael Stitzer, MD

Access: A barrier to care, often where it is most needed

Krishnamurthi et al.2014,

Global Change in HS Burden(1990-2010)

Incidence (INC), Disability Adjusted Life Years (DALYs), Mortality Rate (MRT), Mortality/incidence Ratio (MIR)

Age-standardized mortality rates of HS (2010)

Global disparities in access impact the worldwide burden of ICHThe “future” of ICH care is distributed unevenly…

K-12 College

Medical School

Residency Fellowship

Faculty

The ‘leaky pipeline’ of physician workforce diversity

13%4% 0%

5%

78%

Racial/Ethnic Distribution of US Neurologists (2008)

Asian (n=1021)

Black or African American (n=291)

American Indian/Alaska Native(n=19)Hispanic/Latino(n=408)

US Neurology Faculty by Gender, Race, and Ethnicity (2011)

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Men Women Men Women Men Women Men Women Men Women Men Women Men Women Men Women

Asian Black or AfricanAmerican

American Indian orNative Alaskan

White Other Unknown Multiple All Hispanic

Just how underrepresented is underrepresented?

0

200000

400000

600000

800000

1000000

1200000

1400000

Men Women Men Women Men Women Men Women Men Women Men Women

Asian Black or African American American Indian orNative Alaskan

White Multiple All Hispanic

Pe

rso

ns

pe

r N

eu

rolo

gist

Ratio: Census By Race & Ethnicity (2010)/Neurology Faculty of Same Race & Ethnicity (2011)

Percentage of Active

Physicians Who are Female by

Specialty (2010)

AAMC 2012 Physician Specialty Databook

Why physician diversity matters?

• Increased likelihood of serving underrepresented/underserved populations

• Increases creativity in addressing issues

• Creates greater ease in managing diversity issues

• Enhances recognition of discrimination

1. Altering the Course: Black Males in Medicine. AAMC 2015.

2. Marrast, et al., 2014

• STEM & clinical pipeline programs for developing diverse clinician workforce

• Enhancing diversity in academic medicine leadership to broaden clinical and research priorities

• Funding opportunities for understanding/combating disparities in clinical neuroscience

Summary: Why talk about diversity in ICH? 1. Differences in race, ethnicity, sex, socioeconomic status, nation of origin, and other aspects of identity directly impact the incidence, prevalence, and outcomes of ICH.

2. These same differences map onto national and global inequities with respect to health access and define patient populations with the highest burden of disease.

3. Efforts to address regional, national, and international disparity and inequity with respect to ICH would be enhanced by promoting a diverse physician workforce that is more inclined to work with burdened populations and is socioculturally aligned with populations in need.

4. Making change in this area requires conscious awareness of the issues, desire to enhance diversity, and knowledge of where and how action will be most effective.

• Stroke Health Disparities:

Management and Patient Outcomes

• Gender and Race Disparities in

Stroke Trials

• Building Academic Pipelines to Clinical

Neuroscience

ICH Health Equity Symposium• Diversity 3.0 : Understanding Diversity in 21st Century

Medicine & Academia

• Panel: “Voices of Diversity in Clinical Neuroscience”

• Platform Talks: “ICH: Global Indicators, Management, and Impact”

• “Meet the Experts”Networking Session

• Abstract Presentations by Early Stage Investigators

Monday, May 1 Tuesday, May 2

Wednesday, May 3