Model Disease

Essien has taken atrial fibrillation as the “model disease” for his research, as there is plenty of data on the world’s most common cardiac arrhythmia. Hypertension, diabetes and obesity are the key drivers behind the rise in A-Fib, a diagnosis carried by some 60 million people worldwide. In turn, patients with A-Fib have a fivefold greater chance of stroke.

Black and Asians patients, however, are less likely to be diagnosed with and treated for an irregular heartbeat — therefore twice as likely to develop and die from stroke than whites, despite there being oral anticoagulants that can reduce stroke by up to 70%.

Essien used data from the Veterans Health Administration, the nation’s largest integrated health-care system. He conducted a cohort study, published in JAMA Open Network last summer, of

111,666 patients with A-Fib treated from 2014 to 2018. He found that Black, Hispanic, and American Indian/Alaska Native patients were less likely to receive these life-saving drugs.

In another study published in JAMA Cardiology, Essien found that Black patients were 25% less likely than whites to receive the classic blood thinner warfarin and 37% less likely to be prescribed the newer, more beneficial oral anticoagulants approved by the FDA in 2010.

Unconscious Bias

There are a slew of obstacles preventing Black patients from getting equal medical treatment and quality therapeutics. In the clinical trials for the new A-Fib, only 2.1% of the patients were Black, Essien said. Black patients diagnosed with A-Fib may use Medicare more than white patients, who were more likely to have private insurance. And the new medications, such as Eliquis, Xarelto or Pradaxa, can cost up to $500 a month, an expense many Americans regardless of race cannot afford.

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The research using the VA database found that Black patients had about 16% lower odds of being started on any oral anticoagulants than white and Hispanic patients. Those odds dropped to 25% when it came to being started on the new oral anticoagulants.

“Unconscious bias is an issue; we may have certain assumptions about patients that are irrelevant to health care and because of that, we fail to offer them the full breadth of medical treatment,” Essien said. "And that unconscious bias remains today due to a lingering misconception that Black bodies are biologically different than those of whites."

He called on the clinicians attending the lecture to consider whether unconscious bias creeps into their treatment of patients, regardless of race or income.

“Think about the last patient we saw in clinic, a patient who perhaps has been struggling with housing instability over the last few years who has a new diagnosis of atrial fibrillation and you’re thinking, ‘Well, should I prescribe them with a the less expensive warfarin? Should I prescribe them with nothing? Are they going to be able to afford this $500 pill?’”

This bias showed up during the HIV epidemic, he said, when Black patients had 40% lower odds of being prescribed the newly available antiretroviral therapies — and a 70% lower chance of getting prescriptions to prevent one of the most common and severe complications of HIV, a pneumocystis infection within the lungs.

“These findings over 30 years are so important because they really present how persistent the challenge of pharmacoequity has been within our health-care system,” he said.

The ABCs of Solutions: Access, Bias and Costs

Essien pointed out the Affordable Care Act in 2010 reduced the uninsured in this country from 50 million to 20 million individuals, providing consumers with subsidies and expanding the Medicaid program — though not all states have done so.

That still leaves 30 million individuals without health insurance, he said, and many face high retail costs for prescriptions and live in “pharmacy deserts” due to the closures of their local Walgreens, CVS or Rite Aid.

“We have to think about how we improve access to pharmacies for our patients, so it’s not just about whether they have the ability to get a prescription because they have insurance,” Essien said. “But can they physically, geographically access the care that they need?”

Clinicians must also fight bias against Black patients. A 2016 University of Virginia study found that many medical students wrongly believe that African Americans don’t feel pain the same way as whites, due to thicker skin and tougher nerve endings.

“Sadly, a lot of these conversations stemmed from centuries of false beliefs about the differences between Black and white bodies — differences that feed into the algorithms that we use to care for patients,” Essien said.

Finally, Essien said health policy experts must continue to fight for lower drug costs if racial and ethnic minorities are going to gain medical equity. He pointed to a recent Kaiser Family Foundation study that found that 80% of Americans think that drug costs are unreasonable.

Essien closed his lecture with a quote by Theodore Parker, a 19th century Unitarian minister and abolitionist: I do not pretend to understand the moral universe; the arc is a long one … and from what I see I am sure it bends towards justice.

“And this word ‘justice’ is one that I want us to continue to keep in our minds as we pursue pharmacoequity,” he said. “It’s not just a good thing to do — it’s the right thing to do.”