1 in 17 are Asian 1 in 7 are Asian 5.8% 15% Japanese Korean - - PDF document

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10/10/2017 58YEAROLD ASIAN MALE WITH SHORTNESS OF BREATH Asian American Health Learning from Diversity Asian = ? What is in your differential? Latha Palaniappan, MD, MS Disease pattern differences?

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Latha Palaniappan, MD, MS

Asian American Health – Learning from Diversity

58‐YEAR‐OLD ASIAN MALE WITH SHORTNESS OF BREATH

“Asian” = ?
What is in your differential?
Disease pattern differences?
Sociodemographic differences?
Treatment differences?
Patient satisfaction differences?

Japanese Chinese Asian Indian Korean Vietnamese Filipino

United States

5.8% 1 in 17 are Asian 15% 1 in 7 are Asian

Asian Population by County

50 100 500 1,000 5,000 10,000 50,000 100,000 500,000+

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30% 36% 29% 37%

San Mateo Santa Clara Alameda San Francisco Contra Costa Santa Cruz Stanislaus San Joaquin

Asian Population by County 50 100 500 1,000 5,000 10,000 50,000 100,000 500,000+

1 in 3 are Asian 3.6 billion = 51% 1 in 2 are Asian

U.S. Census Bureau, The 2010 Census Questionnaire: Informational Copy, accessed online at http://2010.census.gov/2010census/pdf/2010_Questionnaire_Info_Copy.pdf, 9/7/15.

9.7%

Population % Growth, 2000 – 2010:

43.3%

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SOURCES: 2010 American Community Survey and other Census Bureau data; Pew Research Center 2012 Asian‐American Survey; U.S. State Department

Meet the New Immigrants: Asians overtake Hispanics

19% 23 23 29 33 36% 59% 55 53 46 42 31%

Hispanic population Asian rise

Korean Immigration Patterns

Sources: Social Explorer, www.socialexplorer.com; Minnesota Population Center; U.S. Census Bureau Matthew Bloch and Robert Gebeloff/The New York Times

1980 1990 2000

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Asian Indian Immigration Patterns

Sources: Social Explorer, www.socialexplorer.com; Minnesota Population Center; U.S. Census Bureau. Matthew Bloch and Robert Gebeloff/The New York Times/

1970 1980 1990 2000

Model Minority?

77% 69% 79%

79%

66% 57%

Income differences: % with income >200% of FPL

NHW: 76%

SOURCES: 2012 American Community Survey http://factfinder.census.gov

Asian Indian Filipino Korean Vietnamese Chinese Japanese

14% 26% 70% 29% 50%

% with bachelor’s and higher:

Non‐Hispanic White Asians (all)

Hmong Cambodian Vietnamese Indian

29%

SOURCES: 2012 American Community Survey http://factfinder.census.gov. https://www.census.gov/prod/2012pubs/acsbr10‐19.pdf

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24 medical centers; 900+ physicians; 933,104 active patients

PAMF Racial/ethnic patient composition

66% PPO 18% HMO 11% Medicare /cal

Asian 25% Black 2% White 45% Other 9% Hispanic 8% Left Blank/ Declined 11%

6% Self‐pay

Asian Indian Chinese Other Asian Vietnamese Korean Japanese 1% 1% 1% 3% 2% 7% 10% Filipino

Coronary Artery Disease, Aggregated Asians: NHW [OR] 1.02 0.92

Holland AT, Wong EC, Lauderdale DS, Palaniappan LP. Spectrum of cardiovascular diseases in Asian American racial/ethnic subgroups. Annals of

Epidemiology. 2011;21(8):608‐14. PMID: 21737048. NIH/NIDDK 5R01DK081371

Men Women

Age‐adjusted

Coronary Artery Disease, Disaggregated Asians:

Asian Indian Filipino Korean Vietnamese Chinese Japanese All Asian NHW

Holland AT, Wong EC, Lauderdale DS, Palaniappan LP. Spectrum of cardiovascular diseases in Asian American racial/ethnic subgroups. Annals of

Epidemiology. 2011;21(8):608‐14. PMID: 21737048. NIH/NIDDK 5R01DK081371

Coronary Artery Disease, Disaggregated Asians:

OR: M W 1.02 1.12 1.77 0.78 1.47 0.72 0.69 1.26 0.72 1.66 0.76 0.34 1.78 0.92 Asian Indian Filipino Korean Vietnamese Chinese Japanese All Asian NHW

Holland AT, Wong EC, Lauderdale DS, Palaniappan LP. Spectrum of cardiovascular diseases in Asian American racial/ethnic subgroups. Annals of

Epidemiology. 2011;21(8):608‐14. PMID: 21737048. NIH/NIDDK 5R01DK081371

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Diabetes, Aggregated Asians: NHW

Men Women

[OR] 2.01 1.9

Wang, E. J., Wong, E. C., Dixit, A. A., Fortmann, S. P., Linde, R. B., & Palaniappan, L. P. (2011). Type 2 diabetes: identifying high risk Asian American subgroups in a clinical population. Diabetes research and clinical practice, 93(2), 248‐254. NIH/NIDDK 5R01DK081371

Diabetes, Disaggregated Asians:

OR: Asian Indian Filipino Korean Vietnamese Chinese Japanese All Asian NHW M W 1.9 2.01 3.54 1.24 4.56 1.48 2.19 1.14 3.44 1.27 3.94 1.56 1.11 1.14

Peripheral Vascular Disease, Aggregated Asians: NHW

Holland AT, Wong EC, Lauderdale DS, Palaniappan LP. Spectrum of cardiovascular diseases in Asian American racial/ethnic subgroups. Annals of Epidemiology. 2011;21(8):608‐14. PMID: 21737048. NIH/NIDDK 5R01DK081371

[OR] 0.45 0.35

Men Women

0.56 0.34 0.27 0.24 0.40 0.31 OR: M W

Peripheral Vascular Disease:

0.5 0.76 0.33 0.96 0.33 0.18 0.11 Asian Indian Filipino Korean Vietnamese Chinese Japanese NHW

Holland AT, Wong EC, Lauderdale DS, Palaniappan LP. Spectrum of cardiovascular diseases in Asian American racial/ethnic subgroups. Annals of

Epidemiology. 2011;21(8):608‐14. PMID: 21737048. NIH/NIDDK 5R01DK081371

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Risk Factor: Smoking

Asian Indian Non-Hispanic White Chinese Filipino Japanese Korean Vietnamese 25% 19% 4% 14% 5% 26% 10% 17% 8% 37% 20% 33% 3%

Caraballo RS, Yee SL, Gfroerer J, Mirza SA. (2008). Adult tobacco use among racial and ethnic groups living in the United States, 2002–2005. Prev Chronic Dis 5(3).

M W 40% HTN(%)

10% 20% 30% 60% 50% 70% 80% 90% 100% 0% 40%

FI: 60% KO: 43% VI: 37% AI: 43% JA: 47% AI: 38% FI: 53% JA: 37% KO: 31% mm Hg VI: 32% CH: 36% c NHW Men: 46% NHW Women: 39% CH: 30%

Risk Factor: Hypertension

Zhao, B., Jose, P. O., Pu, J., Chung, S., Ancheta, I. B., Fortmann, S. P., & Palaniappan, L. P. (2015). Racial/ethnic differences in Hypertension prevalence, treatment, and control for outpatients in Northern California 2010–2012. American Journal of Hypertension, 28(5), 631‐639. NIH/NIDDK 5R01DK081371

High LDL‐C Prevalence (OR)

Asian Indian Filipino Korean Vietnamese Chinese Japanese NHW

Adjusted for: Age, BMI, Primary Insurance, and Smoking Status

Frank, A. T., Zhao, B., Jose, P. O., Azar, K. M., Fortmann, S. P., & Palaniappan, L. P. (2013). Racial/ethnic differences in dyslipidemia patterns. Circulation, CIRCULATIONAHA‐113. NIH/NIDDK 5R01DK081371

1.68

1.31 1.16

0.87 0.94

1.66 1.71 1.25 1.31 0.82 1.15 1.84

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Leading Causes of Death

Asian Indian Filipino Korean Vietnamese Chinese Japanese M W Heart Disease Heart Disease Cancer Cancer Cancer Heart Disease Heart Disease Cancer Cancer Cancer Cancer Cancer

Hastings, K. G., Jose, P. O., Kapphahn, K. I., Frank, A. T., Goldstein, B. A., Thompson, C. A., Eggleston, K., Cullen, M.R., & Palaniappan, L. P. (2015). Leading Causes of Death among Asian American Subgroups (2003–2011). NIH/NIMHD 7R01MD007012‐04

31% 18% 19% 34%

Heart disease Cancer Cancer Heart disease

Lung

23%

Not for Asians

dosing for Chinese, Japanese, and Korean dosing for Blacks/African Americans and Asian Indians

Pharmacological Reviews June 2011 vol. 63 no. 2 437-459

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Agewall, Stefan, et al. "Expert position paper on the use of proton pump inhibitors in patients with cardiovascular disease and antithrombotic therapy." European heart journal 34.23 (2013): 1708‐1713.

CYP2C19:

Loss of function (LOF) CYP2C19*3

Increased risk of thrombosis

Gain of function (GOF) CYP2C19*17

Increased Risk of Bleeding

24% 15% 9% 28%

Japanese Chinese Korean Asian Indian

Hawaii Attorney General Sues Plavix manufacturers for $10,000,000+

38‐79% of Pacific Islanders and 40‐50% of East Asians are poor

metabolizers of Plavix (variations in the CYP2C19 gene)

Hawaii’s demographics:

48% Asian/Pacific Islander

Source U.S. Census Bureau: State and County QuickFacts.

Warfarin Plavix Simvastatin

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Patient Satisfaction: "Very Good" on "Overall Recommendation" question Mean

81% 64% 66% 74% 50% 60% 70% 80% 90% 100% NHW Asian Indian Chinese Other Asian

Summary

Clinically significant differences Better data collection needed! Asians are diverse

Acknowledgments

Fahim Abbasi Themistocles Assimes Dipanjan Banerjee Vivek Bhalla Christopher Gardner Abby King Elsie Wang Cindy Lamendola Tracy McLaughlin Gerald Reaven Fatima Rodriguez Nilay Shah Randall Stafford Viswanathan Mohan Shanmugam Shobana Vasudevan Sudha Ranjit Mohan Anjana Kamala Krishnaswamy Nagappa Malleshi Leonard Lesser Randolph Linde Hal Luft Amy Muzaffar Jose Powell Jia Pu Laurel Trujillo Eric Wong Beinan Zhao Kristen Azar Sukyung Chung Monique‐Nicole Anthony Donald Glacherio Anthony Killeen Melvyn Rubenfire Cetin Ozturk Michael Elliott Wan‐Li Wei Stanley Heshka Steven Heymsfield Anjali Dixit Hamang Patel Thomas Pearson Shankuan Zhu Venkat Narayan Reena Oza‐Frank Peter Wilson Susan Ivey Amlu Natesan Arnab Mukherjea Maria R. Araneta Elizabeth Barrett‐ Connor Michael Criqui Andrea Kwan Gordon Fung Christopher Koenig Regina Otero‐ Sabogal Mercedes Carnethon Namratha Kandula Catherine Crespi Annette Maxwell Mona Pandey Larissa Aviles‐Santa Lisa Diamond Francesca Gany Stephen Fortmann Lora Burke Treveor Orchard Diane Lauderdale

Dr. Latha Palaniappan: lathap@stanford.edu

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CG‐CAHPS Press‐Ganey

[ Instructions: Mark the response that best describes your experience.] Would you recommend this provider’s office to your family and friends? O Yes, definitely O Yes, somewhat O No Likelihood of your recommending our practice to others ………………………….. very very poor poor fair good good 1 2 3 4 5 O O O O O Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this provider? O 0 Worst provider possible O 1 O 2 … O 10 Best provider possible Your confidence in this care provider ….. very very poor poor fair good good 1 2 3 4 5 O O O O O

Answer Scale Matters:

R/E differences in 5‐point vs. 3‐point scales

.2 .4 .6 .8 1 Asian NHW

Likelihood of recommending our practice to others.

Very Good Good Fair Poor Very Poor .2 .4 .6 .8 1 Asian NHW

...recommend the provider's office to family and friends?

Yes, definitely Yes, somewhat No

5‐Point Scale vs. 3‐Point Scale

Answer scale matters:

R/E differences in 5‐point vs. 11‐point scales

43 .2 .4 .6 .8 1 Asian NHW

Likelihood of recommending this care provider to others.

Very Good Good Fair Poor Very Poor .2 .4 .6 .8 1 Asian NHW

...what number would you use to rate this provider?

10 Best possible 9 8 7 6 5 4 3 2 1 0 Worst possible

5‐Point Scale vs. 11‐Point Scale