The Implementation Frontier: Impact on Cardiovascular Health in Racial and Ethnic Minority Populations

Research advances in the prevention, detection, evaluation, and treatment of cardiovascular disease have contributed to the remarkable declines in cardiovascular mortality rates observed over the last half century. Although these improvements have been seen in both men and women and in all racial and ethnic groups at the national level, important differences exist at the sub-national level, especially for population groups defined by race, ethnicity, gender, geography, income, education, and other social and environmental determinants of health. Recent evidence suggests that cardiovascular health disparities remain pervasive. The reasons for these disparities are numerous and include unequal treatment and other important differences in the quality of healthcare delivered to different racial, ethnic, and socioeconomic groups. Impediments to the sustained delivery of evidence-based practices constitute an “implementation frontier” characterized by the underuse of high-value, evidence-based interventions, as well as the overuse of ineffective or low-value interventions—a scenario characterized as a “double jeopardy” often seen in African American and Hispanic populations. This chapter reviews the challenges inherent in the implementation frontier and proposes a framework for exploring strategies to address these challenges. Selected examples used to demonstrate challenges at the frontier include the treatment and control of hypertension; referrals for cardiac catheterization and invasive coronary procedures; utilization and outcomes of structural heart disease interventions; prevention and treatment of heart failure; and anticoagulation for the primary and secondary prevention of ischemic stroke in atrial fibrillation. This chapter concludes with the role that implementors can play in addressing the implementation frontier challenges and the implications for clinical practice and research.