World Heart Day 2020: It's time to make our clinical trials more inclusive

Cardiovascular diseases affect ethnic minorities more than white people, with South Asians being more likely to develop coronary heart disease, and African/African Caribbeans being more likely to develop high blood pressure and twice as likely to have a stroke.

Disparities in cardiovascular health outcomes between different ethnic groups

Despite the progress that’s been made in treating heart disease, there is still a huge difference in mortality between white people and ethnic minorities. Not only do African Americans have a 30% greater chance of dying from cardiovascular disease, they are also more likely to die at a younger age.

Typically, African Americans as a population have more unrecognised risk factors, leading to cardiovascular events being overlooked and left untreated.

So, what are the reasons for these differences? The answer is complex, and involves many social, economic and scientific factors.

Ethnic minorities have repeatedly raised concerns over access to the appropriate healthcare. One study found the average time for a South Asian patient to receive treatment for a heart attack was nearly double compared with a white person. This difference in access to care can be partly attributed to communication barriers, meaning efforts are needed to ensure that language barriers don’t impact the level of care patients receive.  Additionally, there are pronounced ethnic differences in how diseases present themselves. For example, one study found that centrally located pain is symbolic of a heart attack in 87% white people, but this symptom is only displayed in 40% of Bangladeshi patients. The reasons for this aren’t clear, but it could impact the care received by these patients.

Ethnic minorities are more likely to experience discrimination and racial stereotyping, which in turn can impact health outcomes. Dealing with discrimination on a regular basis has been shown to cause chronic stress, and there is compelling evidence to suggest this can lead to increased risk of cardiovascular disease. Ethnic minorities also often perceive physicians and the healthcare industry differently to white people. Racial discrimination and bias, whether conscious or subconscious, in combination with the historical mistreatment of different ethnic groups has led to a lack of trust towards physicians, and ultimately a decrease in the use of health services in these communities.

Health outcomes are also related to how well treatment works for a patient. One study found that black women had the lowest likelihood of responding optimally to treatment, at a rate of approximately 30–36% lower than white men. This is a trend seen across various types of cardiovascular disease treatments, including statins, beta-blockers and ACE inhibitors.

Considering these differences and issues, changes are definitely needed. At COUCH Health, we’re passionate that starts with ensuring diversity in clinical trials.

So, how do we go about increasing diversity in clinical trials?

Unbelievably, around 40% of clinical trials in US-based journals still don’t report on race, despite ethnic minorities bearing the large brunt of burden in these disease areas. And even when ethnicity is reported, ethnic minority groups are often underrepresented – including in heart disease studies. There are many challenges to overcome to increase diversity in clinical trials, which overlap with the barriers mentioned above. These include: low income, investigator bias, medical mistrust, limited health and research literacy and lack of access to transportation. Luckily, these are challenges that can be overcome with the right strategies.

To combat communication barriers, and to ensure patients are properly informed about the clinical trial, we must promote culturally competent communication from study sponsors and sites. Not only will this benefit the patient directly by ensuring they’re playing an active role in their own healthcare, it will help to restore trust between physicians and ethnic minority communities. Next, we need to ensure all recruitment materials are inclusive. For example, producing printed flyers in an array of languages is more likely to engage with people from ethnic minorities where English isn’t their first language. We can also ensure recruitment materials are created based on insights from diverse groups of people, so we thoroughly understand their barriers and motivations.

Here at COUCH Health, we know the importance of diversity and inclusion in clinical trials. By prioritising the inclusion of ethnic minorities in clinical trials, unrecognised risk factors could be identified and treated, drugs that respond optimally between ethnic groups would be identified and produced, all of which would lead to a better version of healthcare for everyone.