This content was developed in April 2025 by Skye Ferris, MPH Candidate at the University of Virginia, in partnership with the VCSQI DEI 2.0 Workgroup. Contributors include UVA’s Halima Walker, DHA, MSN, RN, CCRN, NEA-BC (Champion); Maheswari Murugesan, MD; Lindsay Fielding, RN; Judy Smith, RN; Kierah Barnes; Erik Scott, MD; Robbin Shifflet, BSN, RN-BC; Hilary Bowen; Cynthia Kennedy, RN, Margaret Davis, Adanna Akujou, MD and Emily Schneiderman; Carilion’s David Wyatt, MD; Inova’s Sharmaine McCoy, RN (Champion), and David Reich; Bon Secours: Lindsey P. Guirgues, MJ, MSN, ACNP; Sentara’s Robert Bernstein, MD; and affiliate Vicki Silvius (MemorialCare).
Diversity, Equity & Inclusion (DEI) in Cardiac Care
A Resource for Providers Committed to Equitable Cardiac Outcomes
Equity in cardiac care starts with cultural understanding and compassionate communication. This page is a dedicated resource to help providers at all levels embrace DEI principles and improve outcomes for every patient, regardless of background.
Providing equitable care means recognizing the cultural and systemic factors that influence how patients experience health and healing. It means creating an environment where all providers and patients can thrive.
Understanding DEI
-
Diversity in cardiac care refers to the representation and active engagement of individuals from varied backgrounds, experiences, and perspectives—particularly those historically underrepresented or marginalized in medicine.
-
Equity in cardiac care ensures fair, just, and impartial treatment, with a focus on eliminating barriers to access and opportunity for both patients and healthcare providers.
-
Inclusion in cardiac care involves cultivating a clinical and organizational environment where all individuals feel welcomed, respected, and valued for their unique contributions.
-
Together, Diversity, Equity, and Inclusion (DEI) are essential to fostering a healthcare workforce that can thrive, while also promoting equitable, high-quality care for all patients.
-
By embracing DEI in cardiac care, institutions benefit from a wider range of perspectives, leading to more informed decision-making, greater cultural competency, and improved patient outcomes.
Understanding the Historical Context of Trust
KFF. (n.d.). How History Has Shaped Racial and Ethnic Health Disparities: A Timeline of Policies and Events. Retrieved May 20, 2025, from https://www.kff.org/how-history-has-shaped-racial-and-ethnic-health-disparities-a-timeline-of-policies-and-events/?entry=2020-to-present-dobbs-v-jackson
When treating patients, it is essential to consider the historical and social context that shapes their healthcare experiences and perceptions. One critical factor is the racial and ethnic background of the patient, which can significantly influence their level of trust in medical providers.
Extensive research shows that non-Hispanic Black and Hispanic adults report significantly higher levels of medical mistrust than non-Hispanic White adults. This mistrust stems from a long legacy of systemic racism and unethical treatment of communities of color—such as the Tuskegee Syphilis Study and forced sterilization of Latina women in the 20th century. These historical harms are compounded by ongoing disparities in care quality, access, and outcomes.
Modern policies also continue to affect health equity. For instance, the Dobbs v. Jackson Women's Health Organization (2022) decision, which overturned Roe v. Wade, disproportionately impacts communities of color, particularly Black women, who already face higher rates of maternal mortality and limited access to reproductive care. As highlighted by the Kaiser Family Foundation’s timeline, this is part of a broader pattern where shifts in healthcare policy can deepen existing racial and ethnic disparities.
Resources such as Ending Unequal Treatment: Strategies to Achieve Equitable Health Care and Optimal Health for All by the National Academy of Sciences, Engineering, and Medicine offer comprehensive insights into how these disparities have developed—and what can be done to address them.
By acknowledging and integrating this historical context into every patient encounter, providers can foster deeper trust. When patients feel seen, heard, and respected, they are more likely to trust their providers, adhere to treatment plans, and believe in the care they receive—ultimately improving health outcomes.
It is therefore the responsibility of healthcare professionals to understand how systemic and historical injustices inform a patient’s relationship with medical care, and to engage with patients through empathy, transparency, and culturally informed practices.
Race in Medicine: From Proxy to Precision
For years, race has been embedded into clinical algorithms, lab formulas, and treatment thresholds under the assumption that it reflects biological difference. In reality, race is a social construct, not a physiologic marker. Its continued use as a proxy in medical tools can unintentionally perpetuate disparities—especially in cardiovascular care.
Example: The now-retired race-adjusted eGFR equation often overestimated kidney function in Black patients, delaying access to specialist care, advanced therapies, and transplant referrals.
Where Race Has Gone Wrong
Clinical equations like the race-adjusted eGFR were designed to improve accuracy but instead have delayed referrals, misinformed risk scores, and restricted access to life-saving therapies—particularly for Black patients. These tools often overlook the real drivers of disparity: structural racism, environmental exposures, and unequal access to care.
Where Race Still Matters
Race and ethnicity remain critical in understanding:
-
Outcome disparities (e.g., HF mortality, hospital readmissions)
-
Access barriers to advanced cardiovascular therapies
-
Patient trust and satisfaction, as reflected in Virginia’s HCAHPS scores
Use race to drive equity-based quality improvement—not to determine individual physiology.
Precision Without Bias: What Providers Can Do
We are not abandoning GFR—we are advancing how it’s calculated. Accurate renal function assessment remains essential in cardiology, especially for:
-
Medication dosing (e.g., ACE inhibitors, SGLT2 inhibitors)
-
Contrast safety
-
Surgical risk assessment
To improve precision and equity:
Step 1: Adopt the 2021 CKD-EPI Race-Free Equation as your lab reporting standard
Step 2: Integrate Cystatin C testing to enhance accuracy when creatinine is unreliable
Step 3: Remove race from your EHR decision-support tools and order sets
"We must be race-aware in addressing health disparities, but not race-based in determining physiology."
MisUsed Tool | Why It’s Harmful |
|---|---|
Pulmonary Function Tests | Built-in race adjustments can mask underlying disease severity |
VBAC Calculator | Underestimated risk in Black and Hispanic women
|
eGFR (race-based) | Delayed nephrology referrals and heart failure medication adjustments
|
GFR in Cardiology: Where It Still Matters
Scenario | What’s Needed | Risk If Biased |
|---|---|---|
LVAD/Transplant Eligibility | Cystatin C or direct GFR | Disqualified due to misclassified function |
Cath Lab/PCI | Accurate renal function | Contrast-induced nephropathy |
HF Medication Titration | Race-neutral GFR | Underdosing or delayed care |
Religion & Cardiac Care
Religion can deeply influence how patients perceive treatment, mortality, and medical decisions.
Examples:
-
Fasting & Medication: Can the patient observing Ramadan take meds outside fasting hours?
-
Blood Transfusions: Does their faith allow them?
-
Animal-Derived Treatments: Are porcine valves or other replacements acceptable?
👉 Use cultural humility to engage in open, respectful conversations.
An individual’s religion may impact how they approach their cardiac treatment.
Providing culturally competent cardiac care therefore must take into account how an individual views medical interventions.
A patient’s religion, spirituality, rituals, sacraments, symbols, diet, and how they approach mortality all can impact patient-provider interactions, and the relationship between the patient and their treatment plan .
Examples of how religion may impact cardiac care:
-
Is the patient observing Ramadan? If they are taking medications that are recommended to ingest with food, can this be accomplished before sunrise or after sunset?
-
Does their religion impact the foods they can or cannot eat?
-
What are their beliefs surrounding animal replacements for human body parts?
-
Ex: Using Porcine Valve Replacements
-
-
Does their religion allow for the acceptance of blood transfusions if needed?
A list of religious and spiritual groups commonly encountered in the healthcare environment, with a summary of their views, can be found here:
Communication & Language
The language used when communicating with patients and about patients can significantly impact how they receive cardiac care.
For example, stating that a patient is “noncompliant” with their medication regimen carries negative connotations about who they are as person, which could impact the care they receive both in the present and in the future.
There are many reasons patients may not be able to adhere to their medication regimen (unable to access transportation to the pharmacy, they cannot afford the medication, they have a caregiver who sometimes forgets to give it to them. etc).
Instead, reframing the wording by stating the patient is “not able to adhere to treatment regimen” or is “non adherent” to the treatment plan removes many negative effects of language.
Reflective Practice and Toolkits
Implicit biases have the potential to impact how a provider approaches the care they give to a patient, whether the provider is cognizant of this bias or not. It is therefore important to practice self-reflection to understand our own biases. Being aware of them is the first step toward eliminating them.
The Implicit Association Test, through Project Implicit from Harvard University, offers users the opportunity to measure their attitudes and beliefs that they may be unwilling or unable to report, including informing the user about implicit biases they may not know they have.
Using journaling prompts of self-reflection allow for personal identification, understanding, and elimination of implicit biases. Examples of such prompts include:
-
How did my background influence how I interacted with a patient?
-
Did I stereotype a patient or have preconceived ideas about who they are?
-
Did I use inclusive language?
-
Did I take the time to understand the cultural context surrounding their medical history and treatment plan?
Self-Reflection & Bias Awareness
All providers carry implicit biases. Recognizing them is the first step to change.
Try These:
-
Implicit Association Test (Harvard Project Implicit)
-
Journaling prompts:
-
Did I make assumptions?
-
Did I consider cultural or religious context?
-
Did I communicate with empathy?
-
Strategies to Address Bias:
-
Introspection: Know your biases.
-
Mindfulness: Reduce stress reactions.
-
Perspective-Taking: Seek stories from other lived experiences.
-
Learn to Slow Down: Reflect before responding.
-
Individuation: Treat each patient as unique.
-
Check Your Messaging: Utilize evidence-based statements, and embrace multiculturalism.
-
Institutionalize Fairness: Embrace the goal of improving equity at the organizational level
-
Take Two: In addition to the practice of cultural competence, practicing cultural humility will strengthen provider-patient relationships through lifelong self-reflection to address potential power imbalances.
Patient Voices at the Winter Quarterly Meeting
As part of our Winter Quarterly Meeting, patients from across the Commonwealth are invited to share their personal stories and healthcare experiences.
These firsthand accounts offer valuable insights into patient outcomes and help guide our ongoing efforts to improve care for all.
Strategies for Change
Strengthen Partnerships with Patients and Families
Strengthen Community Connections to Support Whole-Person Care
Integrate Patient and Family Feedback into Quality and Decision-Making
DEI in cardiac care isn’t an initiative—it’s a responsibility. By embracing diversity, addressing inequity, and promoting inclusion, we empower providers to deliver compassionate care and improve outcomes for all.
References
-
Bazargan, M., Cobb, S., & Assari, S. (2021). Discrimination and medical mistrust in a racially and ethnically diverse sample of California adults. Annals of Family Medicine, 19(1), 4–15. https://doi.org/10.1370/afm.2632
-
Edgoose, J. Y. C., Quiogue, M., & Sidhar, K. (2019). How to identify, understand, and unlearn implicit bias in patient care. Family Practice Management, 26(4), 29–33. https://www.aafp.org/pubs/fpm/issues/2019/0700/p29.html
-
Harvard Business School Online. (2023, February 8). What is DEI? Diversity, equity, and inclusion explained. https://online.hbs.edu/blog/post/what-is-dei
-
Inker, L. A., Eneanya, N. D., Coresh, J., et al. (2021). New creatinine- and cystatin C–based equations to estimate GFR without race. New England Journal of Medicine, 385(19), 1737–1749. DOI: 10.1056/NEJMoa2102953
-
National Academies of Sciences, Engineering, and Medicine. (2024). Ending unequal treatment: Strategies to achieve equitable health care and optimal health for all. The National Academies Press. https://nap.nationalacademies.org/catalog/27820/ending-unequal-treatment-strategies-to-achieve-equitable-health-care-and
-
Project Implicit. (n.d.). Take a test. https://implicit.harvard.edu/implicit/takeatest.html
-
Swihart, D. L., Yarrarapu, S. N. S., & Martin, R. L. (2023, July 24). Cultural religious competence in clinical practice. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK493216/
-
Uppal, P., Golden, B. L., Panicker, A., Khan, O. A., & Burday, M. J. (2022). The case against race-based GFR. Delaware Journal of Public Health, 8(3), 86–89. https://doi.org/10.32481/djph.2022.08.014
-
Wu, D., Lowry, P. B., Zhang, D., & Tao, Y. (2022). Patient trust in physicians matters—Understanding the role of a mobile patient education system and patient-physician communication in improving patient adherence behavior: Field study. Journal of Medical Internet Research, 24(12), e42941. https://doi.org/10.2196/42941