June 14, 2007 A large study has found that black Medicare patients are less likely than white patients to receive blood vessel opening procedures such as angioplasty following a heart attack, whether they are admitted to hospitals that provide or do not provide these procedures, but also experience higher mortality rates at 1 year, according to a study in the June 13 issue of JAMA.
Racial differences in care after acute myocardial infarction (AMI - heart attack) appear most marked for the use of invasive and costly technologies, such as coronary revascularization (restoration of adequate blood supply to the heart, such as with a bypass or angioplasty procedure), although studies have documented similar benefits of post-heart attack coronary revascularization in white and nonwhite patients, according to background information in the article. Few studies have examined patterns of care for heart attack patients admitted to hospitals with and without revascularization services.
Ioana Popescu, M.D., M.P.H., of the VA Medical Center and the University of Iowa Carver College of Medicine, Iowa City, and colleagues assessed racial differences in patterns of care and risk of death for heart attack patients who were admitted to hospitals with and without revascularization services. The study included 1,215,924 black and white Medicare beneficiaries age 68 years and older, admitted for a heart attack between January 2000 and June 2005 to 4,627 U.S. hospitals with and without revascularization services.
The researchers found that black patients admitted to hospitals without revascularization services were less likely to be transferred to a hospital with revascularization services within two days (7.4 percent vs. 11.5 percent) and within 30 days (25.2 percent vs. 31.0 percent) of admission. The likelihood of transfer for black patients admitted to hospitals without revascularization was 22 percent lower compared with that of white patients.
Black patients admitted to hospitals with or without revascularization services were about 30 percent less likely to undergo revascularization than white patients (34.3 percent vs. 50.2 percent and 18.3 percent vs. 25.9 percent). In addition, even among patients who were transferred to hospitals with revascularization services, blacks remained 23 percent less likely to undergo revascularization after adjusting for other clinical factors that may influence the use of revascularization.
While the adjusted risk of death was 9 percent lower for blacks during the first 30 days after admission to hospitals with revascularization and 10 percent lower in hospitals without revascularization, risks were higher thereafter. Between 30 days and 1 year after their initial admission, blacks had a 12 to 26 percent higher adjusted risk of death. These differences were attenuated after further adjustment for whether patients received a revascularization procedure, but nonetheless remained statistically higher.
"... the current study provides evidence that racial differences in the use of revascularization after AMI are of similar magnitude for patients admitted to hospitals with and without full revascularization capability and persist even for patients transferred from hospitals without full invasive cardiac services to hospitals providing these services. These differences could be due to unmeasured clinical or socioeconomic factors, patient preferences, and unmeasured aspects of medical decision making but are unlikely to be related to differences in access to hospitals performing revascularization procedures. Although differences in revascularization may reflect overuse of procedures in white patients, the receipt of revascularization could also explain some of the differences in longer-term mortality in black patients and may represent a broader marker of differences in post-AMI care between black and white patients," the authors write.
"Thus, as data on the benefits of revascularization in different patient subgroups continue to emerge, efforts to standardize post-AMI treatment with evidence-based protocols and aggressive risk-factor management are essential to eliminating racial differences in care for AMI and other coronary syndromes."
Reference: JAMA. 2007;297:2489-2495.
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