A large new study suggests that black Medicare patients are less likely to get angioplasty and other blood vessel opening (revascularization) treatments after a heart attack than white patients. This is regardless of whether the hospital they are admitted to provides such treatments or not. Blacks are also at higher risk of death in the first twelve months after a heart attack, the study says.
The study is published in the early online issue of the Journal of the American Medical Association (JAMA).
While research has already shown there are racial disparities in care following acute myocardial infarction (AMI, or heart attack), especially in invasive coronary revascularization operations such as angioplasty, nobody had investigated the pattern with respect to hospitals with and without these services.
The research was conducted by Dr Ioana Popescu of the VA Medical Center and the University of Iowa Carver College of Medicine, Iowa City, and colleagues.
They looked at the racial differences in death risk and care for over a million black and white Medicare heart attack patients admitted to hospitals with and without revascularization services.
The patients were 68 years old or over and were variously admitted to over 4,500 hospitals between January 2000 and June 2005.
The results showed that in terms of receiving revascularization treatment:
- The likelihood that black patients admitted to a hospital without revascularization services would be transferred to one that did have them was 22 per cent lower than for white patients.
- Black patients admitted to a hospital without revascularization services were less likely than white patients to be be transferred to one that did have the services within 2 days (7.4 versus 11.5 per cent) of admission.
- This disparity was also reflected in the 30 day figures which were 25.2 and 31.0 per cent respectively.
- Black patients admitted to hospitals with and without revascularization services were 30 per cent less likely to have a revascularization than white patients.
- For hospitals with revascularization services the figures were 34.3 per cent for black patients versus 50.2 per cent for white patients.
- For hospitals without revascularization services the figures were 18.3 per cent for black patients versus 25.9 per cent for white patients.
- Also, even after transfer, black patients were still 23 per cent less likely than white patients to receive revascularization. This was after adjusting for other reasons why revascularization may not be suitable.
In terms of death risk, the results showed that:
- The adjusted risk of death for black patients during the first 30 days of admission to hospitals with revascularization was 9 per cent lower than for white patients.
- For hospitals without revascularization, the figure was 10 per cent lower for black patients than white patients.
- However, after the 30 day point, the death risk was higher for blacks than for whites.
- Between 30 days and 1 year after admission, black patients had a 12 to 26 per cent higher adjusted risk of death.
- The risk of death for black patients in the 30 days to 1 year period remained higher and statistically significant even after taking into account whether patients received revascularization.
Popescu and colleagues concluded that:
“Black patients admitted to hospitals with and without coronary revascularization services are less likely to receive coronary revascularization. The higher long-term mortality of black patients may reflect the lower use of revascularization or other aspects of AMI care.”
They said that the study provided evidence of racial disparities that persist “even for patients transferred from hospitals without full invasive cardiac services to hospitals providing these services”.
They speculated that the racial 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.”
They suggest that perhaps the difference could also be due to overuse of the procedures in white patients. But, this is unlikely to be the reason why in the longer term the death risk for black patients is higher, and they suggest this study supports the idea that this could be a “broader marker of differences in post-AMI care between black and white patients”.
They hope this study will help to make sure that actual treatment uptake lines up with the emerging evidence of its potential benefit to different patient groups, within the scope of an individual’s risk profile, and not some other non-scientific, spurious reason.
In other words, it is important to “standardize post-AMI treatment with evidence-based protocols and aggressive risk-factor management,” in order to eliminate “racial differences in care for AMI and other coronary syndromes.”
“Differences in Mortality and Use of Revascularization in Black and White Patients With Acute MI Admitted to Hospitals With and Without Revascularization Services.”
Ioana Popescu, Mary S. Vaughan-Sarrazin, Gary E. Rosenthal.
JAMA. 2007;297:2489-2495.
Vol. 297 No. 22, June 13, 2007
Written by: Catharine Paddock
Writer: Medical News Today