Racial Disparities in Revascularization Remain Unexplained

Racial Disparities in Revascularization Remain Unexplained

Black patients are less likely than white patients to undergo revascularization for acute MI, reports a study in JAMA.

Researchers examined Medicare data from 2000 to 2005 on 1.2 million black and white beneficiaries admitted for MI. Overall, blacks were less likely than whites to undergo revascularization by the 30-day mark. When admitted to hospitals without revascularization capabilities, blacks were less likely to be transferred to hospitals with full services. And even after transfer, blacks were less likely to undergo revascularization. Mortality rates were similar in both groups at 30 days but were generally higher for blacks thereafter. The differences persisted after adjustment for sociodemographic factors, clinical characteristics, and distance from the hospital.

The authors conclude that the observed 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."

ABSTRACT:

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, MD, MPH; Mary S. Vaughan-Sarrazin, PhD; Gary E. Rosenthal, MD
JAMA. 2007;297:2489-2495.

Context Racial differences in the use of coronary revascularization after acute myocardial infarction (AMI) have been widely reported. However, few studies have examined patterns of care for AMI patients admitted to hospitals with and without revascularization services.
Objective To compare rates of hospital transfer, coronary revascularization, and mortality after AMI for black and white patients admitted to hospitals with and without revascularization services.

Design, Setting, and Participants Retrospective cohort study of 1 215 924 black and white Medicare beneficiaries aged 68 years and older, admitted with AMI between January 1, 2000, and June 30, 2005, to 4627 US hospitals with and without revascularization services.
Main Outcome Measures For patients admitted to nonrevascularization hospitals, transfer to another hospital with revascularization services; for all patients, risk-adjusted rates of 30-day coronary revascularization and 1-year mortality.

Results Black patients admitted to hospitals without revascularization were less likely (25.2% vs 31.0%; P<.001) to be transferred. Black patients admitted to hospitals with or without revascularization services were less likely to undergo revascularization than white patients (34.3% vs 50.2% and 18.3% vs 25.9%; P<.001) and had higher 1-year mortality (35.3% vs 30.2% and 39.7% vs 37.6%; P<.001). After adjustment for sociodemographics, comorbidity, and illness severity, blacks remained less likely to be transferred (hazard ratio [HR], 0.78; 95% confidence interval [CI], 0.75-0.81; P<.001) and undergo revascularization (HR, 0.71; 95% CI, 0.69-0.74; P<.001; and HR, 0.68; 95% CI, 0.65-0.70; P<.001 in hospitals with and without revascularization, respectively). Risk-adjusted mortality was lower for blacks during the first 30 days after admission (HR, 0.91; 95% CI, 0.88-0.93; P<.001; and HR, 0.90; 95% CI, 0.87-0.92; P<.001 in hospitals with and without revascularization, respectively) but was higher (P<.001) thereafter.

Conclusions 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.

LINK: http://jama.ama-assn.org/cgi/content/abstract/297/22/2489