Session number: 1104
Abstract title: Impact of Race on Cardiac Care and Outcomes in Veterans with Acute Myocardial Infarction
Author(s):
LA Petersen - Houston Center for Quality of Care and Utilization Studies
S Wright - Boston VAMC
ED Peterson - Duke University
J Daley - Massachusetts General Hospital
Objectives: The goal of this study was to assess racial differences in process of care and outcome for acute myocardial infarction in the VA health care system.
Methods: This was a retrospective cohort study using clinical data from 4,760 veterans discharged with a confirmed diagnosis of acute myocardial infarction from 81 acute care VA hospitals. The analysis was restricted to 606 African-American and 4,005 white patients. The main outcome measures were comparison of use of guideline-based medications, invasive cardiac procedures, and all-cause mortality at 30 days, 1 year, and 3 years.
Results: African-American patients were equally likely to receive beta-blockers, more likely than whites to receive aspirin (86.8% vs. 82.0%; P<0.05), and marginally more likely to receive angiotensin converting enzyme inhibitors (55.7% vs. 49.6%; P=0.07) at the time of discharge. In contrast, African-American patients were less likely than whites to receive thrombolytic therapy at the time of arrival (32.4% vs. 48.2%; P<0.01). There was no significant difference in refusal of angiography or percutaneous transluminal coronary angioplasty between African-Americans and whites, or in crude rates of either of these procedures. There was also no difference overall in the percentage of patients who refused coronary artery bypass graft surgery. However, African-American patients were less likely than whites to undergo bypass surgery (6.9% vs. 12.5% by 90 days in either VA or under Medicare financing; P<0.001). African-Americans remained less likely to undergo bypass surgery even when high-risk specific coronary anatomy subgroups were examined. There was no difference in mortality in the two groups at any of the time windows studied.
Conclusions: In this integrated healthcare system, we found no significant racial disparities in use of non-interventional therapies, diagnostic coronary angiography, or short- or long-term mortality. Disparities in use of thrombolytic therapy and coronary artery bypass surgery existed, however, even after accounting for differences in clinical indications for treatment and patient refusals.
Impact statement: Since racial disparities were not a function of clinical indications or patient refusals, further work should assess the role of the medical interaction and physician behavior in racial disparities in use of health care.