3065 — Racial Variation in Implantable Cardioverter-Defibrillator Placement for the Primary Prevention of Sudden Cardiac Death in Veterans

Mohn JN (Center for Research in the Implementation of Innovative Strategies in Practice (CRIISP), Iowa City VA COE; University of Iowa), Richardson KK (CRIISP, Iowa City VAMC COE), Vaughan-Sarrazin MS (CRIISP, Iowa City VAMC COE), Cram PM (CRIISP, Iowa City VA COE. Medicine, University of Iowa Hospitals and Clinics)

Objectives:
Evaluate racial variation in the use of implantable cardioverter-defibrillators (ICDs) among veterans with newly diagnosed ischemic cardiomyopathy (ICM).

Methods:
We used 2003-2007 VA patient treatment files to identify beneficiaries with newly diagnosed ICM and no history of ICD implantation using ICD9-CM codes. Comorbid conditions were identified using the method of Quan et al. The principal outcome was receipt of an ICD within one-year of initial diagnosis of ICM. We compared demographics, rates of comorbid illness, and receipt of ICDs among Blacks, Hispanics, and Whites with newly diagnosed ICM. We used multivariable models to examine odds of ICD implantation for Blacks as compared to Whites after adjusting for patient demographics and comorbidity.

Results:
Between 2003 and 2007, we identified 56,272 veterans (mean age 70.2 years) with newly diagnosed ICM who we considered candidates for ICD: 98.2% were male, 70.2% were White, 20.6% Black, 2.5% Hispanic, 1.3% other, and 5.3% missing race. Black ICD candidates were younger than White or Hispanic candidates (mean age 66.0 vs. 71.4 and 70.4 years, P < 0.05), and had fewer comorbid conditions than White candidates (mean 4.15 vs. 4.27, P < 0.05). In-hospital mortality for Black ICD candidates was lower than for Whites or Hispanics (2.2% vs. 3.2% and 2.9%, P < 0.0001). Within one year of diagnosis of ICM, 6.0% of Blacks received an ICD as compared to 7.0% for Whites and 6.1% for Hispanics (P = 0.0002; Black vs. White). In multivariable models, Blacks were significantly less likely to receive an ICD than Whites (OR: 0.793, 95% CI 0.722-0.870, P = < 0.0001), while Hispanics were not less likely than Whites (OR: 0.847, 95% CI: 0.673-1.064, P = 0.154).

Implications:
Black veterans with ICM are significantly less likely to receive ICDs as compared to Whites.

Impacts:
Given that all veterans theoretically have similar access to ICDs, our findings suggest that differences in patient preferences or provider decision-making may play a role in racial disparities in ICD use.