Impact of race on cardiac care and outcomes in veterans with acute myocardial infarction.
OBJECTIVE
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
Retrospective cohort study using clinical data.


METHODS
Eighty-one acute care VA hospitals.


METHODS
Four thousand seven hundred sixty veterans discharged with a confirmed diagnosis of acute myocardial infarction. The analysis was restricted to 606 black and 4005 white patients.


METHODS
Comparison of use of guideline-based medications, invasive cardiac procedures, and all-cause mortality at 30 days, 1 year, and 3 years.


RESULTS
Black patients were equally likely to receive beta-blockers, more likely than white patients 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, black patients were less likely than white patients 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 black patients and white patients, 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, black patients were less likely than white patients to undergo bypass surgery (6.9% vs. 12.5% by 90 days; P <0.001). Black patients 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.


CONCLUSIONS
In this integrated health care system, no significant racial disparities in use of noninterventional therapies, diagnostic coronary angiography, or short- or long-term mortality was found. 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. Further work should assess the role of the medical interaction and physician behavior in racial disparities in use of health care.
Petersen
Laura A
LA
Houston Center for Quality of Care and Utilization Studies, a Health Services Research and Development Center of Excellence, Houston VA Medical Center, Texas 77030, USA. laurap@bcm.tmc.edu
Wright
Steven M
SM
Peterson
Eric D
ED
Daley
Jennifer
J
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D001741:Black or African American / Q000706:statistics & numerical data*; D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000706:statistics & numerical data; D015331:Cohort Studies; D017023:Coronary Angiography / Q000706:statistics & numerical data; D001026:Coronary Artery Bypass / Q000706:statistics & numerical data; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006302:Health Services Research; D006787:Hospitals, Veterans / Q000592:standards; D006801:Humans; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000208:ethnology / Q000628:therapy*; D010043:Outcome and Process Assessment, Health Care / Q000706:statistics & numerical data*; D010342:Patient Acceptance of Health Care / Q000208:ethnology; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D015912:Thrombolytic Therapy / Q000706:statistics & numerical data; D014481:United States / Q000453:epidemiology; D014728:Veterans / Q000145:classification / Q000706:statistics & numerical data*; D044465:White People / Q000706:statistics & numerical data*
D000319:Adrenergic beta-Antagonists; D005343:Fibrinolytic Agents