Regional variations in racial differences in the treatment of elderly patients hospitalized with acute myocardial infarction.
OBJECTIVE
Racial differences in the treatment of patients with myocardial infarction are often presented as nationally consistent patterns of care, despite known regional variations in quality of care. We sought to determine whether racial differences in myocardial infarction treatment vary by U.S. census region.


METHODS
We conducted a retrospective analysis of medical record data from 138,938 elderly fee-for-service Medicare beneficiaries hospitalized with myocardial infarction between 1994 and 1996. Patients were evaluated for the use (admission, discharge) of aspirin and beta-blockers, and cardiac procedures (cardiac catheterization, any coronary revascularization) within 60 days of admission.


RESULTS
Nationally, black patients had lower crude rates of aspirin and beta-blocker use, cardiac catheterization, and coronary revascularization than did white patients. Racial differences in treatment, however, varied by region. Black patients in the Northeast had rates of aspirin use that were similar to those of white patients on admission (50.6% vs. 49.8%, P = 0.58) and at discharge (77.5% vs. 74.2%, P = 0.07), whereas racial differences were observed in the South (admission: 43.7% vs. 48.8%, P <0.001; discharge: 69.5% vs. 73.2%, P <0.001), Midwest (admission: 48.4% vs. 52.3%, P = 0.004), and West (admission: 49.2% vs. 56.2%, P <0.001; discharge: 70.7% vs. 76.2%, P = 0.02). Racial differences in beta-blocker use were comparable across regions (admission: P = 0.59, discharge: P = 0.89). There were no differences in cardiac catheterization use among black and white patients in the Northeast (38.9% vs. 40.5%, P = 0.24), as opposed to the Midwest (43.3% vs. 48.9%, P <0.001), South (39.2% vs. 48.5%, P <0.001), and West (38.3% vs. 48.6%, P <0.001). Similarly, racial differences in any coronary revascularization use were smallest in the Northeast (22.1% vs. 26.7%, P <0.001), greater in the Midwest (24.7% vs. 33.5%, P <0.001), and largest in the South (20.7% vs. 32.0%, P <0.001) and West (22.9% vs. 33.7%, P <0.001). Regional variations in racial differences persisted after multivariable adjustment for aspirin on admission (P = 0.09) and any coronary revascularization (P = 0.10).


CONCLUSIONS
Racial differences in the use of some therapies for myocardial infarction in patients hospitalized between 1994 and 1996 varied by region, suggesting that national evaluations of racial differences in health care use may obscure potentially important regional variations.
Rathore
Saif S
SS
Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.
Masoudi
Frederick A
FA
Havranek
Edward P
EP
Krumholz
Harlan M
HM
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000368:Aged; D001241:Aspirin / Q000627:therapeutic use; D044383:Black People; D006328:Cardiac Catheterization / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007297:Inpatients; D008297:Male; D008499:Medical Records; D015146:Midwestern United States; D009203:Myocardial Infarction / Q000628:therapy*; D009204:Myocardial Revascularization / Q000706:statistics & numerical data; D015205:Northwestern United States; D011787:Quality of Health Care; D012189:Retrospective Studies; D014481:United States; D044465:White People; D001741:Black or African American
D000319:Adrenergic beta-Antagonists; D001241:Aspirin