(Circulation. 2000;102:642.)
© 2000 American Heart Association, Inc.
Clinical Investigation and Reports |
Race, Sex, Poverty, and the Medical Treatment of Acute Myocardial Infarction in the Elderly
From the Clinical Economics Research Unit (S.S.R., A.K.B., K.P.W., K.A.S.), the Division of Cardiology (A.K.B., B.J.G.), and the Institute for Health Care Research and Policy (M.F.), Georgetown University Medical Center, Washington, DC; Maryland HealthCare Associates, LLC, Clinton, Md, and the Delmarva Foundation for Medical Care, Inc., Easton, Md (W.J.O.). Mr Rathore is now at the University of North Carolina School of Public Health, Chapel Hill. Dr Berger is now at the Division of Cardiology, Yale-New Haven Medical Center, New Haven, Conn. Drs. Weinfurt and Schulman are now at the Center for Clinical and Genetic Economics, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC. Dr Gersh is now at the Cardiovascular Diseases Division, Mayo Clinic, Rochester, Minn.
Correspondence to Dr Schulman, Center for Clinical and Genetic Economics, Duke Clinical Research Institute, Duke University Medical Center, PO Box 17969, Durham, NC 27715. E-mail schul012{at}mc.duke.edu
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Abstract |
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Background—Race, sex, and poverty are associated with the use of diagnostic cardiac catheterization and coronary revascularization during treatment of acute myocardial infarction (AMI). However, the association of sociodemographic characteristics with the use of less costly, more readily available medical therapies remains poorly characterized.
Methods and Results—We evaluated 169 079 Medicare beneficiaries
65 years of age treated for AMI between January 1994 and February
1996 to determine the association of patient race, sex, and poverty
with the use of medical therapy. Multivariable regression models
were constructed to evaluate the unadjusted and adjusted influence of
sociodemographic characteristics on the use of 2 admission (aspirin,
reperfusion) and 2 discharge therapies (aspirin, ß-blockers)
indicated during the treatment of AMI. Therapy use varied by patient
race, sex, and poverty status. Black patients were less likely to
undergo reperfusion (RR 0.84, 95% CI 0.78, 0.91) or receive aspirin on
admission (RR 0.97, 95% CI 0.96, 0.99) and ß-blockers (RR 0.94, 95%
CI 0.88, 1.00) at discharge. Female patients were less likely to
receive aspirin on admission (RR 0.98, 95% CI 0.97, 0.99) and
discharge (RR 0.98, 95% CI 0.96, 0.99). Poor patients were less likely
to receive aspirin (RR 0.97, 95% CI 0.96, 0.98) or reperfusion (RR
0.97, 95% CI 0.93, 1.00) on admission and aspirin (RR 0.98, 95% CI
0.96, 1.00), or ß-blockers (RR 0.95, 95% CI 0.91, 0.99) on
discharge.
Conclusions—Medical therapies are currently underused in the treatment of black, female, and poor patients with AMI.
Key Words: myocardial infarction • sex • outcomes • race
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Introduction |
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Prior studies have documented significant race, sex, and socioeconomic differences in the use of invasive cardiac procedures during treatment of acute myocardial infarction (AMI).1 2 3 4 5 6 7 Although informative, studies evaluating cardiac catheterization and coronary revascularization use during AMI have generally been limited to the subset of patients who were candidates for these procedures, thereby excluding large numbers of sicker and older AMI patients. In addition, most evaluations of AMI care have not examined possible variations in the use of more prevalent, lower-cost medical therapies indicated in the management of AMI.8 Although patient sociodemographic characteristics are associated with the use of cardiac procedures, it is unknown whether these factors influence the medical management of AMI.
The Cooperative Cardiovascular Project (CCP), a data set of Medicare patients hospitalized for AMI, permits an examination of this issue. Using detailed clinical data from the CCP and 1990 US Census-derived community characteristics, we sought to determine the association of patient race, sex, and poverty with use of medical therapy during treatment of AMI.
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Methods |
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Cooperative Cardiovascular Project
Initiated by the Health Care Financing Administration in 1992 in collaboration with peer-review organizations, the CCP is an ongoing national program developed to improve the quality of care for Medicare beneficiaries with AMI.9 Patients in the CCP cohort include a sample of Medicare beneficiaries discharged from a nongovernmental acute-care hospital in the United States with a primary discharge diagnosis of AMI (International Classification of Disease, Ninth Revision Clinical Modification [ICD-9] code 410) between January 1994 and February 1996 with the exception of AMI readmissions. Patients (n=234 769) were identified on the basis of hospital bills (UB-92 claims) in the Medicare National Claims History File associated with hospitalizations during a random 8-month period, which varied for each state. Sampling was modified in Alabama, Connecticut, Iowa, and Wisconsin because these states had participated in the CCP pilot sample and in Minnesota because of an ongoing state study.
Medical records for each sampled hospitalization were forwarded to clinical data abstraction centers. CCP data management and abstraction have been reported elsewhere in greater detail and include 140 variables associated with each hospitalization.10 Data were collected within the following categories: demographics, medications, medical history, clinical presentation, admission therapies, diagnostic tests, laboratory test results, procedures, in-hospital events, and discharge treatments. Data quality was ensured through the use of trained technicians and software abstraction modules and was monitored by random record reabstraction.
Study Sample
We limited our analysis to patients 65 years of age
with a confirmed AMI. AMI was defined as elevation of creatine
kinase-MB >5%, elevation of lactate dehydrogenase enzyme (LDH) levels
with isoenzyme reversal (LDH1>LDH2), or 2 of the following 3 criteria:
chest pain during the prior 48 hours, 2-fold elevation in creatine
kinase, or ECG changes (ST-segment elevation or new Q waves). Patients
with multiple admissions during the sample period were identified, and
readmissions for AMI were excluded. We excluded patients with invalid
ZIP codes because we could not evaluate the association of poverty
(defined by ZIP code of residence) and use of therapy. In addition, we
limited our analysis to patients treated in the 50 states and
the District of Columbia, thus excluding patients treated in Puerto
Rico. Patients transferred into the hospital or documented as refusing
therapy on admission were not considered eligible for admission
therapies and were excluded from evaluations of admission therapy use.
Similarly, patients who transferred out of the hospital or who died
during hospitalization were considered ineligible for discharge therapy
and were excluded from evaluations of discharge therapy use. All
remaining patients were considered eligible for analysis and
constituted the respective eligible cohorts.
Study Outcome
Our principal outcome of interest was the provision of medical
therapy to patients with AMI. We evaluated 4 medical therapies
recommended in the treatment of AMI-2 provided on admission (aspirin,
reperfusion by thrombolysis, or PTCA within 12 hours of
admission) and 2 prescribed on discharge (aspirin, ß-blockers). We
developed restricted cohorts of patients who were ideal candidates for
each therapy, based on current American College of
Cardiology/American Heart Association
guidelines.8 Ideal candidates were derived from the
eligible cohorts and excluded patients with any contraindication to
therapy (Table 1
), regardless of
whether they received treatment, from the primary analysis.
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Statistical Analysis
We first sought to determine the frequency of aspirin and
reperfusion use on admission and prescription of aspirin and
ß-blockers on discharge among ideal patients. The association of
medical therapy use and patients’ sociodemographic characteristics
were assessed in each of the ideal treatment cohorts by means of
2 analyses and t tests.
In the second portion of our study, we evaluated the association of patient sociodemographic characteristics and use of therapy in each of the ideal treatment cohorts by means of multivariate logistic regression analysis. Independent variables incorporated in our analysis included patient race, sex, poverty status, age, illness severity, treating hospital characteristics, physician specialty, and geographic data. Poverty was defined on the basis of ZIP code of residence and characterized as poor or nonpoor. Patients residing in US ZIP codes at or below the 15th percentile of median household income reported in the 1990 US Census were considered to be poor; those residing in other ZIP codes were defined as nonpoor. Patients’ illness severity was estimated with the use of the Medicare Mortality Prediction System (MMPS), a predictive score of a patient’s risk of 30-day mortality.11 Hospital characteristics incorporated in our analysis included the treating hospital’s AMI volume and residency affiliation. Physicians were grouped on the basis of self-reported specialty into cardiologists, internists, family practitioners/general practitioners, or other specialists. Geographic data included patient’s US Census region of residency and residence in a rural area as defined by the US Administration on Aging.12
To obtain estimates of the effects of patient demographics and poverty status adjusted for potential confounder variables, multivariate logistic regression models were constructed for each cohort, adjusting for patient age, illness severity, hospital AMI volume and residency affiliation, attending physician specialty, residence in a rural area, and US Census region of residency. Patient race, sex, and poverty status variables were forced into each of the models. Results are presented as unadjusted and adjusted relative risk ratios by use of the conversion formula outlined by Zhang and Yu.13
Because of the prevalent use of aspirin, ß-blockers, and reperfusion among nonideal patients, we also evaluated the use of AMI therapy among the larger cohort of treatment-eligible patients. Logistic regression analyses were performed for each AMI therapy to separately evaluate patient race, sex, and poverty in each treatment eligible cohort. Models used were identical to those used to evaluate treatment use among ideal patients and included a binary variable to represent the subset of ideal patients.
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Results |
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We identified 169 079 patients
65 years of age with an AMI
meeting study criteria in the Cooperative
Cardiovascular Project. Patients had a mean age of
76 years and were predominantly male and white (Table 2). Of these patients, 115 699 were
ideal candidates for use of aspirin on admission, 17 363 for use of
reperfusion, 74 163 for prescription of aspirin on discharge, and
19 695 for prescription of ß-blockers on discharge. Black, female,
and poor patients were less likely to be classified as ideal for
reperfusion and ß-blockers but were comparable to white, male, and
nonpoor patients for aspirin classification. Overall, use of AMI
therapies ranged from 55.2% for ß-blockers to 80.7% of aspirin on
admission among ideal patients.
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Among the ideal cohort, black, female, and poor patients had
significantly lower rates of therapy use than white, male, and nonpoor
patients, respectively (see Figures 1, 2, and 3). Black patients were
less likely to undergo reperfusion or receive aspirin on admission and
ß-blockers on discharge than white patients. Similarly, female
patients were less likely to undergo reperfusion or to receive aspirin
(admission and discharge) and ß-blockers. Poor patients were less
likely to receive all AMI therapies evaluated (Table 3). In
addition, patients receiving therapy were younger and had less severe
illness than those who did not receive treatment (Table 4).
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After adjustment for confounding variables, black patients remained
less likely to undergo reperfusion (RR 0.84, 95% CI 0.78, 0.91),
receive aspirin on admission (RR 0.97, 95% CI 0.96, 0.99) or
ß-blockers on discharge (RR 0.94, 95% CI 0.88, 1.00), and were
comparable to white patients for aspirin at discharge (RR 1.00, 95% CI
0.98, 1.02). Female patients remained less likely to receive aspirin on
admission (RR 0.98, 95% CI 0.97, 0.99) and discharge (RR 0.98, 95% CI
0.96, 0.99) than male patients but were comparable for ß-blocker (RR
1.00, 95% CI 0.97, 1.02) and reperfusion therapy (RR 1.00, 95% CI
0.98, 1.02). Similarly, poor patients were less likely to receive
aspirin on admission (RR 0.97, 95% CI 0.96, 0.98) and discharge (RR
0.98, 95% CI 0.96, 1.00), ß-blockers (RR 0.95, 95% CI 0.91, 0.99),
and reperfusion (RR 0.97, 95% CI 0.93, 1.00) therapy (Table 5).
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The influence of patient race, sex, and poverty were similar in the
analyses of eligible and ideal patients for aspirin on
admission and aspirin and ß-blockers at discharge. However, findings
varied between the ideal and eligible cohort analyses for
reperfusion therapy. Female (RR 0.95, 95% CI 0.93, 0.98) patients in
the eligible cohort were significantly less likely to receive
reperfusion despite being comparable to male patients in the ideal
subgroup (Table 5
).
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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The health services literature has carefully documented racial and ethnic differences in the use of medical therapies for patients with many conditions. The study reported here extends this work to assess access to low-cost medical therapies and to assess the role of community factors in addition to race and sex in the use of medical therapies. Our findings indicate that black, female, and poor patients were less likely to receive indicated therapies including aspirin, ß-blockers, and reperfusion. These differences in AMI therapy use remained after adjustment for age, severity of illness, physician specialty, geographic location, and treating hospital characteristics.
Although data relating to racial variation in the use of invasive cardiac procedures during AMI is well established, the data concerning medical interventions is less clear. The Myocardial Infarction Triage and Intervention (MITI) registry found no racial differences in thrombolytic use,14 though this finding may be attributable to the nature of the MITI cohort. As a city-specific randomized trial of prehospital treatment of AMI, MITI represents a selected subgroup of patients in one metropolitan area. In contrast, more representative, national observational studies of AMI treatment, such as the National Registry of Myocardial Infarction (NRMI)6 and the Arteriosclerosis Risk in Communities (ARIC) study,7 identified lower thrombolytic use among black patients. The diminished use of reperfusion among black patients in our cohort confirms findings observed in the ARIC and NRMI cohorts and indicates racial variation in AMI treatment influences use of reperfusion. The underutilization of aspirin on admission among black patients has been previously reported15 and parallels the trend toward lower ß-blocker use among black patients observed in our evaluation and a recent analysis of the CCP cohort.16 Taken together, these studies and our findings indicate that there is significant racial variation in the medical treatment of AMI.
Several hypotheses have been advanced to rationalize racial variability in treatment. Although disease prevalence and severity may differ by race, there is no literature to suggest racial variability in efficacy of American College of Cardiology/American Heart Association–recommended medical treatments, particularly among the ideal group of patients we evaluated. Although patient presentation has been postulated to vary by race,14 this potential confounder does not account for the disparate use of medications at discharge when the diagnosis of myocardial infarction has been confirmed. Patients who were documented as having refused treatment were excluded from analysis; thus, variations in care do not reflect racial differences in perceived treatment compliance or patient care preferences.17 Lack of supplemental health insurance may limit access to cardiac procedures or outpatient treatment but should not influence the use of less expensive therapies such as aspirin and ß-blockers among a hospitalized Medicare cohort. Although we adjusted for hospital AMI volume and residency affiliation, some unmeasured facility characteristic may explain differences in the use of aspirin and the trend for ß-blockers. The magnitude of racial variation observed for reperfusion use, however, suggests that factors such as racial differences in physician recommendations18 may be involved.
The influence of patient sex on AMI treatment is not well understood, particularly in the context of medical therapy. Our documentation of comparable reperfusion use among ideal male and female patients parallels findings of thrombolytic use among patients enrolled in the NRMI cohort.5 However, we observed differences in reperfusion use among the larger cohort of eligible patients. The decreased use of reperfusion among nonideal female patients may reflect assumptions of increased treatment risk to nonideal female patients, perceptions of greater treatment benefit among male patients, and in extreme cases, even discounting of female patient symptoms, as documented in other settings.19
Poverty has been associated with diminished use of cardiac procedures in the treatment of AMI1 and poorer quality of care among Medicare beneficiaries in the treatment of other conditions.20 Our study addresses the relation between poverty and the medical treatment of AMI, which has generally been ignored in prior studies. Kahn et al21 found that poor Medicare patients hospitalized with AMI had worse processes of care and greater instability at discharge. We, too, noted diminished use of therapy on admission by poor patients, suggestive of the poorer processes of care documented by Kahn et al. Poorer-quality care at discharge noted by Kahn et al is consistent with the underuse of aspirin and ß-blockers noted among poor patients in our cohort. Differences in AMI care provided to poor patients observed in our cohort suggest poverty is associated with less optimal medical treatment of AMI.
Decreased use of the AMI therapies among poor patients is difficult to explain. While deductibles or copayments required of Medicare beneficiaries might account for variation in the use of high-cost outpatient procedures, it is unlikely that they would influence the use of low-cost medical therapies once a patient is admitted. Since hospitals receive a standard Diagnosis Related Group (DRG) payment for Medicare patients with AMI, there should be no financial incentive to withhold therapy, specific to poor patients, once patients have been hospitalized. Although discharge therapies would not be reimbursed unless patients carried supplemental insurance, both aspirin and ß-blockers are relatively inexpensive. Adjustment for patient race, sex, physician specialty, geographic, and hospital characteristics indicate that undertreatment of poor patients is not attributable to confounding demographic or system factors. Alternatively, the effect observed for poor patients may be explained by unmeasured differences in provider characteristics or other patient socioeconomic resources. Further research is needed to explore this finding.
The statistical precision afforded by our large sample size allowed us to detect very small differences in care among race, sex, and poverty groups. It is reasonable to ask whether, for example, a 2% difference between groups is clinically meaningful. The answer to this question depends on the research context. For example, a well-known trial was terminated early when it was found that the incidence of heart attacks among patients randomized to daily aspirin was 0.77 percentile points less than patients receiving placebos.22 Our ideal cohort was composed of patients who, according to evidence-based guidelines, would benefit from receipt of the treatment. We therefore argue that the effects we found have important implications for patient health.
Our study has several limitations. First, we relied on data from an observational study based on a retrospective chart analysis. However, this observational study of >169 000 AMI patients is the most current study of AMI practice variation to date and the only analysis that we know of to explore the association of poverty and use of medical therapy. In addition, CCP contains a larger population of sicker and older AMI patients than traditionally enrolled in clinical trials or AMI registries and thus is a more contemporary evaluation of AMI therapy use among elderly patients nationwide. Furthermore, chart-abstracted data provide detailed clinical data, allowing for independent confirmation of AMI, assessment of comorbid conditions, and appropriateness of treatment previously unavailable in administrative data set analyses. Second, we were unable to evaluate the influence of individual poverty and instead used an ecological definition as a proxy. Whereas ecological measures incorporate both community- and individual-level characteristics, US Census ZIP-level data have been identified as appropriate proxies in the absence of patient level data.23 Third, our cohort was drawn from a Medicare population and may not reflect healthcare delivery among younger patients. Finally, we were unable to evaluate the influence of supplemental insurance or "Medigap" policies on AMI therapy. Since the purchase of Medigap policies are dependent on personal income (measured by community income), our findings may be confounded by insurance status. However, supplemental insurance status should not contribute to differences in hospital care under the Medicare DRG system.
Conclusions
Our findings indicate that medical therapies are currently
underused in the treatment of black, female, and poor patients with
AMI. Variations in treatment were observed for admission and discharge
therapies among treatment-eligible and treatment-ideal cohorts. This
variation was not explained by severity of illness, physician
specialty, hospital, and geographic characteristics.
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Acknowledgments |
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This research was supported by contract 500-96-P623, sponsored by the Delmarva Foundation for Medical Care and the Health Care Financing Administration, US Department of Health and Human Services. The contents of this publication do not necessarily reflect the views of the US Department of Health and Human Services. The authors assume full responsibility for the accuracy and completeness of the ideas presented. This article is a direct result of the Health Care Quality Improvement Program initiated by the Health Care Financing Administration, which has encouraged identification of quality improvement projects derived from analysis of patterns of care.
Received December 6, 1999; revision received March 1, 2000; accepted March 2, 2000.
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M. R. Goulding Inappropriate Medication Prescribing for Elderly Ambulatory Care Patients Arch Intern Med, February 9, 2004; 164(3): 305 - 312. [Abstract] [Full Text] [PDF]
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 M.-D. Beaulieu, J. Brophy, A. Jacques, R. Blais, R. Battista, and R. Lebeau Drug treatment of stable angina pectoris and mass dissemination of therapeutic guidelines: a randomized controlled trial QJM, January 1, 2004; 97(1): 21 - 31. [Abstract] [Full Text] [PDF]
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S. S. Rathore, H. M. Krumholz, F. A. Masoudi, and E. P. Havranek Racial Disparities in Care of Heart Failure--Reply JAMA, September 10, 2003; 290(10): 1316 - 1317. [Full Text] [PDF]
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W. S. Weintraub and V. Vaccarino Explaining Racial Disparities in Coronary Outcomes in Women Circulation, September 2, 2003; 108(9): 1041 - 1043. [Full Text] [PDF]
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A. K. Jha, P. D. Varosy, A. M. Kanaya, D. B. Hunninghake, M. A. Hlatky, D. D. Waters, C. D. Furberg, and M. G. Shlipak Differences in Medical Care and Disease Outcomes Among Black and White Women With Heart Disease Circulation, September 2, 2003; 108(9): 1089 - 1094. [Abstract] [Full Text] [PDF]
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F C Taylor, R Ascione, K Rees, P Narayan, and G D Angelini Socioeconomic deprivation is a predictor of poor postoperative cardiovascular outcomes in patients undergoing coronary artery bypass grafting Heart, September 1, 2003; 89(9): 1062 - 1066. [Abstract] [Full Text] [PDF]
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A. M. Russo, G. E. Hafley, K. L. Lee, N. J. Stamato, M. H. Lehmann, R. L. Page, T. Kus, and A. E. Buxton Racial Differences in Outcome in the Multicenter UnSustained Tachycardia Trial (MUSTT): A Comparison of Whites Versus Blacks Circulation, July 8, 2003; 108(1): 67 - 72. [Abstract] [Full Text] [PDF]
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 S. V. Rao, P. Kaul, L. K. Newby, A. M. Lincoff, J. Hochman, R. A. Harrington, D. B. Mark, and E. D. Peterson Poverty, process of care, and outcome in acute coronary syndromes J. Am. Coll. Cardiol., June 4, 2003; 41(11): 1948 - 1954. [Abstract] [Full Text] [PDF]
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 K. Steenland, J. Henley, and M. Thun All-Cause and Cause-specific Death Rates by Educational Status for Two Million People in Two American Cancer Society Cohorts, 1959-1996 Am. J. Epidemiol., July 1, 2002; 156(1): 11 - 21. [Abstract] [Full Text] [PDF]
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 E. Kuno and A. B. Rothbard Racial Disparities in Antipsychotic Prescription Patterns for Patients With Schizophrenia Am J Psychiatry, April 1, 2002; 159(4): 567 - 572. [Abstract] [Full Text] [PDF]
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G. A. Beller Presidential address: quality of cardiovascular care in the U.S. J. Am. Coll. Cardiol., September 1, 2001; 38(3): 587 - 594. [Full Text] [PDF]
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V Salomaa, H Miettinen, M Niemela, M Ketonen, M Mahonen, P Immonen-Raiha, S Lehto, T Vuorenmaa, S Koskinen, P Palomaki, et al. Relation of socioeconomic position to the case fatality, prognosis and treatment of myocardial infarction events; the FINMONICA MI Register Study J. Epidemiol. Community Health, July 1, 2001; 55(7): 475 - 482. [Abstract] [Full Text] [PDF]
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D. S. David Cigarette Smoking: How Much Worse Can It Get? Circulation, June 26, 2001; 103 (25): e128 - e128. [Full Text] [PDF]
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