Racial and Ethnic Differences in the Treatment of Acute Myocardial Infarction
Findings From the Get With The Guidelines–Coronary Artery Disease Program
Background— Racial/ethnic differences in cardiovascular care have been well documented. We sought to determine whether racial/ethnic differences in evidence-based acute myocardial infarction care persist among hospitals participating in a national quality improvement program.
Methods and Results— We analyzed 142 593 acute myocardial infarction patients (121 528 whites, 10 882 blacks, and 10 183 Hispanics) at 443 hospitals participating in the Get With the Guidelines–Coronary Artery Disease (GWTG-CAD) program between January 2002 and June 2007. We examined individual and overall composite rates of defect-free care, defined as the proportion of patients receiving all eligible performance measures. In addition, we examined temporal trends in use of performance measures according to race/ethnicity by calendar quarter. Overall, individual performance measure use was high, ranging from 78% for use of angiotensin-converting enzyme inhibitors to 96% for use of aspirin at discharge. Use of each of these improved significantly over the 5 years of study. Overall, defect-free care was 80.9% for whites, 79.5% for Hispanics (adjusted odds ratio versus whites 1.00, 95% confidence interval 0.94 to 1.06, P=0.94), and 77.7% for blacks (adjusted odds ratio versus whites 0.93, 95% confidence interval 0.87 to 0.98, P=0.01). A significant gap in defect-free care was observed for blacks mostly during the first half of the study, which was no longer present during the remainder of the study. Overall, progressive improvements in defect-free care were observed regardless of race/ethnic groups.
Conclusions— Among hospitals engaged in a national quality monitoring and improvement program, evidence-based care for acute myocardial infarction appeared to improve over time for patients irrespective of race/ethnicity, and differences in care by race/ethnicity care were reduced or eliminated.
Received November 11, 2009; accepted March 29, 2010.
Several studies have highlighted the presence of racial and ethnic differences in cardiovascular care.1,2 Among those with acute coronary syndromes, minorities are less likely than whites to receive evidence-based care and are more likely to be treated at facilities with lower adherence to composite measures.3–6 Recent studies have shown that quality improvement programs can enhance hospital adherence to care guidelines and patients’ short-term and long-term outcomes,7–9 yet the effect of the implementation of a quality improvement program on racial and ethnic differences in quality of cardiovascular care is unknown. We sought to determine whether racial/ethnic differences in use of evidence-based care for acute myocardial infarction (AMI) exist among hospitals participating in the national quality improvement (QI) program Get With the Guidelines–Coronary Artery Disease (GWTG-CAD) and to assess whether a QI program is associated with decreasing health disparities over time.
Editorial see p 2253
Clinical Perspective on p 2301
The data source for the present study was the GWTG-CAD database, a national, prospective, observational registry and QI initiative established by the American Heart Association as a collaborative effort among researchers, professional organizations, and hospitals to provide feedback on performance and strategies to improve the care of patients with coronary artery disease. The details of the program have been described elsewhere.10–12 The GWTG-CAD program includes learning sessions, didactic sessions, best practice sharing, interactive workshops, and postmeeting follow-up. Hospitals participating in the registry submit clinical information on the medical history, hospital care, and outcomes of consecutive patients using an online, interactive case report form and patient management tool (Patient Management Tool, Outcome Sciences Inc, Cambridge, Mass).12 This World Wide Web–based tool provides the opportunity for concurrent data collection, ongoing real-time feedback of hospital data, and clinical decision support to enable rapid cycle improvement. As an incentive, GWTG-CAD rewards hospitals by use of a performance recognition program. The program began in 2000. The length of participation of each hospital in the present study depended on the date it entered the program. Because GWTG-CAD is a QI program, hospitals are encouraged to consecutively enroll all eligible patients. Case finding was preferentially based on clinical identification of patients, but some hospitals used retrospective Joint Commission core measure identification with clinical verification.10 Teaching and nonteaching, rural and urban, large and small hospitals from all geographic areas of the United States are represented in the program. Participating sites were granted a waiver of informed consent under the common rule. The population included patients admitted to participating hospitals who were entered into the World Wide Web–based patient management tool with a discharge diagnosis of AMI. Data were collected concurrently or by chart review and included patient demographics, medical history, symptoms on arrival, results of laboratory testing, in-hospital treatment and events, discharge treatment and counseling, and patient disposition. Data entry was performed by highly trained abstracters and clinical personnel using standard data definitions and coding instructions. With an Internet-based system, data quality was monitored to ensure the completeness and accuracy of the submitted data. Outcome Sciences Inc serves as the data collection and coordination center for GWTG.
Between January 2, 2000, and June 28, 2007, data on 295 730 patients treated for unstable angina or AMI at 548 hospitals in the United States were available in the GWTG-CAD database. For the purposes of the present study, we selected 177 044 patients with International Classification of Diseases, 9th revision diagnosis code 410 (ST-segment elevation, non–ST-segment elevation, and unspecified). To help ensure adequate sample sizes and powering, the study cohort was further restricted to patients enrolled during calendar quarters when data were collected on 1000 or more patients. In addition, we excluded 24 883 patients with missing data on race/ethnicity and 6181 patients whose race/ethnicity was not white, black, or Hispanic. The characteristics of excluded patients are presented in the online-only Data Supplement. Therefore, the study population consisted of 142 593 patients of white, black, or Hispanic race/ethnicity enrolled at 443 US sites between January 2, 2002, and June 28, 2007. Using methodology similar to national cardiovascular registries and many randomized trials, data on race and ethnicity were collected for the purpose of evaluating subgroup differences. Admission and/or medical staff recorded race/ethnicity, usually as the patient was registered. Patients were assigned to race and ethnicity categories by use of options defined by the case report forms.
Objectives and Outcome Measures
The major goals of the present study were to assess the overall racial/ethnic differences in individual and composite core coronary artery disease performance measures and to assess whether a QI program is associated with decreasing health disparities over time. We also examined the temporal trend of the summary “defect-free care” performance measure in hospitals that treated a greater proportion of black or Hispanic patients.
Individual core performance measures considered in the GWTG-CAD program were the use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in patients with documented left ventricular systolic dysfunction, use of β-blockers at discharge, use of lipid-lowering therapy in patients with low-density lipoprotein cholesterol >100 mg/dL, smoking cessation counseling, use of aspirin within 24 hours of admission, and use of aspirin at discharge. The composite (summary) performance measure of “defect-free care” was defined as the proportion of patients who received all interventions for which they were eligible.13 Data on door-to-balloon time of ≤90 minutes or door-to-thrombolysis time of ≤30 minutes in eligible patients presenting with ST-elevation myocardial infarction were collected in the GWTG-CAD program and considered quality measures and were not part of the composite measure “defect-free care.”
The descriptive analyses included comparisons according to race/ethnicity (whites, blacks, and Hispanics) for demographics, comorbidities, baseline clinical characteristics, clinical performance measures, invasive procedures, and in-hospital mortality. Categorical variables are presented as percentages and were compared with χ2 tests. Continuous and ordinal categorical variables are presented as medians with 25th and 75th percentiles and were compared with the Kruskal-Wallis test.
We examined trends in racial/ethnic differences according to the overall duration of the program (calendar quarters). To examine the association between time, race/ethnicity, and performance measures, multivariable logistic regression was used to estimate the marginal effects of time and race/ethnicity. The generalized estimating equation method with exchangeable working correlation structure was used to account for within-hospital clustering, because patients at the same hospital are more likely to have similar responses relative to patients in other hospitals (ie, within-center correlation for response). The method produces estimates similar to those from ordinary logistic regression, but the estimated variances of the estimates are adjusted for the correlation of outcomes within each hospital.14 In a first step, adjustments were performed for baseline variables only, including age, gender, body mass index, medical history, systolic blood pressure, and cardiac diagnosis. In a second step, insurance and hospital characteristics were added to baseline variables in the multivariable model. To analyze the temporal trend of the composite performance measure “defect-free care” in hospitals that treated a greater proportion of blacks or Hispanics, we further divided the study population into quintiles according to the percent of Hispanic and blacks treated at the site-level.
P<0.05 was considered statistically significant for all tests, and all tests of statistical significance were 2-tailed. Outcome Sciences Inc serves as the data collection (through their Patient Management Tool) and coordination center for GWTG. The Duke Clinical Research Institute serves as the data analysis center and has an agreement to analyze the aggregate deidentified data for research purposes. All analyses were performed with SAS software (version 9.1, SAS Institute, Cary, NC).
The study included 142 593 patients enrolled at 443 US sites between January 2, 2002, and June 28, 2007. Demographic, clinical, and geographic distribution data by ethnic/racial group are shown in Tables 1 and 2⇓. The sample sizes for each reported variable are presented in the Data Supplement. Compared with white and Hispanic patients, blacks were younger, were more likely female, and had a higher prevalence of hypertension, smoking, prior history of stroke, and renal insufficiency. Black and Hispanic patients were significantly more likely to be uninsured or covered by Medicaid than were white patients. The geographic distribution of recruitment for the 3 racial/ethnic groups somewhat paralleled the US census distribution. A large proportion of black patients were recruited in the South, whereas Hispanic patients were mostly recruited in the Southwest. Compared with the other racial/ethnic groups, black patients sought care at facilities that had more beds and were more likely academic but had similar interventional and surgical capabilities.
Quality and Performance Measures
Percutaneous coronary intervention was used in 74.3% of the 40 843 ST-elevation myocardial infarction patients (74.7% of whites, 69.5% of blacks, and 73.7% of Hispanics; P<0.0001). After the analysis was confined to patients eligible for primary percutaneous coronary intervention and after the exclusion of transfers and those without time intervals recorded (n=13 446), the delays in performing primary percutaneous coronary intervention were significantly longer in minority patients than in white patients. The median (25th, 75th percentile) door-to-balloon time was 91 (66, 130) minutes in white patients, 105 (75, 160) minutes in black patients, and 102 (75, 154) minutes in Hispanic patients. As a consequence of these delays, a lower proportion of Hispanic and black patients had a door-to-balloon time of ≤90 minutes than white patients, even after adjustment for patient and hospital variables (Table 3). Use of thrombolytic therapy was low and comparable among the 3 groups (3.5% in white, 3.4% in black, and 3.9% in Hispanic patients; P=0.46). Black patients experienced greater delays in thrombolysis administration, with a median door-to-thrombolysis time of 52 (30, 84) minutes, which was substantially longer than that for whites and Hispanics, who had a time-to-thrombolysis of 38 (23, 64) and 35 (22, 60) minutes, respectively (P=0.001). Of note, the proportion of patients who received thrombolysis within 30 minutes of hospital arrival remained unchanged over the study period, as depicted in Figure 1; however, there was a positive trend in the proportion of patients who received timely mechanical reperfusion over time.
All racial/ethnic groups had a similar median length of stay of 4 days. Unadjusted hospital mortality rates were 5.7% for white, 5.0% for black, and 5.5% for Hispanic patients (P<0.0001).
Performance measures and defect-free care by race/ethnicity are displayed in Table 3. The numerators and denominators for each performance and quality metric are presented in the online-only Data Supplement. Use of aspirin within 24 hours from admission, aspirin use at discharge, and use of β-blockers at discharge were >90% in the 3 groups, with a nonsignificant trend toward lower use among black patients. A similar trend toward a lower use of lipid-lowering therapy was also observed in blacks. Overall, defect-free care was 80.9% for whites, 79.5% for Hispanics, and 77.7% for blacks.
After adjustment for baseline patient variables only and for patient variables along with hospital characteristics, black patients had significantly lower use of aspirin at discharge and of smoking cessation counseling, and they were less likely to receive defect-free care than white patients. On the other hand, there were no significant adjusted differences for these variables between Hispanic and white patients.
Temporal trends in timely reperfusion therapies, performance measures, and defect-free care by calendar time and by racial/ethnic group are shown in Figures 1, 2, and 3⇓⇓, respectively. The numbers of white, black, and Hispanic patients included in each quarter are presented in the online-only Data Supplement. There were progressive improvements in performance measures and in defect-free care for all racial/ethnic groups. These positive trends were present even after adjustments for patient baseline characteristics, and patient baseline characteristics and hospital variables. Further analysis of temporal trends revealed that blacks received lower defect-free care during the first year of the study; however, the care of blacks improved relative to that for the other groups, and the difference was no longer apparent during the remainder of the study period. As depicted in Figure 3, during the second half of 2002, the first and fourth quarters in 2003, and the first quarter of 2004, the differences in defect-free care received by blacks and whites had a P value of <0.01. During these quarters, black patients were 27% to 41% less likely to receive defect-free care than white patients. In subsequent quarters, the differences were reduced and did not reach statistical significance. In the last quarter of the registry (2nd quarter of 2007), the odds ratio (95% confidence interval) was 1.10 (0.64–1.90).
Finally, we assessed differential trends in care between sites that treated lower and higher proportions of black and Hispanic patients. To accomplish this objective, we divided the hospitals according to quintiles of black or Hispanic patients treated. Figure 4A shows the temporal trends in defect-free care at sites according to the proportion of treated black patients. The use of defect-free care appeared to improve across all quintiles, and the curves converged during the second half of the study period. Figure 4B shows trends of care at sites according to the proportion of treated Hispanic patients. Care improved at all sites regardless of the proportion of Hispanic patients treated.
The elimination of disparate health care is one of the principal goals of Healthy People 2010.15 The present study of contemporary AMI care at 443 hospitals suggests that there were small differences in the use of evidence-based process performance among racial/ethnic groups; however, we also observed that this initial gap in care quality by race/ethnicity narrowed as hospital care improved over time. By the end of the study period, all patients treated in GWTG-participating centers received similar quality of AMI care.
The present analysis examined patients with a diagnosis of AMI, for which there are established performance measures supported by strong evidence and clear consensus. These performance measures have been developed by professional associations to improve in-hospital AMI care; they provide practitioners and institutions that deliver care with tools, such as GTWG-CAD, to measure the quality of their care and identify opportunities for improvement. Performance measures are suitable for public reporting, external comparisons, QI, and possibly for pay-for-performance programs.16,17 Despite this solid evidence, the results of the present study suggest that care at the beginning of the analysis period was suboptimal, and there were small but significant differences in the quality of this care according to race/ethnic groups.
The present work extends previous studies in this field by demonstrating that the overall trends toward improved guideline adherence and defect-free AMI care observed in the general population extend to the 2 largest racial/ethnic groups in the United States, blacks and Hispanics. This finding represents a significant step toward resolving longstanding inequities in care that have historically affected minority patients, even after controlling for socioeconomic differences and other healthcare-related access factors.2,18 The present study demonstrates that among participating hospitals in the GWTG-CAD program, equitable quality care for many performance measures is attainable across major racial and ethnic groups. There was also consistent improvement in the delivery of equitable quality care among all AMI patients in the GWTG-CAD program, even among those treated at hospitals with a higher share of minority patients. These findings are in contrast to previous analyses that have suggested worse quality and outcomes for AMI patients at hospitals that disproportionally care for minority populations. A prior analysis of the Medicare database demonstrated that in-hospital AMI mortality of patients treated at hospitals that disproportionately cared for black patients was significantly higher than in those that did not.6
Despite this remarkable progress, small gaps remained in the care received by blacks, which included less use of aspirin at discharge and less provision of smoking cessation advice. Conversely, the care received by Hispanic patients was almost identical to that of whites in terms of adherence to core performance measures. Similar findings have been reported previously in clinical trials and prospective registries.19–22 The present findings support the notion that QI initiatives may be important instruments in reducing or eliminating racial/ethnic differences in the delivery of cardiovascular care.
Even though black and Hispanic patients face similar difficulties when seeking access to healthcare, these 2 minorities are culturally different and have unique features that require special consideration when interventions aimed at reducing disparities are designed. Hispanics, particularly recent immigrants, have a significant language barrier and are unfamiliar with the US healthcare system.25
We did not find substantial differences in hospital mortality between racial/ethnic groups; however, the effects of treatment disparities may become evident after the patient leaves the hospital. In addition, minorities are at a significant disadvantage due to difficulties in affording long-term treatments, lower health literacy, lack of safe environments to practice physical activity, and limited access to healthy foods.26,27 In fact, long-term follow up data have demonstrated increased mortality, rehospitalization rates, and worse quality of life in black patients treated for MI than in white patients.28 Thus, the quest for equal care should now focus on secondary prevention and continuity of care.
Temporal improvements in care driven by the publication of clinical guidelines have been documented previously. In the 1990s, comparisons between the Thrombolysis In Myocardial Infarction (TIMI) III and Global Unstable Angina Registry and Treatment Evaluation (GUARANTEE) observational registries performed before and after publication of the first unstable angina and non–ST-elevation MI guidelines,29 respectively, demonstrated increased use of aspirin, heparin, and β-blockers regardless of race, age, and gender in the GUARANTEE registry, although the use of these therapies was still suboptimal.30 Subsequent efforts focused not only on data collection but on the development of hospital multidisciplinary teams to improve guideline adherence. The single-center Cardiac Hospitalization Atherosclerosis Management Program (CHAMP) used a number of tools designed to facilitate initiation of evidence-based therapies during hospital stay in patients without contraindications. Increased adherence to recommended therapies resulted in a significant reduction of recurrent ischemic events, heart failure, rehospitalization, and death at 1 year.7 A regional program involving a group of hospitals in southeast Michigan had similarly encouraging results.8 On a national level, implementation of the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) Quality Improvement Initiative was associated with a significant temporal trend toward improved adherence to therapies with a class IA/IB guideline recommendation over time.9 Patients treated at hospitals that provided higher quality of care with increased use of guidelines-recommended therapies had significantly improved in-hospital outcomes.31
There are several limitations and issues that should be considered in the interpretation of the results of the present study. First and most importantly, sites participating in GWTG-CAD were self-selected and interested in QI and may not be representative of actual national care patterns. Although prior analyses have suggested that hospitals participating in GTWG are representative of those in the United States, their care and outcomes are slightly better than national averages.10 Second, race/ethnicity categories were recorded by hospital staff at the time of registration and may not accurately reflect the patients’ self-identified race/ethnicity. Third, the findings of the present study can only apply to hospitalized patients. QI initiatives in the ambulatory setting are most needed, particularly with the addition of cardiac rehabilitation to the list of performance measures,17 and perhaps long-term adherence to prescribed therapy. Fourth, we could not account for the effect of the growing focus on elimination of disparities in care and additional overlapping QI programs that hospitals could have implemented in addition to GTWG-CAD. There is still a need to address whether longitudinal compliance and risk factor goal attainment are similar across racial/ethnic groups.
In conclusion, we found that among hospitals engaged in a national quality monitoring and improvement system, evidence-based care for AMI has improved over time for all patients regardless of race/ethnicity. Furthermore, the present study suggests that participation in GWTG-CAD was associated with differences by race/ethnicity in guidelines-recommended care being reduced or eliminated. Small remaining gaps in care potentially may be targeted by intervention programs that address the specific needs of each racial/ethnic group.
Sources of Funding
The GWTG-CAD program is supported by the American Heart Association in part through an unrestricted education grant from Merck/Schering-Plough Partnership, which did not participate in the design or analysis of the study or in manuscript preparation.
Dr Fonarow has received research grants from the National Heart, Lung, and Blood Institute; honoraria from AstraZeneca, Bristol-Myers Squibb/Sanofi, GlaxoSmithKline, Merck/Schering-Plough, and Pfizer; and consultant/advisory board fees from Merck/Schering-Plough and GlaxoSmithKline. Dr Peterson has received research grants from Bristol-Myers Squibb/Sanofi, Merck/Schering-Plough, Lilly, and Johnson & Johnson. Dr Moscucci has received a research grant from Blue Cross Blue Shield of Michigan–Quality Improvement Program in PCI. Dr Hernandez has received a research grant from Johnson & Johnson and honoraria from AstraZeneca and Medtronic. The remaining authors report no conflicts.
Davis AM, Vinci LM, Okwuosa TM, Chase AR, Huang ES. Cardiovascular health disparities: a systematic review of health care interventions. Med Care Res Rev. 2007; 64: 29S–100S.
Yancy CW, Benjamin EJ, Fabunmi RP, Bonow RO. Discovering the full spectrum of cardiovascular disease: Minority Health Summit 2003: executive summary. Circulation. 2005; 111: 1339–1349.
Sonel AF, Good CB, Mulgund J, Roe MT, Gibler WB, Smith SC Jr, Cohen MG, Pollack CV Jr, Ohman EM, Peterson ED. Racial variations in treatment and outcomes of black and white patients with high-risk non-ST-elevation acute coronary syndromes: insights from CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines?). Circulation. 2005; 111: 1225–1232.
Stone PH, Thompson B, Anderson HV, Kronenberg MW, Gibson RS, Rogers WJ, Diver DJ, Theroux P, Warnica JW, Nasmith JB, Kells C, Kleiman N, McCabe CH, Schactman M, Knatterud GL, Braunwald E. Influence of race, sex, and age on management of unstable angina and non-Q-wave myocardial infarction: the TIMI III registry. JAMA. 1996; 275: 1104–1112.
Skinner J, Chandra A, Staiger D, Lee J, McClellan M. Mortality after acute myocardial infarction in hospitals that disproportionately treat black patients. Circulation. 2005; 112: 2634–2641.
Mehta RH, Montoye CK, Gallogly M, Baker P, Blount A, Faul J, Roychoudhury C, Borzak S, Fox S, Franklin M, Freundl M, Kline-Rogers E, LaLonde T, Orza M, Parrish R, Satwicz M, Smith MJ, Sobotka P, Winston S, Riba AA, Eagle KA. Improving quality of care for acute myocardial infarction: the Guidelines Applied in Practice (GAP) Initiative. JAMA. 2002; 287: 1269–1276.
Mehta RH, Roe MT, Chen AY, Lytle BL, Pollack CV Jr, Brindis RG, Smith SC Jr, Harrington RA, Fintel D, Fraulo ES, Califf RM, Gibler WB, Ohman EM, Peterson ED. Recent trends in the care of patients with non-ST-segment elevation acute coronary syndromes: insights from the CRUSADE initiative. Arch Intern Med. 2006; 166: 2027–2034.
Krumholz HM, Anderson JL, Brooks NH, Fesmire FM, Lambrew CT, Landrum MB, Weaver WD, Whyte J, Bonow RO, Bennett SJ, Burke G, Eagle KA, Linderbaum J, Masoudi FA, Normand SL, Pina IL, Radford MJ, Rumsfeld JS, Ritchie JL, Spertus JA. ACC/AHA clinical performance measures for adults with ST-elevation and non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. Circulation. 2006; 113: 732–761.
Liang KY, Zeger SL. Longitudinal data analysis using generalized linear models. Biometrika. 1986; 73: 13–22.
Bonow RO, Masoudi FA, Rumsfeld JS, Delong E, Estes NA III, Goff DC Jr, Grady K, Green LA, Loth AR, Peterson ED, Pina IL, Radford MJ, Shahian DM. ACC/AHA classification of care metrics: performance measures and quality metrics: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. J Am Coll Cardiol. 2008; 52: 2113–2117.
Krumholz HM, Anderson JL, Bachelder BL, Fesmire FM, Fihn SD, Foody JM, Ho PM, Kosiborod MN, Masoudi FA, Nallamothu BK. ACC/AHA 2008 performance measures for adults with ST-elevation and non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. J Am Coll Cardiol. 2008; 52: 2046–2099.
Smedley BD, Stith AY, Nelson AR, Institute of Medicine (US); Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academy Press; 2003.
Cohen MG, Granger CB, Ohman EM, Stebbins AL, Grinfeld LR, Cagide AM, Elizari MV, Betriu A, Kong DF, Topol EJ, Califf RM. Outcome of Hispanic patients treated with thrombolytic therapy for acute myocardial infarction: results from the GUSTO-I and III trials: Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries. J Am Coll Cardiol. 1999; 34: 1729–1737.
Yarzebski J, Bujor CF, Lessard D, Gore JM, Goldberg RJ. Recent and temporal trends (1975 to 1999) in the treatment, hospital, and long-term outcomes of Hispanic and non-Hispanic white patients hospitalized with acute myocardial infarction: a population-based perspective. Am Heart J. 2004; 147: 690–697.
Cohen MG, Roe MT, Mulgund J, Peterson ED, Sonel AF, Menon V, Smith SC Jr, Saucedo JF, Lytle BL, Pollack CV Jr, Garza L, Gibler WB, Ohman EM. Clinical characteristics, process of care, and outcomes of Hispanic patients presenting with non-ST-segment elevation acute coronary syndromes: results from Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines (CRUSADE). Am Heart J. 2006; 152: 110–117.
Echols MR, Mahaffey KW, Banerjee A, Pieper KS, Stebbins A, Lansky A, Cohen MG, Velazquez E, Santos R, Newby LK, Gurfinkel EP, Biasucci L, Ferguson JJ, Califf RM. Racial differences among high-risk patients presenting with non-ST-segment elevation acute coronary syndromes (results from the SYNERGY trial). Am J Cardiol. 2007; 99: 315–321.
Kaplan GA, Keil JE. Socioeconomic factors and cardiovascular disease: a review of the literature. Circulation. 1993; 88: 1973–1998.
Braunwald E, Jones RH, Mark DB, Brown J, Brown L, Cheitlin MD, Concannon CA, Cowan M, Edwards C, Fuster V, Goldman L, Green LA, Grines CL, Lytle BW, McCauley KM, Mushlin AI, Rose GC, Smith EE III, Swain JA, Topol EJ, Willerson JT. Diagnosing and managing unstable angina: Agency for Health Care Policy and Research. Circulation. 1994; 90: 613–622.
Scirica BM, Cannon CP, Gibson CM, Murphy SA, Moliterno DJ, Anderson HV, Aguirre FV, Granger CB, Lambrew CT, Rabbani LE, Sapp SK, Booth JE, Ferguson JJ, Braunwald E. Assessing the effect of publication of clinical guidelines on the management of unstable angina and non-ST elevation myocardial infarction in the TIMI III (1990–1993) and the GUARANTEE (1995–1996) Registries. Crit Pathw Cardiol. 2002; 1: 150–158.
Racial/ethnic differences in process of care and outcomes among patients treated for acute coronary syndromes have been documented; however, the effect of implementing a quality improvement program on health disparities has never been demonstrated. To address this question, we analyzed the use of individual performance measures and the composite performance measure “defect-free care” in 142 593 patients (121 528 whites, 10 882 blacks, and 10 183 Hispanics) treated for myocardial infarction at 443 hospitals participating in the Get With the Guidelines–Coronary Artery Disease program between January 2002 and June 2007. We also examined temporal trends to determine whether a quality improvement program was associated with reduced health disparities over time. Our results demonstrated small differences in the use of evidence-based performance measures among racial/ethnic groups. Black patients were less likely to receive aspirin at discharge or smoking cessation counseling. Defect-free care occurred in 80.9% of whites, 79.5% of Hispanics, and 77.7% of blacks. Progressive improvements in care occurred for all racial/ethnic groups over time. In addition, racial/ethnic gaps in care, which were evident during the first half of the study period, narrowed over time. Overall care also improved at hospitals that disproportionately cared for Hispanic or black patients. Our work extends previous studies by demonstrating that the overall trends in improved myocardial infarction evidence-based care observed in the general population also apply to the 2 largest racial/ethnic groups in the United States. Participation in Get With the Guidelines–Coronary Artery Disease was associated with a reduction or elimination of disparities in care.
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The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/CIRCULATIONAHA.109.922286/DC1.