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)

Building a post-myocardial infarction discharge intervention program for Hispanic patients

Hispanic patients disproportionally suffer from disparities in care delivery in the setting of acute myocardial infarction (AMI). More specifically, Hispanic patients have higher 30-day readmission rates post-AMI and are less likely to be referred to cardiac rehab. Because of the challenges Hispanic patients face with post-AMI care, the Hispanic Acute Myocardial Infarction Discharge Intervention Study (HAMIDI) was launched to provide a culturally sensitive discharge framework to improve readmission and mortality rates in this population. Patients enrolled in this study participate in a comprehensive post-discharge program involving follow-up with a Spanish-speaking cardiologist, a two-part educational virtual group visit program, and access to support throughout the study. During the initial year of the study, 35 patients enrolled and successfully participated in the program. This case study reviews the implementation process, initial outcomes, challenges, and future plans of the program.

US Initiative to Eliminate Racial and Ethnic Disparities in Health: The Impact on the Outcomes of ST-Segment-Elevation Myocardial Infarction in New Jersey

Background In 1998, President Clinton launched a federal initiative to eliminate racial and ethnic health disparities. The impact on the outcomes of ST-segment-elevation myocardial infarction has not been well studied. Methods and Results ST-segment-elevation myocardial infarction outcomes from 1994 to 2015 were studied in 7942 Black, 27 665 Hispanic, and 88 727 White patients with first admission of ST-segment-elevation myocardial infarction using the Myocardial Infarction Data Acquisition System. Logistic regressions were used to assess mortality adjusting for demographics, comorbidities, and interventional procedures. There was an overall rise from 1994 to 2015 in the use of percutaneous coronary interventions in all 3 groups. Before 1998, White patients received more percutaneous coronary interventions compared with Black and Hispanic patients (P<0.05). After 1998, the disparity in use of percutaneous coronary interventions in Black and Hispanic patients was greatly reduced compared with White patients, and the difference reversed in favor of Hispanic patients after 2005 (P<0.05). There was an overall downward trend of in-hospital mortality without evidence of disparity among Black, Hispanic, and White patients. A linear regression model was used with a change point in 1998. Before 1998, the slope of 1-year all-cause and cardiovascular mortality was not statistically significant. After 1998, the mortality showed negative slopes for all 3 groups, however, with lower overall crude mortality for Hispanic patients compared with Black and White patients (P<0.0001). Conclusions The initiative launched in 1998 may have contributed to a reduction in percutaneous coronary intervention usage disparity in patients with ST-segment-elevation myocardial infarction. Short- and long-term mortality decreased in all 3 groups, but more in the Hispanic population.

Association between race/ethnicity and income on the likelihood of coronary revascularization among postmenopausal women with acute myocardial infarction: Women's health initiative study

BACKGROUND

Historically, race, income, and gender were associated with likelihood of receipt of coronary revascularization for acute myocardial infarction (AMI). Given public health initiatives such as Healthy People 2010, it is unclear whether race and income remain associated with the likelihood of coronary revascularization among women with AMI.

METHODS

Using the Women's Health Initiative Study, hazards ratio (HR) of revascularization for AMI was compared for Black and Hispanic women vs White women and among women with annual income <$20,000/year vs ≥$20,000/year over median 9.5 years follow-up(1993-2019). Proportional hazards models were adjusted for demographics, comorbidities, and AMI type. Results were stratified by revascularization type: percutaneous coronary intervention and coronary artery bypass grafting(CABG). Trends by race and income were compared pre- and post-2010 using time-varying analysis.

RESULTS

Among 5,284 individuals with AMI (9.5% Black, 2.8% Hispanic, and 87.7% White; 23.2% <$20,000/year), Black race was associated with lower likelihood of receiving revascularization for AMI compared to White race in fully adjusted analyses [HR:0.79(95% Confidence Interval:[CI]0.66,0.95)]. When further stratified by type of revascularization, Black race was associated with lower likelihood of percutaneous coronary intervention for AMI compared to White race [HR:0.72(95% CI:0.59,0.90)] but not for CABG [HR:0.97(95%CI:0.72,1.32)]. Income was associated with lower likelihood of revascularization [HR:0.90(95%CI:0.82,0.99)] for AMI. No differences were observed for other racial/ethnic groups. Time periods (pre/post-2010) were not associated with change in revascularization rates.

CONCLUSION

Black race and income remain associated with lower likelihood of revascularization among patients presenting with AMI. There is a substantial need to disrupt the mechanisms contributing to race, sex, and income disparities in AMI management.

Racial and ethnic disparities in coronary, vascular, structural, and congenital heart disease

Cardiovascular disease (CVD) remains the leading cause of death in the United States. However, percutaneous interventional cardiovascular therapies are often underutilized in Blacks, Hispanics, and women and may contribute to excess morbidity and mortality in these vulnerable populations. The Society for Cardiovascular Angiography and Interventions (SCAI) is committed to reducing racial, ethnic, and sex-based treatment disparities in interventional cardiology patients. Accordingly, each of the SCAI Clinical Interest Councils (coronary, peripheral, structural, and congenital heart disease [CHD]) participated in the development of this whitepaper addressing disparities in diagnosis, treatment, and outcomes in underserved populations. The councils were charged with summarizing the available data on prevalence, treatment, and outcomes and elucidating potential reasons for any disparities. Given the huge changes in racial and ethnic composition by age in the United States (Figure 1), it was difficult to determine disparities in rates of diagnosis and we expected to find some racial differences in prevalence of disease. For example, since the average age of patients undergoing transcatheter aortic valve replacement (TAVR) is 80 years, one may expect 80% of TAVR patients to be non-Hispanic White. Conversely, only 50% of congenital heart interventions would be expected to be performed in non-Hispanic Whites. Finally, we identified opportunities for SCAI to advance clinical care and equity for our patients, regardless of sex, ethnicity, or race.

Role of HEART score in evaluating clinical outcomes among emergency department patients with different ethnicities

Objective

We aimed to examine the role of the HEART (history, EKG, age, risk factors, and troponin) score in the evaluation of six clinical outcomes among three groups of patients in the emergency department (ED).

Methods

We performed a retrospective observational study among three ED patient groups including White, Black, and Hispanic patients. ED providers used the HEART score to assess the need for patient hospital admission and for emergent cardiac imaging tests (CITs). HEART scores were measured using classification accuracy rates. Performance accuracies were measured in terms of HEART score in relation to four clinical outcomes (positive findings of CITs, ED returns, hospital readmissions, and 30-day major adverse cardiac events [MACE]).

Results

A high classification accuracy rate (87%) was found for use of the HEART score to determine hospital admission. HEART scores showed moderate accuracy (area under the receiver operating characteristic curve 0.66–0.78) in predicting results of emergent CITs, 30-day hospital readmissions, and 30-day MACE outcomes.

Conclusions

Providers adhered to use of the HEART score to determine hospital admission. The HEART score may be associated with emergent CIT findings, 30-day hospital readmissions, and 30-day MACE outcomes, with no differences among White, Black, and Hispanic patient populations.

Prognostic Impact of Race in Patients Undergoing PCI: Analysis From 10 Randomized Coronary Stent Trials

OBJECTIVES

The aim of this study was to assess race-based differences in patients undergoing percutaneous coronary intervention from a large pooled database of randomized controlled trials.

BACKGROUND

Data on race-based outcomes after percutaneous coronary intervention are limited, deriving mainly from registries and single-center studies.

METHODS

Baseline characteristics and outcomes at 30 days, 1 year, and 5 years were assessed across different races, from an individual patient data pooled analysis from 10 randomized trials. Endpoints of interest included death, myocardial infarction, and major adverse cardiac events (defined as cardiac death, myocardial infarction, or ischemia-driven target lesion revascularization). Multivariate Cox proportional hazards regression was performed to assess associations between race and outcomes, controlling for differences in 12 baseline covariates.

RESULTS

Among 22,638 patients, 20,585 (90.9%) were white, 918 (4.1%) were black, 404 (1.8%) were Asian, and 473 (2.1%) were Hispanic. Baseline and angiographic characteristics differed among groups. Five-year major adverse cardiac event rates were 18.8% in white patients (reference group), compared with 23.9% in black patients (p = 0.0009), 11.2% in Asian patients (p = 0.0007), and 21.5% in Hispanic patients (p = 0.07). Multivariate analysis demonstrated an independent association between black race and 5-year risk for major adverse cardiac events (hazard ratio: 1.28; 95% confidence interval: 1.05 to 1.57; p = 0.01).

CONCLUSIONS

In the present large-scale individual patient data pooled analysis, comorbidities were significantly more frequent in minority-group patients than in white patients enrolled in coronary stent randomized controlled trials. After accounting for these differences, black race was an independent predictor of worse outcomes, whereas Hispanic ethnicity and Asian race were not. Further research examining race-based outcomes after percutaneous coronary intervention is warranted to understand these differences.

Ethnic and Racial Disparities in Acute Myocardial Infarction

PURPOSE OF REVIEW

Significant racial and ethnic healthcare disparities exist in the management and outcomes of patients with acute myocardial infarction (AMI). This review will highlight the recent studies focusing on disparities in AMI care and how practice patterns have changed over time, and discuss solutions and future directions to overcome disparities in AMI care.

RECENT FINDINGS

AMI continues to be a leading cause of morbidity and mortality in the USA. Racial and ethnic disparities continue to be present in the care and outcomes associated with AMI. Non-white individuals continue to receive less guideline-concordant care and experience higher rates of adverse outcomes compared with white individuals. Health policy and quality improvement interventions have helped to narrow the gap; however, ongoing efforts are needed to continue to attempt to eliminate this disparity. Racial and ethnic disparities persist in the presentation, management, and outcomes of patients with AMI. Improvements in care have narrowed some of the inequalities. Ongoing research and efforts directed at improving access to care, eliminating bias in healthcare, and focusing on coronary heart disease prevention are needed to eliminate disparities.

Differences in Patient Experience Between Hispanic and Non-Hispanic White Patients Across U.S. Hospitals

INTRODUCTION

Despite the increased emphasis on patient experience, little is known about whether there are meaningful differences in hospital satisfaction between Hispanic and non-Hispanic whites.

METHODS

To determine if satisfaction differs, we used Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey data (2009-2010) reported by hospitals to compare responses between Hispanic and non-Hispanic white patients. Clustered logistic regression models identified within-hospital and between-hospital differences in satisfaction.

RESULTS

Of the 3,864,938 respondents, 6.2% were Hispanics, who were more often younger and females and less likely to have graduated from high school. Hispanics were overall more likely to recommend their hospital (74.1% vs. 70.9%, p < .001) and to rate it 9 or 10 (72.5% vs. 65.9%, p < .001) than whites. Increased satisfaction among Hispanics was more pronounced when compared with whites within the same hospitals, with significantly higher ratings on all HCAHPS measures. However, hospitals serving a higher percentage of Hispanics had lower satisfaction scores for both Hispanic and white patients than other hospitals.

CONCLUSION

There were significant but only modest-sized differences in patient experience between Hispanic and white patients across U.S. hospitals. Hispanics tended to be more satisfied with their care but received care at lower-performing hospitals.

Association of elevated triglycerides and acute myocardial infarction in young Hispanics

BACKGROUND

Previous studies have demonstrated that acute myocardial infarction (AMI) in young patients (age <45years) is associated with a high prevalence of smoking, obesity, hyperlipidemia and single vessel coronary artery disease (CAD). Hispanics represent the largest growing ethnic minority in the United States, yet features of AMI in young Hispanics have not been described.

METHODS

Patients undergoing percutaneous coronary intervention for AMI at Los Angeles County + University of Southern California Medical Center and Keck Medical Center were studied. We compared young Hispanics (age<45, n=47) with older patients (Hispanics and non-Hispanics age ≥45, n=888) to identify unique features of AMI in young Hispanics. We also compared young Hispanics with young non-Hispanics (n=33) and older Hispanics (n=447) in regards to traditional CAD risk factors, laboratory values and in-hospital outcomes. Multivariable logistic regression was performed to identify variables independently associated with in-hospital mortality.

RESULTS

Young Hispanics had higher triglyceride levels than young non-Hispanics and older patients (234.5±221.0mg/dL vs. 145.3±67.4mg/dL vs. 156±118.2mg/dL, p<0.0004); and higher triglyceride than older Hispanics (234.5±221.0 vs. 147.0±98.9mg/dL, p<0.02). Body mass index was independently associated with the logarithm (base10) of triglyceride levels (p<0.0001). Hispanic ethnicity and age<45years, however, were not independently associated with in-hospital mortality.

CONCLUSIONS

Young Hispanics with AMI have higher triglyceride levels than young non-Hispanics and older Hispanics. The elevated triglyceride levels may be related to lifestyle changes experienced by a young immigrant population transitioning to life in the United States.

Ethnic Minorities and Coronary Heart Disease: an Update and Future Directions

Heart disease remains the leading cause of death in the USA. Overall, heart disease accounts for about 1 in 4 deaths with coronary heart disease (CHD) being responsible for over 370,000 deaths per year. It has frequently and repeatedly been shown that some minority groups in the USA have higher rates of traditional CHD risk factors, different rates of treatment with revascularization procedures, and excess morbidity and mortality from CHD when compared to the non-Hispanic white population. Numerous investigations have been made into the causes of these disparities. This review aims to highlight the recent literature which examines CHD in ethnic minorities and future directions in research and care.

Young Hispanic Women Experience Higher In-Hospital Mortality Following an Acute Myocardial Infarction

Background

Although mortality rates for acute myocardial infarction (AMI) have declined for men and women, prior studies have reported a sex gap in mortality such that younger women were most likely to die after an AMI.

Methods and Results

We sought to explore the impact of race and ethnicity on the sex gap in AMI patterns of care and mortality for younger women in a contemporary patient cohort. We constructed multivariable hierarchical logistic regression models to examine trends in AMI hospitalizations, procedures, and in-hospital mortality by sex, age (<65 and ≥65 years), and race/ethnicity (white, black, and Hispanic). Analyses were derived from 194 071 patients who were hospitalized for an AMI with available race and ethnicity data from the 2009–2010 National Inpatient Sample. Hospitalization rates, procedures (coronary angiography, percutaneous coronary interventions, and cardiac bypass surgery), and inpatient mortality were analyzed across age, sex, and race/ethnic groups. There was significant variation in hospitalization rates by age and race/ethnicity. All racial/ethnic groups were less likely to undergo invasive procedures compared with white men (P<0.001). After adjustment for comorbidities, younger Hispanic women experienced higher in-hospital mortality compared with younger white men, with an odds ratio of 1.5 (95% CI 1.2 to 1.9), adjusted for age and comorbidities.

Conclusion

We found significant racial and sex disparities in AMI hospitalizations, care patterns, and mortality, with higher in-hospital mortality experienced by younger Hispanic women. Future studies are necessary to explore determinants of these significant racial and sex disparities in outcomes for AMI.

Do gender and race/ethnicity influence acute myocardial infarction quality of care in a hospital with a large Hispanic patient and provider representation?

Background. Disparities in acute myocardial infarction (AMI) care for women and minorities have been extensively reported in United States but with limited information on Hispanics. Methods. Medical records of 287 (62%) Hispanic and 176 (38%) non-Hispanic white (NHW) patients and 245 women (53%) admitted with suspected AMI to a southern California nonprofit community hospital with a large Hispanic patient and provider representation were reviewed. Baseline characteristics, outcomes (mortality, CATH, PCI, CABG, and use of pertinent drug therapy), and medical insurance were analyzed according to gender, Hispanic and NHW race/ethnicity when AMI was confirmed. For categorical variables, 2 × 2 chi-square analysis was conducted. Odds ratio and 95% confidence interval for outcomes adjusted for gender, race/ethnicity, cardiovascular risk factors, and insurance were obtained. Results. Women and Hispanics had similar drug therapy, CATH, PCI, and mortality as men and NHW when AMI was confirmed (n = 387). Hispanics had less private insurance than NHW (31.4% versus 56.3%, P < 0.001); no significant differences were found according to gender. Conclusions. No differences in quality measures and outcomes were found for women and between Hispanic and NHW in AMI patients admitted to a facility with a large Hispanic representation. Disparities in medical insurance showed no influence on these findings.

Predictors of adherence to performance measures in patients with acute myocardial infarction

BACKGROUND

There have been substantial improvements in the use of evidence-based, guideline-recommended therapies for patients with acute myocardial infarction. Nevertheless, some gaps, disparities, and variations in use remain. To understand how such gaps in recommended care may be narrowed further, it may be useful to determine those factors associated with lessened adherence to guideline-based care.

METHODS

The Get with the Guidelines-Coronary Artery Disease registry measured adherence with 6 performance measures (aspirin within 24 hours, discharge on aspirin and beta-blockers, patients with low ejection fraction discharged on angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, smoking cessation counseling, use of lipid-lowering medications) in 148,654 patients with acute myocardial infarction between 2002 and 2009. Logistic multivariable regression models using generalized estimating equations were utilized to identify patient and hospital characteristics associated with adherence to each of 6 measures, and to a summary score of performance for all measures, in eligible patients.

RESULTS

We identified 10 variables that were associated significantly with either greater adherence (hypertension, hyperlipidemia, hospital with full interventional capabilities, calendar year) or worse adherence (age, female sex, congestive heart failure, chronic renal insufficiency, atrial fibrillation, chronic dialysis) in at least 4 of the 6 treatment adherence models, as well as the summary score adherence model. Age, sex, and calendar year were significant in all models.

CONCLUSIONS

Use of evidence-based acute myocardial infarction treatments remains less than ideal for certain high-risk populations. The close correlations among factors associated with underperformance highlights the potential for specifically targeting and tailoring quality improvement interventions.

Results of a survey assessing provider beliefs of adherence barriers to antiplatelet medications

The guidelines published by the American College of Cardiology Foundation/American Heart Association provide an evidence-based rationale and continuum of care for patients with unstable angina/non-ST-segment elevation acute coronary syndromes (UA/NSTE-ACS) from acute through to chronic management. Antiplatelet therapy forms an integral part of the care regimen, and a wealth of evidence supports appropriate dual or triple antiplatelet therapy in significantly reducing the frequency of potentially fatal secondary ischemic events. However, as is often the case with long-term therapies, adherence issues become apparent that limit this potential. In this article, we report on the results of a national survey of health care providers involved in the care of UA/NSTE-ACS patients on chronic (posthospital discharge) antiplatelet therapy. Our data reveal that the participants believe costs, lack of patient understanding of their condition or medication, and perception of the value of their therapy are important patient factors that promote nonadherence. Participants indicated that nonadherence occurs more frequently among minority and elderly patients, and less frequently when a caregiver is involved. We also show that deficits of knowledge, competence, and confidence exist in providers who treat patients with UA/NSTE-ACS. These deficits were generally greater in primary/family care providers compared with internal medicine and cardiologists, and for nurse practitioners/physician assistants compared with physicians (MDs/DOs). In addition, providers of all types frequently did not use adherence-improving tools or resources with their staff or patients. Our data suggest that because of its potential impact on patient outcomes, there is a pressing need to improve provider antiplatelet therapy adherence management in UA/NSTE-ACS.

Regional differences in clinical profile, quality of care, and outcomes among Hispanic patients hospitalized with acute myocardial infarction in the Get with Guidelines-Coronary Artery Disease (GWTG-CAD) registry

BACKGROUND

Although Hispanics constitute the largest minority in the United States, it is unknown whether regional differences in quality of care and outcomes exist among Hispanic patients hospitalized with acute myocardial infarction (MI).

METHODS

Using the GWTG-CAD Registry, clinical characteristics, conformity with quality measures, and in-hospital outcomes were assessed among Hispanic patients from different geographic regions admitted for acute MI in participating hospitals.

RESULTS

A total of 11,299 Hispanic patients treated for acute MI at 277 hospitals from 4 regions were included in the study. Midwestern Hispanics were more likely to be younger, with male predominance in all regions. Northeastern Hispanics were more often insured with Medicaid. All subgroups showed high rates of hypertension, dyslipidemia, diabetes, and smoking, with the highest rates observed in the northeast region. Northeastern Hispanics were more likely to be discharged on angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, β-blockers, and statin or other lipid-lowering therapy. No significant regional differences were observed in aspirin, clopidogrel, and guideline-recommended door-to-balloon and door-to-thrombolysis times. Although Hispanics in the south and northeast were more likely to have a longer hospital stay compared with the west, there were no regional differences in in-hospital mortality.

CONCLUSIONS

Among Hispanics with acute MI enrolled in the GWTG-CAD program, there were modest regional differences in clinical profile; high rates of use and, with few exceptions, no regional differences in guideline-recommended therapies; and no regional variation in in-hospital mortality.

Readmission rates for Hispanic Medicare beneficiaries with heart failure and acute myocardial infarction

BACKGROUND

Hispanics are the fastest growing segment of the US population and have a higher prevalence of cardiovascular risk factors than non-Hispanic whites. However, little is known about whether elderly Hispanics have higher readmission rates for heart failure (HF) and acute myocardial infarction (AMI) than whites and whether this is due to site of care.

METHODS

We examined hospitalizations for Medicare patients with a primary discharge diagnosis of HF and AMI in 2006 to 2008. We categorized hospitals in the top decile of proportion of Hispanic patients as "Hispanic serving" and used logistic regression to examine the relationship between patient ethnicity, hospital Hispanic-serving status, and readmissions.

RESULTS

Hispanic patients had higher risk-adjusted readmission rates than whites for both HF (27.9% vs 25.9%, odds ratio [OR] 1.11, 95% CI 1.07-1.14, P < .001) and AMI (23.0% vs 21.0%, OR 1.12, 95% CI 1.07-1.18, P < .001). Similarly, Hispanic-serving hospitals had higher readmission rates than non-Hispanic-serving hospitals for both HF (27.4% vs 25.8%, OR 1.09, 95% CI 1.06-1.12, P < .001) and AMI (23.0% vs 20.8%, OR 1.13, 95% CI 1.09-1.18, P < .001). In analyses considering ethnicity and site of care simultaneously, both Hispanics and whites had higher readmission rates at Hispanic-serving hospitals.

CONCLUSIONS

Elderly Hispanic patients are more likely to be readmitted for HF and AMI than whites, partly due to the hospitals where they receive care. Our findings suggest that targeting the site of care and these high-risk patients themselves will be necessary to reduce disparities in readmissions for this growing group of patients.

Association of race/ethnicity with clinical risk factors, quality of care, and acute outcomes in patients hospitalized with heart failure

BACKGROUND

Black and Hispanic populations are at increased risk for developing heart failure (HF) at a younger age and experience differential morbidity and possibly differential mortality compared with whites. Yet, there have been insufficient data characterizing the clinical presentation, quality of care, and outcomes of patients hospitalized with HF as a function of race/ethnicity.

METHODS

We analyzed 78,801 patients from 257 hospitals voluntarily participating in the American Heart Association's Get With The Guidelines-HF Program from January 2005 thru December 2008. There were 56,266 (71.4%) white, 17,775 (22.6%) black, and 4,760 (6.0%) Hispanic patients. In patients hospitalized with HF, we sought to assess clinical characteristics, adherence to core and other guideline-based HF care measures, and in-hospital mortality as a function of race and ethnicity.

RESULTS

Relative to white patients, Hispanic and black patients were significantly younger (median age 78.0, 63.0, 64.0 years, respectively), had lower left ventricular ejection fractions, and had more diabetes mellitus and hypertension. With few exceptions, the provision of guideline-based care was comparable for black, Hispanic, and white patients. Black and Hispanic patients had lower in-hospital mortality than white patients: black/white odds ratio 0.69, 95% CI 0.62-0.78, P < .001 and Hispanic/white odds ratio 0.81, 95% CI 0.67-0.98, P = .03.

CONCLUSIONS

Hispanic and black patients hospitalized with HF have more cardiovascular risk factors than white patients; however; they have similar or better in-hospital mortality rates. Within the context of a national HF quality improvement program, HF care was equitable and improved in all racial/ethnic groups over time.

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.

Managing care? Medicare managed care and patient use of cardiologists

OBJECTIVE

To examine the impact of Medicare managed care (MMC) versus Medicare fee for service (MFFS) on stent patients' use of physicians with lower resource use and better outcomes.

DATA SOURCES/STUDY SETTING

Retrospective secondary data from 2003 through 2006 for 67,476 patients without acute myocardial infarction, staying 2 or more days in hospital, and treated by 486 physicians in Florida performing 10 or more cases per quarter.

STUDY DESIGN

Analysis was at the patient level. Multivariate logistic models estimated the probability of an MMC patient using a physician with a particular risk-adjusted profile rank with respect to hospital peers.

PRINCIPAL FINDINGS

No differences were found in usage of physicians with shorter admissions. Compared with MFFS, MMC patients were significantly less likely to use physicians whose average mortality was the lowest/lowest quartiles/below median among facility peers, and more likely to use a physician ranked below median on live discharges directly home (not needing home health care, skilled nursing care, or a subacute hospital convalescence). Similar results were found with emergency admissions, and where physicians both attended and treated.

CONCLUSIONS

Florida percutaneous coronary interventions patients insured by MMC used physicians with worse outcome profiles than those of MFFS patients. Results were not consistent with hospital care differences, physician-patient, or payor-physician selection, but they were consistent with selection of unobservably sicker members into MMC and concentration of MMC among physicians.

Clopidogrel in the management of acute coronary syndromes: indications, results, obstacles

Atherothrombosis is the underlying pathology of the acute coronary syndromes (ACS), in which platelet activation plays a key role. Therefore, antiplatelet therapy is an essential component of guideline-recommended ACS management. Considerable evidence clearly demonstrates the benefits of the antiplatelet agent clopidogrel in reducing mortality, decreasing recurrent cardiovascular events, and increasing arterial patency in ACS patients. Despite this evidence, data from patient registries and clinical initiatives such as CRUSADE (Can Rapid stratification of Unstable angina Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association guidelines) and GRACE (Global Registry of Acute Coronary Events) indicate that clopidogrel is underused in patients with ACS. This is especially true for patients receiving conservative medical management, many of whom have significant risk for recurrent ischemic events. The purpose of this review is to compare "real-life" clopidogrel therapy with evidence-based guidelines, and to highlight clinical factors that drive clopidogrel implementation or provide barriers to its use in ACS patients.

Emergency medical practice: advancing cultural competence and reducing health care disparities

In an increasingly diverse patient population, language differences, socioeconomic circumstances, religious values, and cultural practices may present barriers to the delivery of quality care. These obstacles contribute to the health care disparities observed in all areas of medical care. Increasing cultural competence has been cited as part of the solution to reduce disparities. The emergency department (ED) is an environment where cultural sensitivity is particularly needed, as it is often a primary source of health care for the underserved and ethnic and racial minorities and a place where high patient volume and acuity place the provider under demanding time pressures, yet the emergency medicine (EM) literature on health care disparities and cultural competence is limited. The authors present three clinical scenarios highlighting challenges in providing equitable emergency care to minority populations. Using these cases as illustrations, three processes are proposed that may improve the quality of care delivered to minority populations: 1) increase cultural awareness and reduce provider biases, enabling providers to interact more effectively with different patient populations; 2) accommodate patient preferences and needs in medical settings through practice adjustments and cultural modifications; and 3) increase provider diversity to raise levels of tolerance, awareness, and understanding for other cultures and create more racially and/or ethnically concordant patient-physician relationships.

Implementing critical pathways and a multidisciplinary team approach to cardiovascular disease management

According to several medical registries, there is a need to improve the care of post-myocardial infarction (MI) patients, especially those with left ventricular dysfunction (LVD) and heart failure. This can potentially be achieved by implementing disease management programs, which include critical pathways, patient education, and multidisciplinary hospital teams. Currently, algorithms for critical pathways, including discharge processes, are lacking for post-MI LVD patients. Such schemes can increase the use of evidence-based medicines proved to reduce mortality. Educational programs are aimed at increasing patients' awareness of their condition, promoting medication compliance, and encouraging the adoption of healthy behaviors; such programs have been shown to be effective in improving outcomes of post-MI LVD patients. Reductions in all-cause hospitalizations and medical costs as well as improved survival rates have been observed when a multidisciplinary team (a nurse, a pharmacist, and a hospitalist) is engaged in patient care. In addition, the use of the "pay for performance" method, which can be advantageous for patients, physicians, and hospitals, may potentially improve the care of post-MI patients with LVD.

Effect of an American Heart Association Get With the Guidelines program-based clinical pathway on referral and enrollment into cardiac rehabilitation after acute myocardial infarction

Cardiac rehabilitation (CR)/secondary prevention programs are an important part of patient care after acute myocardial infarction (AMI). However, only 10% to 15% of eligible patients enroll in such programs. The purpose of this study was to evaluate the effect of an American Heart Association Get With the Guidelines (GWTG)-based clinical pathway on referral and enrollment into CR after AMI. Patients (n = 780) admitted to a single center during an 18-month period with AMI and discharged to home were evaluated retrospectively for referral and enrollment into CR programs. A total of 714 patients (92%) were on the GWTG pathway; 392 (55%) were referred and 135 (19%) were enrolled into CR. Higher referral was associated with pathway use (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.1 to 4.9, p = 0.03), percutaneous coronary intervention (OR 3.1, 95% CI 1.9 to 5.2, p <0.0001), and in-patient physical therapy consultation (OR 13, 95% CI 8.2 to 20.5, p <0.0001). Ethnicity did not affect referral, but was the only variable associated with lower enrollment. Hispanic and black patients had 92% (OR 0.08, 95% CI 0.01 to 0.55, p = 0.02) and 57% (OR 0.43, 95% CI 0.19 to 1.05, p = 0.06) lower odds to enroll compared with white patients, respectively. In conclusion, use of the American Heart Association GWTG pathway showed a significantly higher referral rate to CR after AMI than previously reported in the literature. Nonetheless, most referred patients did not enroll. Strategies to bridge the gap between referral and enrollment in CR should be incorporated into AMI clinical pathways, with special emphasis on increasing enrollment in ethnic minorities.

Influence of Hispanic Ethnicity on Blood Pressure Control and Cardiovascular Outcomes in Women with CAD and Hypertension: Findings from INVEST

BACKGROUND

Prospective data regarding blood pressure (BP) control and cardiovascular (CV) outcomes in Hispanic women are lacking.

METHODS

We analyzed 5017 Hispanic and 4710 non-Hispanic white hypertensive women with coronary artery disease (CAD) in the INternational VErapamil SR/Trandolapril STudy (INVEST) to determine the impact of baseline characteristics and BP control on CV outcomes.

RESULTS

At baseline, Hispanic women were younger and a had lower prevalence of most established CV risk factors than non-Hispanic white women. At 24 months, BP control (< 140/90 mm Hg) was achieved in 75% of Hispanic and 68% of non-Hispanic white women, (p < 0.001), with most women, regardless of ethnicity, requiring > or =2 antihypertensive agents. Following 26,113 patient-years of follow-up, the primary outcome (first occurrence of nonfatal myocardial infarction [MI], nonfatal stroke, or all cause death) occurred in 5.7% of Hispanic and 12.3% of non-Hispanic white women (adjusted HR = 0.84, 95% CI = 0.71-0.98, p = 0.03). There was no difference in outcome in either group of women comparing the randomized antihypertensive treatment strategies.

CONCLUSIONS

Despite accounting for a lower risk profile, deployment of protocol-based antihypertensive treatment regimens resulted in superior BP control and fewer CV events in Hispanic women compared with non-Hispanic white women.

Racial differences among high-risk patients presenting with non-ST-segment elevation acute coronary syndromes (results from the SYNERGY trial)

Management and outcomes of patients with acute coronary syndromes (ACSs) may vary according to patient race and ethnicity. To assess racial differences in presentation and outcome in high-risk North American patients with non-ST-segment elevation (NSTE) ACS, we analyzed baseline racial/ethnic differences and all-cause death or nonfatal myocardial infarction (MI) in 6,077 white, 586 African-American, and 344 Hispanic patients through 30-day, 6-month, and 1-year follow-up. Frequencies of hypertension were 66% for whites, 83% for African-Americans, and 78% for Hispanics (overall p <0.001). Use of angiography was similar across groups. Use of percutaneous coronary intervention (46% for whites, 41% for African-Americans, and 45% for Hispanics, overall p = 0.046) and coronary artery bypass grafting (20% for whites, 16% for African-Americans, and 22% for Hispanics, overall p = 0.044) differed. African-American patients had significantly fewer diseased vessels compared with white patients (p = 0.0001). Thirty-day death or MI was 14% for whites, 10% for African-Americans, and 14% for Hispanics (overall p = 0.034). After adjustment for baseline variables, African-American patients had lower 30-day death or MI compared with white patients (odds ratio 0.73, 95% confidence interval 0.55 to 0.98). There were no differences in 6-month death or MI across racial/ethnic groups. In conclusion, baseline clinical characteristics differed across North American racial/ethnic groups in the SYNERGY trial. African-American patients had significantly better adjusted 30-day outcomes but similar 6-month outcomes compared with white patients.