Do race-specific models explain disparities in treatments after acute myocardial infarction?

Minority-Serving Hospitals Are Associated With Low Within-Hospital Disparity

BACKGROUND

Disparities in obstetric care have been well documented, but disparities in the within-hospital population have not been as extensively explored. The objective is to assess cesarean delivery rate disparities at the hospital level in a nationally recognized low risk of cesarean delivery group.

METHODS

An observational study using a national population-based database, Nationwide Inpatient Sample, from 2008 to 2011 was conducted. All patients with nulliparous, term, singleton, vertex pregnancies from Black and White patients were included. The primary outcome was delivery mode (cesarean vs vaginal). The primary independent variable was race (Black vs White).

RESULTS

A total of 1,064,351 patients were included and the overall nulliparous, term, singleton, and vertex pregnancies cesarean delivery rate was 14.1%. The within-hospital disparities of cesarean delivery rates were lower in minority-serving hospitals (OR: 1.20 95% CI: 1.12-1.28), rural hospitals (OR 1.11 95% CI: 1.02-1.20), and the South (OR 1.24 95% CI 1.19-1.30) compared to their respective counterparts. Non-minority serving hospitals (OR: 1.20 95% CI 0.12-1.25), and urban hospitals (OR1.32 95% CI 1.28-1.37), the Northeast (OR 1.41 95% CI 1.30-1.53) or West (OR 1.52 95% CI 1.38-1.67), had higher within-hospital racial disparities of cesarean delivery rates. The odds ratios reported are comparing within-hospital cesarean delivery rates in Black and White patients.

DISCUSSION

Significant within-hospital disparities of cesarean delivery rates across hospitals highlight the importance of facility-level factors. Policies aimed at advancing health equity must address hospital-level drivers of disparities in addition to structural racism.

Racial Disparities in Patient Characteristics and Survival After Acute Myocardial Infarction

IMPORTANCE

Black patients experience worse outcomes than white patients following acute myocardial infarction (AMI).

OBJECTIVE

To examine the degree to which nonrace characteristics explain observed survival differences between white patients and black patients following AMI.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used the extensive socioeconomic and clinical characteristics from patients recovering from an AMI that were prospectively collected at 31 hospitals across the contiguous United States between 2003 and 2008 for the Prospective Registry Evaluating Myocardial Infarction: Events and Recovery registry and the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status registry. Survival was assessed using data from the National Death Index. Data were analyzed from December 2016 to July 2018.

MAIN OUTCOMES AND MEASURES

Patient characteristics were categorized into 8 domains, and the degree to which each domain discriminated self-identified black patients from white patients was determined by calculating propensity scores associated with black race for each domain as well as cumulatively across all domains. The final propensity score was associated with 1- and 5-year mortality rates.

RESULTS

Among 6402 patients (mean [SD] age, 60 [13] years; 2127 [33.2%] female; 1648 [25.7%] black individuals), the 5-year mortality rate following AMI was 28.9% (476 of 1648) for black patients and 18.0% (856 of 4754) for white patients (hazard ratio, 1.72; 95% CI, 1.54-1.92; P < .001). Most categories of patient characteristics differed substantially between black patients and white patients. The cumulative propensity score discriminated race, with a C statistic of 0.89, and the propensity scores were associated with 1- and 5-year mortality rates (hazard ratio for the 75th percentile of the propensity score vs 25th percentile, 1.72; 95% CI, 1.43-2.08; P < .001). Patients in the lowest propensity score quintile associated with being a black individual (regardless of whether they were of white or black race) had a 5-year mortality rate of 15.5%, while those in the highest quintile had a 5-year mortality rate of 31.0% (P < .001). After adjusting for the propensity associated with being a black patient, there was no significant mortality rate difference by race (adjusted hazard ratio, 1.09; 95% CI, 0.93-1.26; P = .37) and no statistical interaction between race and propensity score (P = .42).

CONCLUSIONS AND RELEVANCE

Characteristics of black patients and white patients differed significantly at the time of admission for AMI. Those characteristics were associated with an approximately 3-fold difference in 5-year mortality rate following AMI and mediated most of the observed mortality rate difference between the races.

Classification tree analysis of race-specific subgroups at risk for a central venous catheter-related bloodstream infection

BACKGROUND

Studies of racial disparities in patient safety events often do not use race-specific risk adjustment and do not account for reciprocal covariate interactions. These limitations were addressed by using classification tree analysis separately for black patients and white patients to identify characteristics that segment patients who have increased risks for a venous catheter-related bloodstream infection.

METHODS

A retrospective, cross-sectional analysis of 5,236,045 discharges from 103 Florida acute hospitals in 2005-2009 was conducted. Hospitals were rank ordered on the basis of the black/white Patient Safety Indicator (PSI) 7 rate ratio as follows: Group 1 (white rate higher), Group 2, (equivalent rates), Group 3, (black rate higher), and Group 4, (black rate highest). Predictor variables included 26 comorbidities (Elixhauser Comorbidity Index) and demographic characteristics. Four separate classification tree analyses were completed for each race/hospital group.

RESULTS

Individual characteristics and groups of characteristics associated with increased PSI 7 risk differed for black and white patients. The average age for both races was different across the hospital groups (p < .01). Weight loss was the strongest single delineator and common to both races. The black subgroups with the highest PSI 7 risk were Medicare beneficiaries who were either < or = 25.5 years without hypertension or < or = 39.5 years without hypertension but with an emergency or trauma admission. The white subgroup with the highest PSI 7 risk consisted of patients < or = 45.5 years who had congestive heart failure but did not have either hypertension or weight loss.

DISCUSSION

Identifying subgroups of patients at risk for a rare safety event such as PSI 7 should aid effective clinical decisions and efficient use of resources and help to guide patient safety interventions.

Disparity in race-specific comorbidities associated with central venous catheter-related bloodstream infection (AHRQ-PSI7)

Studies of racial disparities in hospital-level patient safety outcomes typically apply a race-common approach to risk adjustment. Risk factors specific to a minority population may not be identified in a race-common analysis if they represent only a small percentage of total cases. This study identified patient comorbidities and characteristics associated with the likelihood of a venous catheter-related bloodstream infection (Agency for Healthcare Research and Quality Patient Safety Indicator 7 [PSI7]) separately for blacks and whites using race-specific logistic regression models. Hospitals were ranked by the racial disparity in PSI7 and segmented into 4 groups. The analysis identified both black- and white-specific risk factors associated with PSI7. Age showed race-specific reverse association, with younger blacks and older whites more likely to have a PSI7 event. These findings suggest the need for race-specific covariate adjustments in patient outcomes and provide a new context for examining racial disparities.

Impact of race on cumulative exposure to antihypertensive medications in dialysis

BACKGROUND

Racial minorities typically have less exposure than non-minorities to antihypertensive medications across an array of cardiovascular conditions in the general population. However, cumulative exposure has not been investigated in dialysis patients.

METHODS

In a longitudinal analysis of 38,381 hypertensive dialysis patients, prescription drug data from Medicaid was linked to Medicare data contained in United States Renal Data System core data, creating a national cohort of dialysis patients dually eligible for Medicare and Medicaid services. The proportion of days covered (PDC) was calculated to determine cumulative exposure to angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), β-blockers, and calcium-channel blockers (CCDs). The factors associated with use of these medications were modeled through weighted linear regression, with derivation of the adjusted odds ratios (AORs) for exposure.

RESULTS

Relative to non-Hispanic Caucasians, African-American, Hispanic, or Other race/ethnicity were significantly associated with less exposure to β-blockers (AOR 0.56-0.69, P < 0.001 in each case) and CCBs (AOR 0.84-0.85, P < 0.001 in each case); African-American race and Hispanic ethnicity had AORs of 0.78 and 0.73 for ACEIs and ARBs, respectively (P < 0.001 in both cases). Collectively, the odds of exposure to each class of medication for minorities was about three-quarters of that for Caucasians.

CONCLUSIONS

Given that dually Medicare-and-Medicaid-eligible dialysis patients have insurance coverage for prescription medications as well as regular contact with health care providers, differences by race in exposure to antihypertensive medications should with time be minimal among patients who are candidates for these drugs. The causes of differences by race in exposure to antihypertensive medications over the course of time should be further examined.

Outcomes for whites and blacks at hospitals that disproportionately care for black Medicare beneficiaries

OBJECTIVE

Hospital care for blacks is concentrated among a small number of hospitals and whether they have worse outcomes across common medical conditions is unknown.

DATA SOURCE

We used the 2007 100% Medicare file to calculate 30- and 90-day mortality rates for white and black patients admitted for acute myocardial infarction (AMI), congestive heart failure (CHF), or pneumonia.

STUDY DESIGN

We ranked all hospitals in the country by their proportion of discharged black patients and identified the top 10 percent of these hospitals as black serving. We examined race-specific adjusted mortality rates and adjusted for differences in hospital characteristics.

PRINCIPAL FINDINGS

At 30 days, black-serving hospitals had, compared with nonblack-serving hospitals, similar mortality for AMI, lower mortality for CHF, and higher mortality for pneumonia. At 90 days, mortality was higher at black-serving hospitals for both AMI and pneumonia and comparable for CHF compared with nonblack-serving hospitals. White patients had worse outcomes at black-serving hospitals for two conditions at 30 days and all three conditions at 90 days. Blacks also had worse outcomes at black-serving hospitals.

CONCLUSIONS

Hospitals with a high proportion of black patients had worse outcomes than other hospitals for both their white and black elderly patients.

Ethnic/race differences in the attrition of older American survey respondents: implications for health-related research

OBJECTIVE

To compare models of attrition across race/ethnic groups of aging populations and discuss implications for health-related research.

DATA SOURCES

The Health and Retirement Study (1992-2008).

STUDY DESIGN

A competing risks model was estimated using a multinomial logit model when respondents faced competing types of risks, such as dying, being lost from the study, and nonresponse in some years for different groups of elderly. Key explanatory variables were foreign birth, health insurance, and health status.

PRINCIPAL FINDINGS

Variables describing foreign birth, health insurance, and health status differed in their prediction of attrition across ethnic groups of aging populations.

CONCLUSIONS

Differences in the predictors of attrition across ethnic groups of elderly could potentially lead to biased estimates in health-related research using longitudinal data sources.

Thirty-day readmission rates for Medicare beneficiaries by race and site of care

CONTEXT

Understanding whether and why there are racial disparities in readmissions has implications for efforts to reduce readmissions.

OBJECTIVE

To determine whether black patients have higher odds of readmission than white patients and whether these disparities are related to where black patients receive care.

DESIGN

Using national Medicare data, we examined 30-day readmissions after hospitalization for acute myocardial infarction (MI), congestive heart failure (CHF), and pneumonia. We categorized hospitals in the top decile of proportion of black patients as minority-serving. We determined the odds of readmission for black patients compared with white patients at minority-serving vs non-minority-serving hospitals.

SETTING AND PARTICIPANTS

Medicare Provider Analysis Review files of more than 3.1 million Medicare fee-for-service recipients who were discharged from US hospitals in 2006-2008.

MAIN OUTCOME MEASURE

Risk-adjusted odds of 30-day readmission.

RESULTS

Overall, black patients had higher readmission rates than white patients (24.8% vs 22.6%, odds ratio [OR], 1.13; 95% confidence interval [CI], 1.11-1.14; P < .001); patients from minority-serving hospitals had higher readmission rates than those from non-minority-serving hospitals (25.5% vs 22.0%, OR, 1.23; 95% CI, 1.20-1.27; P < .001). Among patients with acute MI and using white patients from non-minority-serving hospitals as the reference group (readmission rate 20.9%), black patients from minority-serving hospitals had the highest readmission rate (26.4%; OR, 1.35; 95% CI, 1.28-1.42), while white patients from minority-serving hospitals had a 24.6% readmission rate (OR, 1.23; 95% CI, 1.18-1.29) and black patients from non-minority-serving hospitals had a 23.3% readmission rate (OR, 1.20; 95% CI, 1.16-1.23; P < .001 for each); patterns were similar for CHF and pneumonia. The results were unchanged after adjusting for hospital characteristics including markers of caring for poor patients.

CONCLUSION

Among elderly Medicare recipients, black patients were more likely to be readmitted after hospitalization for 3 common conditions, a gap that was related to both race and to the site where care was received.

Racial disparities in age at time of cardiovascular events and cardiovascular-related death in patients with systemic lupus erythematosus

OBJECTIVE

To determine whether racial disparities exist with regard to the age at which patients with systemic lupus erythematosus (SLE) experience cardiovascular disease (CVD) and CVD-associated death.

METHODS

Using the 2003-2006 Nationwide Inpatient Sample, we calculated the age difference between patients with SLE and their race- and sex-matched controls at the time of hospitalization for a cardiovascular event and for CVD-associated death. In addition, we calculated the age difference between white patients with SLE and sex-matched controls for each minority group for the same outcomes.

RESULTS

The mean age difference between women with and those without SLE at the time of admission for a CVD event was 10.5 years. All age differences between women with SLE (n = 3,627) and women without SLE admitted for CVD were significant (P < 0.0001). Among different racial groups with SLE, black women were the youngest to be admitted with CVD (53.9 years) and to have a CVD-associated in-hospital death (52.8 years; n = 218). Black women with SLE were 19.8 years younger than race- and sex-matched controls at the time of CVD-associated death. Admission trends for CVD were reversed for black women, such that the highest proportions of these patients were admitted before age 55 years, and then the proportions steadily decreased across age categories. Among the 805 men with SLE who were admitted with a CVD event, those who were black or Hispanic were youngest.

CONCLUSION

There are significant racial disparities with regard to age at the time of hospital admission for CVD events and CVD-related hospitalization resulting in death in patients with SLE.

The effect of patients' race on provider treatment choices in coronary care: a literature review for model development

This selective literature review provides insight into the depth and breadth of the problem of unequal medical treatment of Blacks compared with Whites, with particular focus on coronary heart disease. Poor health outcomes among Blacks, when compared with Whites, are well documented, and these disparities are linked to lower quality of and less aggressive medical treatment. It is not clear why these disparities in treatment occur. This review provides theoretical frameworks that attempt to explain the effect of race on treatment and presents an analysis of the quality and strength of existing evidence of racial disparity related to coronary care. Based on the review, implications for policy makers and providers are identified.

Factors affecting usage patterns of memantine in Alzheimer disease

Memantine is approved by the US Food and Drug Administration for the treatment of moderate to severe Alzheimer disease (AD). We investigated the frequency and variables associated with its use in mild to moderate/severe AD as defined by criteria involving the Mini-Mental Status Examination (MMSE) and Clinical Dementia Rating (CDR) scale. Consecutive possible and probable AD patients seen at our research center from November 2003 to December 2006 were included. Individuals were classified as mild dementia either by CDR=1 or MMSE >or=15, using criteria derived in part from the pivotal trials of memantine used for its approval by the Food and Drug Administration. Of 117 patients, 37% of those with mild AD by MMSE criterion (total N=94), and 38% of those with mild AD by CDR criterion (total N=86) used memantine. Logistic regression was used to simultaneously estimate the odds ratios (ORs) of the likelihood of memantine usage associated with a set of predictor variables. Lower MMSE was associated with a greater likelihood of using memantine independent of CDR [ORMMSE=7.45, 95% confidence interval (CI)=1.50-37.05]; CDR was not significantly related to memantine use. Controlling both MMSE and CDR, Whites were more likely to use memantine than African Americans (OR=6.47, 95% CI=1.25-33.39). Patients who used other antidementia medications were more likely to use memantine than those who did not (OR=3.15, 95% CI=0.995-9.97). Eight other patient characteristics were not significant predictors. Use of memantine in mild AD was common. Patterns of memantine usage are complex and deserve further study in a larger sample because of their implications for medical system cost, equitable access to care, and risk of drug interactions.