Underutilization of reperfusion therapy in eligible African Americans with acute myocardial infarction: Role of presentation and evaluation characteristics

Regional and socioeconomic disparities in calcium scans

INTRODUCTION

Disparities in cardiovascular care are well recognized, with socioeconomic status being one of the strongest determinants of cardiovascular disease outcomes. This study evaluates whether these disparities translate to coronary artery calcium (CAC) scan utilization. Specifically, we aim to describe regional variation and socioeconomic variables that impact CAC utilization across the United States relative to the prevalence of coronary artery disease (CAD) and related comorbidities.

METHODS

This cross-sectional study integrates county-level CAC utilization with CAD prevalence and publicly available socioeconomic variables including self-identified ethnicity, education, and adjusted gross income. CAC utilization rates were sourced from 2022 hospital commercial claims, outpatient Medicare service claims, and independent imaging center claims. Heart disease prevalence and socioeconomic variables were extracted from the Centers for Disease Control and Prevention and the National Center for Chronic Disease Prevention and Health Promotion. Adjusted gross income per capita was gathered from Internal Revenue Service data.

RESULTS

CAC utilization was evaluated across 808 counties within the United States, representing 600,379 claims. Median utilization was 1.62 scans per 1,000 persons with a range of 0.03 to 104.39. The West had the highest CAC scan utilization rate (median 3.09 scans per 1,000 persons) with a CAD prevalence of 548 per 100,000 persons. In contrast, the Midwest had the lowest utilization rate (median 1.24 scans per 1,000 persons) with a CAD prevalence of 635 per 100,000 persons. Socioeconomic factors that favor higher CAC utilization include a larger density of White/Caucasian ethnicity (p = 0.007) and a higher adjusted gross income per capita (p = 0.006). Counties with the lowest rates of CAC utilization have a higher population of African Americans (p <0.001) and a higher proportion of females (p <0.001).

CONCLUSION

This analysis highlights regional and socioeconomic differences in CAC utilization in the United States. Under-represented ethnicities such as African Americans have among the lowest rates of CAC utilization despite having a higher burden and mortality from heart disease. Discordance between CAC utilization, heart disease prevalence and socioeconomic status reveals a need for targeted interventions and policies aimed at mitigating structural barriers that perpetuate health inequities.

Trampoline Injuries in Children and Adolescents: A Jumping Threat

OBJECTIVE

As trampoline use grows more popular in the United States, the frequency of injuries continues to climb. We hypothesized that toddlers would be at the highest risk for trampoline injuries requiring hospitalization.

METHODS

The National Electronic Injury Surveillance System database was examined for trampoline injuries from 2009 to 2018. Patients were categorized into 3 main age groups: toddlers (<2 years), children (2-12 years), and adolescents (13-18 years). Regression models were used to identify patients at high risk for injury or hospitalization.

RESULTS

There was a total of 800,969 meeting inclusion criteria, with 433,827 (54.2%) occurring at their own homes and 86,372 (18.1%) at the sporting venue. Of the total, 36,789 (4.6%) were admitted to a hospital. Fractures (N = 270,884, 34%), strain/sprain injuries (N = 264,990, 33%), followed by skin contusions/abrasions (N = 115,708, 14%) were the most common diagnoses. The most frequent injury sites were lower and upper extremities accounting for 329,219 (41.1%) and 244,032 (30.5%), whereas 175,645 (21.9%) had head and neck injuries. Musculoskeletal injuries (74%) and concussions (2.6%) were more frequent in adolescents than children (67.6% and 1.6%) and toddlers (56.3% and 1.3%). Internal organ and soft tissue injuries were frequent in toddlers. There were no fatalities reported in the injured patients. Multivariate analysis showed adolescents, female sex, extremity injuries, and musculoskeletal injuries were associated with hospitalization. Injury at a sporting venue was not associated with hospitalization.

CONCLUSIONS

Adolescents and girls are at increased risk of trampoline injury, warranting hospitalization. Safety standards may help prevent extremity and musculoskeletal injuries in the pediatric population. Finally, use of trampolines at sporting venues does not appear to be particularly dangerous.

Differences in admitting hospital characteristics for black and white Medicare beneficiaries with acute myocardial infarction

BACKGROUND

Racial disparities in acute myocardial infarction treatment may be due to differences in admitting hospitals. Little is known about factors associated with hospital selection for black and white acute myocardial infarction patients.

METHODS AND RESULTS

We identified black and white Medicare beneficiaries with acute myocardial infarction in 63 hospital referral regions with at least 50 black admissions during 2005 (n=65,633). We calculated distance from patient home to hospital referral region hospitals using ZIP code centroids. We assessed hospital quality using a composite score made up of hospital risk-adjusted 30-day mortality and acute myocardial infarction performance measures. Hospitals with a score in the top 20% were categorized as high quality, and those in the lowest 20% as low quality. We used conditional multinomial logit models to examine differences in hospital selection for blacks and whites. On average, blacks lived closer to revascularization hospitals (mean, 3.8 versus 6.8 miles; P<0.001) and to high-quality hospitals (mean, 5.6 versus 9.7 miles; P<0.001). After distance was accounted for, blacks were relatively less likely (P<0.001) to be admitted to revascularization hospitals (risk ratio [RR], 0.87; 95% confidence interval [CI], 0.80 to 0.95) and to high-quality hospitals (RR, 0.88; 95% CI, 0.801 to 0.95) but more likely (P<0.001) to be admitted to low-quality hospitals (RR, 1.17; 95% CI, 1.05 to 1.29). In analyses matched by home ZIP code, differences in admissions to revascularization (RR, 0.92; 95% CI, 0.80 to 1.05), high-quality (RR, 0.94; 95% CI, 0.81 to 1.07), and low-quality (RR, 1.15; 95% CI, 0.94 to 1.35) hospitals were not significant.

CONCLUSIONS

Differences in admissions to revascularization and high-quality hospitals may contribute to disparities in acute myocardial infarction care. These differences may be due in part to residential ZIP code characteristics.

Preferences for cardiac tests and procedures may partially explain sex but not race disparities

OBJECTIVE

There are known race and sex differences in emergent cardiac care. Many feel these differences reflect a bias from the physician. We hypothesized these differences may be the result of patient preferences.

METHODS

Emergency department (ED) patients 40 years and older with a chief complaint of chest pain were surveyed from July 11 through December 9, 2005, at 2 academic EDs. This prospective survey study included demographics and prior cardiac test experience. Preferences for hypothetical cardiac tests and procedures were compared between race and sex using chi(2) or Fisher exact tests.

RESULTS

Two hundred sixteen patients were enrolled. The mean age was 55 +/- 12 years (43% men and 51% black). Blacks compared with whites preferred the electrocardiogram (ECG) to the technetium-99m sestamibi (MIBI) stress test. Blacks also preferred a percutaneous coronary intervention (PCI) compared with whites who were more likely to forego PCI. These racial differences disappeared when a physician recommended a procedure. There were no race preferences between PCI vs coronary artery bypass graft, whether or not a doctor recommended the procedure. For sex, there were no preferences between ECG vs MIBI stress test or cardiac catheterization, whether or not a doctor recommended the test or procedure. With regard to a choice between PCI and coronary artery bypass graft, women were more likely to decline the procedure than men. Even with a physician-recommended procedure, women were more likely to refuse than men, whereas men were more likely to accept it.

CONCLUSIONS

Blacks were more likely to prefer the less invasive stress test and wanted PCIs more, but these racial differences disappeared when a physician-recommended test was offered. Women were more likely to refuse the most invasive cardiac procedure compared with men. The sex-related preferences might partially explain why women receive fewer invasive cardiac procedures than men. However, race-related cardiac preferences suggest that other factors beyond patient preference account for fewer PCIs in black patients.

Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: a scientific statement from the American Heart Association Council on Cardiovascular Nursing and Stroke Council

Patient delay in seeking treatment for acute coronary syndrome and stroke symptoms is the major factor limiting delivery of definitive treatment in these conditions. Despite decades of research and public education campaigns aimed at decreasing patient delay times, most patients still do not seek treatment in a timely manner. In this scientific statement, we summarize the evidence that (1) demonstrates the benefits of early treatment, (2) describes the extent of the problem of patient delay, (3) identifies the factors related to patient delay in seeking timely treatment, and (4) reveals the inadequacies of our current approaches to decreasing patient delay. Finally, we offer suggestions for clinical practice and future research.

The Role of Race in Time to Treatment after Subarachnoid Hemorrhage

OBJECTIVE

Blacks have higher mortality rates from aneurysmal subarachnoid hemorrhage (SAH) than Caucasians. The time to treatment for aneurysmal SAH has been found to correlate with mortality and outcome. Therefore, we examined racial differences in the time to treatment of aneurysmal SAH among patients from the Greater Cincinnati area.

METHODS

We evaluated data from 439 adult aneurysmal SAH patients prospectively identified from May 1997 to August 2001 and July 2002 to March 2005. The primary outcome measure was time to treatment, defined as elapsed time from arrival in the emergency department to aneurysm treatment. A multivariable model was constructed to determine the role of potential variables, including race, on time to treatment for SAH.

RESULTS

In univariate analysis, Caucasian patients were significantly older than black patients (P &lt; 0.0001) and were more likely to be male (P = 0.014), insured (P &lt; 0.0001), and transferred from emergency departments of presentation to other hospitals (P &lt; 0.0001). Black patients were more likely to have anterior circulation aneurysms (P = 0.009) and preexisting hypertension (P &lt; 0.001). In univariate analysis, anterior circulation aneurysms showed a trend toward earlier treatment than posterior circulation aneurysms (P = 0.07). In multivariable models, race was not associated with time to treatment or case-fatality rate. Patients transferred from other facilities were treated more expeditiously than patients who presented directly to the emergency department (P = 0.003), and a history of diabetes mellitus was associated with delay in treatment (P = 0.05).

CONCLUSION

Race was not associated with time to treatment after aneurysmal SAH in the Greater Cincinnati area. Reducing the increased burden of SAH mortality among blacks must be addressed at the prevention stage.

Symptom expression in coronary heart disease and revascularization recommendations for black and white patients

OBJECTIVES

We examined whether symptoms of coronary heart disease vary between Black and White patients with coronary heart disease, whether presenting symptoms affect physicians' revascularization recommendations, and whether the effect of symptoms upon recommendations differs in Black and White patients.

METHODS

We interviewed Black and White patients in Pittsburgh in 1997 to 1999 who were undergoing elective coronary catheterization. We interviewed them regarding their symptoms, and we interviewed their cardiologist decision-makers regarding revascularization recommendations. We obtained coronary catheterization results by chart review.

RESULTS

Black and White patients (N=1196; 9.7% Black) expressed similar prevalence of chest pain, angina equivalent, fatigue, and other symptoms, but Black patients had more shortness of breath (87% vs 72%, P=.001). When we considered only those patients with significant stenosis (n=737, 7.1% Black) and controlled for race, age, gender, and number of stenotic vessels, those who expressed shortness of breath were less likely to be recommended for revascularization (odds ratio=0.535; 95% confidence interval=0.375, 0.762; P<.001), but there was no significant interaction with race.

CONCLUSIONS

Black patients reported shortness of breath more frequently than did White subjects. Shortness of breath was a negative predictor for revascularization for all patients with significant stenosis, but there was no difference in the recommendations by symptom by race.

The influence of race and gender on time to initial electrocardiogram for patients with chest pain

OBJECTIVES

To determine whether race or gender affected time to initial electrocardiogram (ECG) for patients who presented to an emergency department with chest pain.

METHODS

This was a prospective cohort study of patients with chest pain. Patients were divided into three groups based on final diagnosis of acute myocardial infarction or unstable angina and all others with noncardiac chest pain. Data were analyzed using ranks in a two-way analysis of covariance adjusted for age.

RESULTS

A total of 4,358 patients were studied; 58.6% were women and 41.4% men, and 70.3% were African American, 26.0% white, and 3.6% other. Overall, nonwhite patients had longer times to initial ECG compared with white patients. These effects were consistent regardless of ultimate diagnosis. Overall, women had longer times to initial ECG than men. However, ECG time differed by final diagnosis. There were no differences in time to ECG for women compared with men with acute myocardial infarction or unstable angina, but women received an ECG significantly slower than men for noncardiac chest pain.

CONCLUSIONS

The first screening test for acute coronary syndrome, the ECG, took longer to obtain for nonwhite patients, regardless of final diagnosis. This was unfortunately consistent with the literature that shows racial disparities in all aspects of emergent cardiac care. For women, the overall delay in ECG time can be explained by delays for those women with noncardiac chest pain.

Reducing Delay in Seeking Treatment by Patients With Acute Coronary Syndrome and Stroke

Patient delay in seeking treatment for acute coronary syndrome and stroke symptoms is the major factor limiting delivery of definitive treatment in these conditions. Despite decades of research and public education campaigns aimed at decreasing patient delay times, most patients still do not seek treatment in a timely manner. In this scientific statement, we summarize the evidence that (1) demonstrates the benefits of early treatment, (2) describes the extent of the problem of patient delay, (3) identifies the factors related to patient delay in seeking timely treatment, and (4) reveals the inadequacies of our current approaches to decreasing patient delay. Finally, we offer suggestions for clinical practice and future research.

Chest Pain: Physician Perceptions and Decisionmaking in a London Emergency Department

STUDY OBJECTIVE

We describe physician perceptions of decision-making for acute coronary syndromes in the emergency department (ED) and the ways in which patient characteristics influence diagnosis.

METHODS

This is a qualitative analysis of semistructured interview data from physicians practicing at an ethnically diverse and lower-income London ED. All physicians working more than 3 shifts in the department during a 1-month period were approached for interview.

RESULTS

Four themes emerged from the interviews: (1) physicians emphasized the medical history when diagnosing acute coronary syndrome; (2) physicians reported communication barriers as an impediment to diagnosis; (3) physicians cited both epidemiologic data and cultural beliefs when explaining presentation differences between patient groups; (4) physicians interpreted patient complaints by comparing their clinical impressions to a "classic" or "textbook" norm.

CONCLUSION

In most cases, physicians relied on the clinical history when making decisions for patients with suspected acute coronary syndromes. In reaching judgments, physicians elicited features of the presentation they thought were salient, interpreted those features in light of epidemiologic knowledge and cultural beliefs, and compared their overall impression of the patient to a "classic" or "textbook" norm. At each step, physicians' perceptions about patients influenced the data gathered and the interpretation of that data. In addition, the expected features of acute coronary syndrome were thought to differ for some patient groups. These results highlight the need for further research into the role of provider beliefs in medical decision-making.

Gender, ethnicity, and genes in cardiovascular disease. Part 2: implications for pharmacotherapy

Women are underrepresented in clinical trials. Lower doses of beta-blockers are required for Southeast Asians. ACE and ARB's are teratogenic in the second trimester. Torsades de Pointes is more common in women related to a longer QT-interval. Lower dose OCPs decrease the risk of MI, stroke and thrombosis. HRTs are not effective for CAD prevention.

Perceptions of chest pain differ by race

BACKGROUND

African American patients are less likely to receive thrombolytic therapy and coronary revascularization than are white patients. Delay and clinical presentation may be keys to understanding differences in care.

OBJECTIVE

To determine how symptom recognition and perception influence clinical presentation as a function of race, we characterized symptoms and care-seeking behavior in African American and white patients seen in the ED with chest pain.

METHODS

The prospective study was conducted from April 1999 to September 1999 among patients who were seen in the ED and were admitted or observed in the ED Chest Pain Unit (n = 215). Interviews were conducted within 48 hours with a structured set of questions.

RESULTS

Thirty-one percent of white patients and 8.9% of African American patients were admitted with a diagnosis of acute myocardial infarction (P =.001). African American patients were as likely as white patients to report "typical" objective symptoms but were more likely to attribute their symptoms to a gastrointestinal source rather than a cardiac source (P =.05). Of those patients with the final diagnosis of myocardial infarction (n = 45), 61% of African American patients attributed symptoms to a gastrointestinal source and 11% to a cardiac source, versus 26% and 33%, respectively, for white patients. The median prehospital delay for African American patients was 263 minutes (interquartile range, 120 to 756 minutes), similar to the 247 minutes for white patients (interquartile range, 101 to 825 minutes, P =.72), despite African American patients (80%) being more likely than white patients (66%) to perceive their symptoms as severe/life-threatening at onset (P =.05).

CONCLUSION

Racial differences in symptom perception exist. Although the proportion of objectively defined typical symptoms were similar, self-attribution was more often noncardiac in African American patients than in white patients. Self-attribution, in addition to objective clinical findings, is likely to influence caregiver diagnostic approaches and therefore therapeutic approaches, and merits further study.