Racial and ethnic differences in the treatment of acute myocardial infarction: findings from the Get With the Guidelines-Coronary Artery Disease program

Artificial Intelligence-Based Prediction of Cardiovascular Diseases from Chest Radiography

Chest radiography (CXR) is the most frequently performed radiological test worldwide because of its wide availability, non-invasive nature, and low cost. The ability of CXR to diagnose cardiovascular diseases, give insight into cardiac function, and predict cardiovascular events is often underutilized, not clearly understood, and affected by inter- and intra-observer variability. Therefore, more sophisticated tests are generally needed to assess cardiovascular diseases. Considering the sustained increase in the incidence of cardiovascular diseases, it is critical to find accessible, fast, and reproducible tests to help diagnose these frequent conditions. The expanded focus on the application of artificial intelligence (AI) with respect to diagnostic cardiovascular imaging has also been applied to CXR, with several publications suggesting that AI models can be trained to detect cardiovascular conditions by identifying features in the CXR. Multiple models have been developed to predict mortality, cardiovascular morphology and function, coronary artery disease, valvular heart diseases, aortic diseases, arrhythmias, pulmonary hypertension, and heart failure. The available evidence demonstrates that the use of AI-based tools applied to CXR for the diagnosis of cardiovascular conditions and prognostication has the potential to transform clinical care. AI-analyzed CXRs could be utilized in the future as a complimentary, easy-to-apply technology to improve diagnosis and risk stratification for cardiovascular diseases. Such advances will likely help better target more advanced investigations, which may reduce the burden of testing in some cases, as well as better identify higher-risk patients who would benefit from earlier, dedicated, and comprehensive cardiovascular evaluation.

Racial/Ethnic Disparities in Outcomes After Percutaneous Coronary Intervention

Asian American/Pacific Islanders (AAPIs) and Hispanics are growing minority United States populations, but are poorly represented in the cardiovascular literature. This study examines guideline adherence and outcomes in AAPIs and Hispanics compared with non-Hispanic Whites (NHWs) in a quaternary care center after inpatient percutaneous coronary intervention (PCI). The primary end points were inpatient post-PCI bleed, heart failure, cardiogenic shock, and all-cause mortality, whereas the secondary end point was the prescription rate of post-PCI guideline-directed medical therapy including aspirin, statins, P2Y12 receptor blockers, and cardiopulmonary rehabilitation. Intergroup differences were assessed through analysis of variance or two-way chi-square tests, and the association of race with binary outcomes was examined through logistic regression with NHW as the reference group. Compared with NHW, AAPIs, and Hispanics had higher odds of diabetes mellitus, and AAPIs had higher odds of hypertension and being on dialysis. Hispanics had higher odds of post-PCI mortality versus NHW, both in acute coronary syndrome (odds ratio [OR] 2.04, p = 0.03) and elective PCI (OR 2.51, p = 0.04). AAPI also trended toward higher mortality than NHW in both categories. AAPIs were found to have higher odds of statin prescription (OR 1.91, p = 0.04). Hispanics had lower odds of ticagrelor prescription versus NHW (OR 0.65, p = 0.04), and AAPIs trended toward such. No differences were found for cardiopulmonary rehabilitation prescriptions in groups. This study suggests that despite quality improvement efforts, disparities remain in postprocedural outcomes in minority groups in comparison with NHW.

Sex Disparities in Management and Outcomes Among Patients With Acute Coronary Syndrome

Importance

Sex disparities in the management and outcomes of acute coronary syndrome (ACS) have received increasing attention.

Objective

To evaluate the association of a quality improvement program with sex disparities among patients with ACS.

Design, Setting, and Participants

The National Chest Pain Centers Program (NCPCP) is an ongoing nationwide program for the improvement of quality of care in patients with ACS in China, with CPC accreditation as a core intervention. In this longitudinal analysis of annual (January 1, 2016, to December 31, 2020) cross-sectional data of 1 095 899 patients with ACS, the association of the NCPCP with sex-related disparities in the care of these patients was evaluated using generalized linear mixed models and interaction analysis. The robustness of the results was assessed by sensitivity analyses with inverse probability of treatment weighting. Data were analyzed from September 1, 2021, to June 30, 2022.

Exposure

Hospital participation in the NCPCP.

Main Outcomes and Measures

Differences in treatment and outcomes between men and women with ACS. Prehospital indicators included time from onset to first medical contact (onset-FMC), time from onset to calling an emergency medical service (onset-EMS), and length of hospital stay without receiving a percutaneous coronary intervention (non-PCI). In-hospital quality indicators included non-PCI, use of statin at arrival, discharge with statin, discharge with dual antiplatelet therapy, direct PCI for ST-segment elevation myocardial infarction (STEMI), PCI for higher-risk non-ST-segment elevation ACS, time from door to catheterization activation, and time from door to balloon. Patient outcome indicators included in-hospital mortality and in-hospital new-onset heart failure.

Results

Data for 1 095 899 patients with ACS (346 638 women [31.6%] and 749 261 men [68.4%]; mean [SD] age, 63.9 [12.4] years) from 989 hospitals were collected. Women had longer times for onset-FMC and onset-EMS; lower rates of PCI, statin use at arrival, and discharge with medication; longer in-hospital delays; and higher rates of in-hospital heart failure and mortality. The NCPCP was associated with less onset-FMC time, more direct PCI rate for STEMI, lower rate of in-hospital heart failure, more drug use, and fewer in-hospital delays for both men and women with ACS. Sex-related differences in the onset-FMC time (β = -0.03 [95% CI, -0.04 to -0.01), rate of direct PCI for STEMI (odds ratio, 1.11 [95% CI, 1.06-1.17]), time from hospital door to balloon (β = -1.38 [95% CI, -2.74 to -0.001]), and rate of in-hospital heart failure (odds ratio, 0.90 [95% CI, 0.86-0.94]) were significantly less after accreditation.

Conclusions and Relevance

In this longitudinal cross-sectional study of patients with ACS from hospitals participating in the NCPCP in China, sex-related disparities in management and outcomes were smaller in some aspects by regionalization between prehospital emergency and in-hospital treatment systems and standardized treatment procedures. The NCPCP should emphasize sex disparities to cardiologists; highlight compliance with clinical guidelines, particularly for female patients; and include the reduction of sex disparities as a performance appraisal indicator.

Effects of star ratings bonus payments on disparities in medication utilization issues

Background

Previous literature suggested that the consequences of inappropriate medication use may be borne disproportionately by racial/ethnic minorities. It is, therefore, essential to examine if quality improvement initiatives, such as Medicare Part D Star Ratings (Star Ratings), can improve these disparities.

Objective

To assess the impact of Star Ratings bonus payments to Medicare Advantage prescription drug plans (MAPDs) implemented in 2012 on racial/ethnic disparities in medication utilization issues (MUIs).

Methods

This study mainly used secondary data from Medicare administrative data linked to Area Health Resources Files for years before (2010-2011) and after MAPD bonus payment implementation (2016-2017). Patients in MAPDs were treated as the intervention group, and those in independent prescription drug plans (PDPs) were used as the comparison group because PDPs were ineligible for bonuses. MUIs targeted and not targeted in Star Ratings were both examined to determine spillover effects. A difference-in-differences approach was applied by including in a logistic regression a 3-way interaction term for dummy variables for racial/ethnic minorities, later period of 2016-2017, and MAPD plan.

Results

Racial/ethnic minorities experienced more MUIs: e.g., the odds of MUIs targeted in Star Ratings among MAPD enrollees were 83% higher (odds ratio [OR] = 1.83; 95% confidence interval [CI] = 1.71-1.96) for Black than White patients. Black-White disparities in MUIs targeted in Star Ratings decreased 16% more (OR = 0.84; 95% = CI 0.78-0.91) over time among MAPD enrollees than those in PDPs. This pattern was not found for non-Star Ratings measures. Changes in Hispanic-White disparities were similar between MAPD and PDP enrollees for MUIs targeted and not-targeted by Star Ratings. Asian-White and Other-White disparities in MUIs did not experience a higher reduction among MAPD enrollees than PDP enrollees.

Conclusions

Part D bonus payments are associated with lower Black-White disparities in MUIs targeted by Star Ratings. However, Part D bonus payments may not have reduced Hispanic-White or Asian-White disparities. Future research should explore the causes of the bonus payments' heterogeneous effects across racial/ethnic groups.

Race-Based Differences in ST-Segment-Elevation Myocardial Infarction Process Metrics and Mortality From 2015 Through 2021: An Analysis of 178 062 Patients From the American Heart Association Get With The Guidelines-Coronary Artery Disease Registry

BACKGROUND

Systems of care have been developed across the United States to standardize care processes and improve outcomes in patients with ST-segment-elevation myocardial infarction (STEMI). The effect of contemporary STEMI systems of care on racial and ethnic disparities in achievement of time-to-treatment goals and mortality in STEMI is uncertain.

METHODS

We analyzed 178 062 patients with STEMI (52 293 women and 125 769 men) enrolled in the American Heart Association Get With The Guidelines-Coronary Artery Disease registry between January 1, 2015, and December 31, 2021. Patients were stratified into and outcomes compared among 3 racial and ethnic groups: non-Hispanic White, Hispanic White, and Black. The primary outcomes were the proportions of patients achieving the following STEMI process metrics: prehospital ECG obtained by emergency medical services; hospital arrival to ECG obtained within 10 minutes for patients not transported by emergency medical services; arrival-to-percutaneous coronary intervention time within 90 minutes; and first medical contact-to-device time within 90 minutes. A secondary outcome was in-hospital mortality. Analyses were performed separately in women and men, and all outcomes were adjusted for age, comorbidities, acuity of presentation, insurance status, and socioeconomic status measured by social vulnerability index based on patients' county of residence.

RESULTS

Compared with non-Hispanic White patients with STEMI, Hispanic White patients and Black patients had lower odds of receiving a prehospital ECG and achieving targets for door-to-ECG, door-to-device, and first medical contact-to-device times. These racial disparities in treatment goals were observed in both women and men, and persisted in most cases after multivariable adjustment. Compared with non-Hispanic White women, Hispanic White women had higher adjusted in-hospital mortality (odds ratio, 1.39 [95% CI, 1.12-1.72]), whereas Black women did not (odds ratio, 0.88 [95% CI, 0.74-1.03]). Compared with non-Hispanic White men, adjusted in-hospital mortality was similar in Hispanic White men (odds ratio, 0.99 [95% CI, 0.82-1.18]) and Black men (odds ratio, 0.96 [95% CI, 0.85-1.09]).

CONCLUSIONS

Race- or ethnicity-based disparities persist in STEMI process metrics in both women and men, and mortality differences are observed in Hispanic White compared with non-Hispanic White women. Further research is essential to evolve systems of care to mitigate racial differences in STEMI outcomes.

Locking the Revolving Door: Racial Disparities in Cardiovascular Disease

Racial disparities in cardiovascular disease are unjust, systematic, and preventable. Social determinants are a primary cause of health disparities, and these include factors such as structural and overt racism. Despite a number of efforts implemented over the past several decades, disparities in cardiovascular disease care and outcomes persist, pervading more the outpatient rather than the inpatient setting, thus putting racial and ethnic minority groups at risk for hospital readmissions. In this article, we discuss differences in care and outcomes of racial and ethnic minority groups in both of these settings through a review of registries. Furthermore, we explore potential factors that connote a revolving door phenomenon for those whose adverse outpatient environment puts them at risk for hospital readmissions. Additionally, we review promising strategies, as well as actionable items at the policy, clinical, and educational levels aimed at locking this revolving door.

Racial and Ethnic Disparities in Acute Coronary Syndrome: A Nationally Representative Sample

Background

Disparities in acute coronary syndrome (ACS) outcomes exist between racial and ethnic groups. We aimed to evaluate disparities in resource utilization and inpatient outcomes across multiple ethnic and racial groups using contemporary data.

Methods

We identified hospital discharges for ACS in the United States using the National Inpatient Sample from 2015 to 2018. The International Classification of Diseases, Tenth Revision, Clinical Modification codes were used to identify variables of interest. The primary outcomes were in-hospital complications, length of stay, and total hospital charge. Statistical analysis was performed using STATA version 17.

Results

Our analysis included 1,911,869 ACS discharges. Our sample was made up of 78.6% White, 12.1% Black, and 9.3% Hispanic patients. Hispanic and Black patients presenting with ACS were younger and had more cardiometabolic comorbidities than their White counterparts, especially hypertension, diabetes mellitus, and obesity. Despite social determinants of health being more likely to be unfavorable for Hispanics than their White counterparts, they were more likely to incur higher total hospital charges than their White counterparts. Black patients were the least likely to undergo revascularization procedures. Despite these differences, White patients had higher in-hospital mortality rates than Black and Hispanic patients.

Conclusions

In this nationally representative study, despite having higher cardiometabolic comorbidity burden, lower socioeconomic status, and percutaneous intervention, Black and Hispanic patients experienced lower mortality rates than their White counterparts. Hispanic patients incurred the highest amount of total hospital charges for an ACS admission.

Racial Disparities in Hospitalization Among Patients Who Receive a Diagnosis of Acute Coronary Syndrome in the Emergency Department

Background Timely hospitalization of patients who are diagnosed with an acute coronary syndrome (ACS) at the emergency department (ED) is a crucial step to lower the risk of ACS mortality. We examined whether there are racial and ethnic differences in the risk of being discharged home among patients who received a diagnostic code of ACS at the ED and whether having health insurance plays a role. Methods and Results We examined 51 022 910 discharge records of ED visits in Florida, New York, and Utah in the years 2008, 2011, 2014, and 2016/2017 using state-specific data from the Healthcare Cost and Utilization Project. We identified ED admissions for acute myocardial infarction or unstable angina using the International Classification of Diseases, Ninth Revision (ICD-9)/International Statistical Classification of Diseases, Tenth Revision (ICD-10) diagnostic codes. We used generalized estimating equation models to compare the risk of being discharged home across racial and ethnic groups. We used Poisson marginal structural models to estimate the mediating role of health insurance status. The proportion discharged home with a diagnostic code of ACS was 12% among Black patients, 6% among White patients, 9% among Hispanic patients, and 9% among Asian/Pacific Islander patients. The incidence risk ratio for being discharged home was 1.26 (95% CI, 1.18-1.34) in Black patients, 1.23 (95% CI, 1.15-1.32) in Hispanic patients, and 1.11 (95% CI, 0.93-1.31) in Asian/Pacific Islander patients compared with White patients. Race and ethnicity were marginally associated with discharge home via pathways not mediated by health insurance. Conclusions Racial and ethnic disparities exist in the hospitalization of patients who received a diagnostic code of ACS in the ED. Possible causes need to be investigated.

Ethnic disparities in care and outcomes of non-ST-segment elevation myocardial infarction: a nationwide cohort study

AIMS

Little is known about ethnic disparities in care and clinical outcomes of patients admitted with non-ST-segment elevation myocardial infarction (NSTEMI) in national cohorts from universal healthcare systems derived from Europe.

METHODS AND RESULTS

We identified 280 588 admissions with NSTEMI in the UK Myocardial Infarction National Audit Project (MINAP), 2010-2017, including White patients (n = 258 364) and Black, Asian, and Minority Ethnic (BAME) patients (n = 22 194). BAME patients were younger (66 years vs. 73 years, P < 0.001) and more frequently had hypertension (66% vs. 54%, P < 0.001), hypercholesterolaemia (49% vs. 34%, P < 0.001), and diabetes (48% vs. 24%, P < 0.001). BAME patients more frequently received invasive coronary angiography (80% vs. 68%, P < 0.001), percutaneous coronary intervention (PCI) (52% vs. 43%, P < 0.001), and coronary artery bypass graft surgery (9% vs. 7%, P < 0.001). Following propensity score matching, BAME compared with White patients had similar in-hospital all-cause mortality [odds ratio (OR) 0.91, confidence interval (CI) 0.76-1.06; P = 0.23], major bleeding (OR 0.99, CI 0.75-1.25; P = 0.95), re-infarction (OR 1.15, CI 0.84-1.46; P = 0.34), and major adverse cardiovascular events (MACE) (OR 0.94, CI 0.80-1.07; P = 0.35).

CONCLUSION

BAME patients with NSTEMI had higher cardiometabolic risk profiles and were more likely to undergo invasive angiography and revascularization, with similar clinical outcomes as those of their White counterparts. Among the quality indicators assessed, there is no evidence of care disparities among BAME patients presenting with NSTEMI.

Racism and Cardiology: A Global Call to Action

Racism and racial bias influence the lives and cardiovascular health of minority individuals. The fact that minority groups tend to have a higher burden of cardiovascular disease risk factors is often a result of racist policies that restrict opportunities to live in healthy neighbourhoods and have access to high-quality education and healthcare. The fact that minorities tend to have the worst outcomes when cardiovascular disease develops is often a result of institutional or individual racial bias encountered when they interact with the healthcare system. In this review, we discuss bias, discrimination, and structural racism from the viewpoints of cardiologists in Canada, the United Kingdom, and the US, and how racial bias impacts cardiovascular care. Finally, we discuss proposals to mitigate the impact of racism in our specialty.

Artificial intelligence-based detection of aortic stenosis from chest radiographs

Aims

We aimed to develop models to detect aortic stenosis (AS) from chest radiographs-one of the most basic imaging tests-with artificial intelligence.

Methods and results

We used 10 433 retrospectively collected digital chest radiographs from 5638 patients to train, validate, and test three deep learning models. Chest radiographs were collected from patients who had also undergone echocardiography at a single institution between July 2016 and May 2019. These were labelled from the corresponding echocardiography assessments as AS-positive or AS-negative. The radiographs were separated on a patient basis into training [8327 images from 4512 patients, mean age 65 ±  (standard deviation) 15 years], validation (1041 images from 563 patients, mean age 65 ± 14 years), and test (1065 images from 563 patients, mean age 65 ± 14 years) datasets. The soft voting-based ensemble of the three developed models had the best overall performance for predicting AS with an area under the receiver operating characteristic curve, sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of 0.83 (95% confidence interval 0.77-0.88), 0.78 (0.67-0.86), 0.71 (0.68-0.73), 0.71 (0.68-0.74), 0.18 (0.14-0.23), and 0.97 (0.96-0.98), respectively, in the validation dataset and 0.83 (0.78-0.88), 0.83 (0.74-0.90), 0.69 (0.66-0.72), 0.71 (0.68-0.73), 0.23 (0.19-0.28), and 0.97 (0.96-0.98), respectively, in the test dataset.

Conclusion

Deep learning models using chest radiographs have the potential to differentiate between radiographs of patients with and without AS.

Lay Summary

We created artificial intelligence (AI) models using deep learning to identify aortic stenosis (AS) from chest radiographs. Three AI models were developed and evaluated with 10 433 retrospectively collected radiographs and labelled from echocardiography reports. The ensemble AI model could detect AS in a test dataset with an area under the receiver operating characteristic curve of 0.83 (95% confidence interval 0.78-0.88). Since chest radiography is a cost-effective and widely available imaging test, our model can provide an additive resource for the detection of AS.

Towards automatic diagnosis of rheumatic heart disease on echocardiographic exams through video-based deep learning

OBJECTIVE

Rheumatic heart disease (RHD) affects an estimated 39 million people worldwide and is the most common acquired heart disease in children and young adults. Echocardiograms are the gold standard for diagnosis of RHD, but there is a shortage of skilled experts to allow widespread screenings for early detection and prevention of the disease progress. We propose an automated RHD diagnosis system that can help bridge this gap.

MATERIALS AND METHODS

Experiments were conducted on a dataset with 11 646 echocardiography videos from 912 exams, obtained during screenings in underdeveloped areas of Brazil and Uganda. We address the challenges of RHD identification with a 3D convolutional neural network (C3D), comparing its performance with a 2D convolutional neural network (VGG16) that is commonly used in the echocardiogram literature. We also propose a supervised aggregation technique to combine video predictions into a single exam diagnosis.

RESULTS

The proposed approach obtained an accuracy of 72.77% for exam diagnosis. The results for the C3D were significantly better than the ones obtained by the VGG16 network for videos, showing the importance of considering the temporal information during the diagnostic. The proposed aggregation model showed significantly better accuracy than the majority voting strategy and also appears to be capable of capturing underlying biases in the neural network output distribution, balancing them for a more correct diagnosis.

CONCLUSION

Automatic diagnosis of echo-detected RHD is feasible and, with further research, has the potential to reduce the workload of experts, enabling the implementation of more widespread screening programs worldwide.

Black lives matter … in the cath lab, too! A proposal for the interventional cardiology community to counteract bias and racism

Structural racism in the United States underlies racial disparities in the criminal justice system, in the healthcare system generally, and with regards to the COVID-19 pandemic. In the year 2020, these inequities combined and magnified to such a degree that it left Black Americans and physicians caring for them questioning how much Black lives matter. Academic medical centers and the major cardiology organizations responded to a global call to end racism with bold statements and initiatives. Interventional cardiologists utilize advanced equipment to mechanically treat a wide spectrum of heart problems, yet this technology has not been applied in an equitable manner. Interventional therapies are often underutilized in Blacks, exacerbating healthcare disparities and contributing to the excess cardiovascular morbidity and mortality in these communities. Racial bias, whether intentional, unconscious, systemic, or at the individual level, plays a role in these disparities. Many in the interventional cardiology community aspire to take intentional steps to reduce the impact of bias and racism in our specialty. We discuss several proposals here and provide a "report card" for interventional programs to perform a self-assessment.

Racial differences in management and outcomes of acute myocardial infarction during COVID-19 pandemic

OBJECTIVE

There are concerns that healthcare and outcomes of black, Asian and minority ethnic (BAME) communities are disproportionately impacted by the COVID-19 pandemic. We investigated admission rates, treatment and mortality of BAME with acute myocardial infarction (AMI) during COVID-19.

METHODS

Using multisource national healthcare records, patients hospitalised with AMI in England during 1 February-27 May 2020 were included in the COVID-19 group, whereas patients admitted during the same period in the previous three consecutive years were included in a pre-COVID-19 group. Multilevel hierarchical regression analyses were used to quantify the changes in-hospital and 7-day mortality in BAME compared with whites.

RESULTS

Of 73 746 patients, higher proportions of BAME patients (16.7% vs 10.1%) were hospitalised with AMI during the COVID-19 period compared with pre-COVID-19. BAME patients admitted during the COVID-19 period were younger, male and likely to present with ST-elevation acute myocardial infarction. COVID-19 BAME group admitted with non-ST-elevation acute myocardial infarction less frequently received coronary angiography (86.1% vs 90.0%, p<0.001) and had a longer median delay to reperfusion (4.1 hours vs 3.7 hours, p<0.001) compared with whites. BAME had higher in-hospital (OR 1.68, 95% CI 1.27 to 2.28) and 7-day mortality (OR 1.81 95% CI 1.31 to 2.19) during COVID-19 compared with pre-COVID-19 period.

CONCLUSION

In this multisource linked cohort study, compared with whites, BAME patients had proportionally higher hospitalisation rates with AMI, less frequently received guidelines indicated care and had higher early mortality during COVID-19 period compared with pre-COVID-19 period. There is a need to develop clinical pathways to achieve equity in the management of these vulnerable populations.

The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women-Chapter 2: Scope of the Problem

Background

This Atlas chapter summarizes the epidemiology of cardiovascular disease (CVD) in women in Canada, discusses sex and gender disparities, and examines the intersectionality between sex and other factors that play a prominent role in CVD outcomes in women, including gender, indigenous identity, ethnic variation, disability, and socioeconomic status.

Methods

CVD is the leading cause of premature death in Canadian women. Coronary artery disease, including myocardial infarction, and followed by stroke, accounts for the majority of CVD-related deaths in Canadian women. The majority of emergency department visits and hospitalizations by women are due to coronary artery disease, heart failure, and stroke. The effect of traditional cardiovascular risk factors and their association with increasing cardiovascular morbidity is unique in this group.

Results

Indigenous women in Canada experience increased CVD, linked to colonization and subsequent social, economic, and political challenges. Women from particular racial and ethnic backgrounds (ie, South Asian, Afro-Caribbean, Hispanic, and Chinese North American women) have greater CVD risk factors, and CVD risk in East Asian women increases with duration of stay in Canada.

Conclusions

Canadians living in northern, rural, remote, and on-reserve residences experience greater CVD morbidity, mortality, and risk factors. An increase in CVD risk among Canadian women has been linked with a background of lower socioeconomic status, and women with disabilities have an increased risk of adverse cardiac events.

Bias and Racism Teaching Rounds at an Academic Medical Center

Racism and events of racial violence have dominated the US news in 2020 almost as much as the novel coronavirus pandemic. The resultant civil unrest and demands for racial justice have spawned a global call for change. As a subset of a society that struggles with racism and other explicit biases, it is inescapable that some physicians and health-care employees will have the same explicit biases as the general population. Patients who receive care at academic medical centers interact with multiple individuals, some of whom may have explicit and implicit biases that influence patient care. In fact, multiple reports have documented that some physicians, health-care workers, and health professional students have negative biases based on race, ethnicity, obesity, religion, and sexual identity, among others. These biases can influence decision-making and aggravate health-care disparities and patient-physician mistrust. We review four actual cases from academic medical centers that illustrate how well-intended physicians and health-care workers can be influenced by bias and how this can put patients at risk. Strategies to mitigate bias are discussed and recommended. We introduce what we believe can be a powerful teaching tool: periodic "bias and racism rounds" in teaching hospitals, in which real patient interactions are reviewed critically to identify opportunities to reduce bias and racism and to attenuate the impact of bias and racism on patient outcomes.

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.

Predictors of Aspirin Nonadherence in Adults With Prior Myocardial Infarction

BACKGROUND

Medication nonadherence is an alarming public health concern due to its effect on both individual treatment success and overall health care costs. This study sought to identify the predictors of aspirin nonadherence in adults with prior myocardial infarction (MI).

METHODS

The 2017 Centers for Disease Control's Behavioral Risk Factor Surveillance Survey, a nationally representative, cross-sectional survey, was utilized to identify a cohort of community-dwelling adults (age ≥ 18 years) with prior MI (n = 2173). The primary outcome of interest was presence of self-reported aspirin nonadherence.

RESULTS

Among 2173 participants with prior MI studied, a total of 550 participants (25.3%) reported aspirin nonadherence, whereas 1623 participants (74.7%) reported adherence to aspirin. Adults with aspirin nonadherence were younger and more likely to be female, Black, and of Hispanic ethnicity. They also had lower annual income and were less likely to have health insurance or own a home. Participants with aspirin nonadherence had less frequent medical checkups and lower rates of multiple comorbidities including diabetes mellitus, hypertension, hyperlipidemia, and obesity. In multivariable analysis, independent predictors of aspirin nonadherence included female sex [odds ratio (OR), 1.42; 95% confidence interval (CI), 1.14-1.83], Black race (OR, 1.64; 95% CI, 1.19-2.26), Hispanic ethnicity (OR, 2.27; 95% CI, 1.60-3.21), current employment (OR, 1.74; 95% CI, 1.28-2.36), and absence of homeowner status (OR, 0.71; 95% CI, 0.55-0.93).

CONCLUSIONS

In this observational contemporary study of adults with prior MI, predictors of aspirin nonadherence included female sex, Black race, Hispanic ethnicity, currently employed status, and absence of homeowner status.

Deep learning interpretation of echocardiograms

Echocardiography uses ultrasound technology to capture high temporal and spatial resolution images of the heart and surrounding structures, and is the most common imaging modality in cardiovascular medicine. Using convolutional neural networks on a large new dataset, we show that deep learning applied to echocardiography can identify local cardiac structures, estimate cardiac function, and predict systemic phenotypes that modify cardiovascular risk but not readily identifiable to human interpretation. Our deep learning model, EchoNet, accurately identified the presence of pacemaker leads (AUC = 0.89), enlarged left atrium (AUC = 0.86), left ventricular hypertrophy (AUC = 0.75), left ventricular end systolic and diastolic volumes (R 2  = 0.74 andR 2  = 0.70), and ejection fraction (R 2  = 0.50), as well as predicted systemic phenotypes of age (R 2  = 0.46), sex (AUC = 0.88), weight (R 2  = 0.56), and height (R 2  = 0.33). Interpretation analysis validates that EchoNet shows appropriate attention to key cardiac structures when performing human-explainable tasks and highlights hypothesis-generating regions of interest when predicting systemic phenotypes difficult for human interpretation. Machine learning on echocardiography images can streamline repetitive tasks in the clinical workflow, provide preliminary interpretation in areas with insufficient qualified cardiologists, and predict phenotypes challenging for human evaluation.

Using electronic health record system triggers to target delivery of a patient-centered intervention to improve venous thromboembolism prevention for hospitalized patients: Is there a differential effect by race?

Background

Racial disparities are common in healthcare. Venous thromboembolism (VTE) is a leading cause of preventable harm, and disparities observed in prevention practices. We examined the impact of a patient-centered VTE education bundle on the non-administration of preventive prophylaxis by race.

Methods

A post-hoc, subset analysis (stratified by race) of a larger nonrandomized trial. Pre-post comparisons analysis were conducted on 16 inpatient units; study periods were October 2014 through March 2015 (baseline) and April through December 2015 (post-intervention). Patients on 4 intervention units received the patient-centered, nurse educator-led intervention if the electronic health record alerted a non-administered dose of VTE prophylaxis. Patients on 12 control units received no intervention. We compared the conditional odds of non-administered doses of VTE prophylaxis when patient refusal was a reason for non-administration, stratified by race.

Results

Of 272 patient interventions, 123 (45.2%) were white, 126 (46.3%) were black, and 23 (8.5%) were other races. A significant reduction was observed in the odds of non-administration of prophylaxis on intervention units compared to control units among patients who were black (OR 0.61; 95% CI, 0.46–0.81, p<0.001), white (OR 0.57; 95% CI, 0.44–0.75, p<0.001), and other races (OR 0.50; 95% CI, 0.29–0.88, p = 0.015).

Conclusion

Our finding suggests that the patient education materials, developed collaboratively with a diverse group of patients, improved patient’s understanding and the importance of VTE prevention through prophylaxis. Quality improvement interventions should examine any differential effects by patient characteristics to ensure disparities are addressed and all patients experience the same benefits.

Sex Differences in Acute Myocardial Infarction Hospital Management and Outcomes: Update From Facilities With Comparable Standards of Quality Care

Supplemental digital content is available in the text.

Background:

Acute myocardial infarction (AMI) sex disparities in management and outcomes have long been attributed to multiple factors, although questions regarding their relevance have not been fully addressed.

Objective:

The aim of this study was to identify current factors associated with sex-related AMI management and outcomes disparities in hospitals with comparable quality care standards.

Methods:

This is a cross-sectional study of 299 women and 540 men with AMI discharged in 2013 from 3 southern California hospitals with tertiary cardiac care. Outcomes (adjusted by demographic/clinical variables using multiple logistic regression) included mortality (in-hospital, 30 days), 30-day readmissions, invasive/revascularization procedures, and quality medication performance measures (aspirin, statins/antilipids, β-blockers, angiotensin-converting enzyme inhibitors, <90-minute door-balloon time).

Results:

Performance was similar to the top 10% National Inpatient Quality AMI Measures. Women had similar mortality, 30-day readmission rates, and performance on medication quality measures compared with men; readmissions were higher in patients with County Services/Medicaid or no medical insurance regardless of sex. Women had similar cardiac catheterization and ST-segment elevation myocardial infarction percutaneous coronary intervention rates but significantly less percutaneous coronary intervention for non–ST-segment elevation myocardial infarction (39.1% vs 52.1%, P = .008) and coronary artery bypass graft (6.7% vs 14.1%, P < .001) than men.

Conclusions:

Women with AMI had similar early mortality, 30-day readmissions and quality performance measures compared with men across hospitals with current quality care standards. Type of medical insurance influenced readmission rates for both sexes. Sex disparities in coronary revascularization procedures were likely determined by differences in AMI type and coronary disease vascular expression.

Fifteen-Year Trends in Management and Outcomes of Non-ST-Segment-Elevation Myocardial Infarction Among Black and White Patients: The ARIC Community Surveillance Study, 2000-2014

Background

Standardization of evidence‐based medical therapies has improved outcomes for patients with non–ST‐segment–elevation myocardial infarction (NSTEMI). Although racial differences in NSTEMI management have previously been reported, it is uncertain whether these differences have been ameliorated over time.

Methods and Results

The ARIC (Atherosclerosis Risk in Communities) Community Surveillance study conducts hospital surveillance of acute myocardial infarction in 4 US communities. NSTEMI was classified by physician review, using a validated algorithm. From 2000 to 2014, 17 755 weighted hospitalizations for NSTEMI (patient race: 36% black, 64% white) were sampled by ARIC. Black patients were younger (aged 60 versus 66 years), more often female (45% versus 38%), and less likely to have medical insurance (88% versus 93%) but had more comorbidities. Black patients were less often administered aspirin (85% versus 92%), other antiplatelet therapy (45% versus 60%), β‐blockers (85% versus 88%), and lipid‐lowering medications (68% versus 76%). After adjustments, black patients had a 24% lower probability of receiving nonaspirin antiplatelets (relative risk: 0.76; 95% confidence interval, 0.71–0.81), a 29% lower probability of angiography (relative risk: 0.71; 95% confidence interval, 0.67–0.76), and a 45% lower probability of revascularization (relative risk: 0.55; 95% confidence interval, 0.50–0.60). No suggestion of a changing trend over time was observed for any NSTEMI therapy (P values for interaction, all >0.20).

Conclusions

This longitudinal community surveillance of hospitalized NSTEMI patients suggests black patients have more comorbidities and less likelihood of receiving guideline‐based NSTEMI therapies, and these findings persisted across the 15‐year period. Focused efforts to reduce comorbidity burden and to more consistently implement guideline‐directed treatments in this high‐risk population are warranted.

Hospital participation in clinical trials for patients with acute myocardial infarction: Results from the National Cardiovascular Data Registry

BACKGROUND

Little is known about the proportion of hospitals in the United States that offer clinical trial enrollment opportunities and how patient outcomes differ between hospitals that do and do not participate in clinical trials.

METHODS

In the nationwide Chest Pain-MI registry, we described the proportion of hospitals that enrolled patients with acute myocardial infarction (MI) in clinical trials from 2009 to 2014. Hospital-level adherence to every eligible MI performance measure was compared between hospitals that did and did not enroll patients in clinical trials. Using linked Medicare data, we also compared 1-year major adverse cardiovascular events (MACE: death, MI, heart failure, or stroke) among patients ≥65 years old treated at trial versus nontrial hospitals.

RESULTS

Among 766 hospitals, 430 (56.1%) enrolled ≥1 MI patient in a clinical trial during the study period, but the proportion of hospitals enrolling patients in clinical trials declined from 36.8% in 2009 to 26.6% in 2014. Complete adherence to performance measures was delivered to a greater proportion of patients at trial hospitals than nontrial hospitals (72.6% vs 64.9%, P < .001; adjusted OR 1.07, 95% CI 1.03-1.12). One-year MACE rates were also lower for trial hospitals (adjusted HR 0.96, 95% CI 0.93-0.99).

CONCLUSIONS

Hospitals are becoming less likely to engage in clinical trials for patients with MI. Patients admitted to hospitals that participated in clinical trials more often received guideline-adherent care and had better long-term outcomes.

Comparative Outcomes After Percutaneous Coronary Intervention Among Black and White Patients Treated at US Veterans Affairs Hospitals

Importance

Current comparative outcomes among black and white patients treated with percutaneous coronary intervention (PCI) in the Veterans Affairs (VA) health system are not known.

Objective

To compare outcomes between black and white patients undergoing PCI in the VA health system.

Design, Setting, and Participants

This study compared black and white patients who underwent PCI between October 1, 2007, and September 30, 2013, at 63 VA hospitals using data recorded in the VA Clinical Assessment, Reporting, and Tracking System for Cardiac Catheterization Laboratories (CART-CL) program. A generalized linear mixed model with a random intercept for site assessed the relative difference in odds of outcomes between black and white patients. The setting was integrated institutionalized hospital care. Excluded were all patients of other races or those with multiple listed races and those with missing data regarding race or the diagnostic cardiac catheterization. The dates of analysis were January 7, 2016, to April 17, 2017.

Exposure

Percutaneous coronary intervention at a VA hospital.

Main Outcomes and Measures

The primary outcome was 1-year mortality. Secondary outcomes were 30-day all-cause readmission rates, 30-day acute kidney injury, 30-day blood transfusion, and 1-year readmission rates for myocardial infarction. In addition, variations in procedural and postprocedural care were examined, including the use of intravascular ultrasound, optical coherence tomography, fractional flow reserve measurements, bare-metal stents, postprocedural medications, and radial access.

Results

A total of 42 391 patients (13.3% black and 98.4% male; mean [SD] age, 65.2 [9.1] years) satisfied the inclusion and exclusion criteria. In unadjusted analyses, black patients had higher rates of 1-year mortality (7.1% vs 5.9%, P < .001) as well as secondary outcomes of 30-day acute kidney injury (20.8% vs 13.8%, P < .001), 30-day blood transfusion (3.4% vs 2.7%, P < .01), and 1-year readmission rates for myocardial infarction (3.3% vs 2.7%, P = .01) compared with white patients. After adjustment for demographics, comorbidities, and procedural characteristics, odds for 1-year mortality (odds ratio, 1.04; 95% CI, 0.90-1.19) were not different between black and white patients. There were also no differences in secondary outcomes with the exception of a higher rate of adjusted 30-day acute kidney injury (odds ratio, 1.22; 95% CI, 1.10-1.36).

Conclusions and Relevance

While black patients had a higher rate of mortality than white patients in unadjusted analyses, race was not independently associated with 1-year mortality among patients undergoing PCI in VA hospitals.

Temporal Changes in the Racial Gap in Survival After In-Hospital Cardiac Arrest

Importance

Previous studies have found marked differences in survival after in-hospital cardiac arrest by race. Whether racial differences in survival have narrowed as overall survival has improved remains unknown.

Objectives

To examine whether racial differences in survival after in-hospital cardiac arrest have narrowed over time and if such differences could be explained by acute resuscitation survival, postresuscitation survival, and/or greater temporal improvement in survival at hospitals with higher proportions of black patients.

Design, Setting, and Participants

In this cohort study from Get With the Guidelines-Resuscitation, performed from January 1, 2000, through December 31, 2014, a total of 112 139 patients with in-hospital cardiac arrest who were hospitalized in intensive care units or general inpatient units were studied. Data analysis was performed from April 7, 2015, to May 24, 2017.

Exposure

Race (black or white).

Main Outcomes and Measures

The primary outcome was survival to discharge. Secondary outcomes were acute resuscitation survival and postresuscitation survival. Multivariable hierarchical (2-level) regression models were used to calculate calendar-year rates of survival for black and white patients after adjusting for baseline characteristics.

Results

Among 112 139 patients with in-hospital cardiac arrest, 30 241 (27.0%) were black (mean [SD] age, 61.6 [16.4] years) and 81 898 (73.0%) were white (mean [SD] age, 67.5 [15.2] years). Risk-adjusted survival improved over time in black (11.3% in 2000 and 21.4% in 2014) and white patients (15.8% in 2000 and 23.2% in 2014; P for trend <.001 for both), with greater survival improvement among black patients on an absolute (P for trend = .02) and relative scale (P for interaction = .01). A reduction in survival differences between black and white patients was attributable to elimination of racial differences in acute resuscitation survival (black individuals: 44.7% in 2000 and 64.1% in 2014; white individuals: 47.1% in 2000 and 64.0% in 2014; P for interaction <.001). Compared with hospitals with fewer black patients, hospitals with a higher proportion of black patients with in-hospital cardiac arrest achieved larger survival gains over time.

Conclusions and Relevance

A substantial reduction in racial differences in survival after in-hospital cardiac arrest has occurred that has been largely mediated by elimination of racial differences in acute resuscitation survival and greater survival improvement at hospitals with a higher proportion of black patients. Further understanding of the mechanisms of this improvement could provide novel insights for the elimination of racial differences in survival for other conditions.

Disparities in Revascularization After ST Elevation Myocardial Infarction (STEMI) Before and After the 2002 IOM Report

OBJECTIVES

To examine nationwide trends for racial disparities in Percutaneous Coronary Intervention after ST elevated Myocardial Infarction (STEMI).

BACKGROUND

The Institute of Medicine (IOM) report published in 2002 showed that African Americans were less likely to receive coronary revascularization such as CABG and stents even after controlling for socioeconomics. It recommended increased awareness of these disparities among health professionals to reduce this. We hypothesized that increased awareness of disparities since this report would have translated to reduction in racial disparities in percutaneous coronary intervention.

METHODS

A retrospective analysis was conducted using data from the Agency of Healthcare Research and Quality's (AHRQ) National Inpatient Sample (NIS) 1998-2007. All patients with STEMI during this period were identified. The proportion that received Percutaneous Coronary Intervention (PCI) during the incident admission was compared by different ethnicities over the time period. Multivariable regression for each year was conducted using Poisson regression with robust variances. The analysis controlled for gender, insurance status, co-morbidities, hospital bed size, location and teaching status.

RESULTS

Based on the database, about 2.04 million patients were managed for acute Myocardial Infarction from 1998 to 2007, of these 938,176 had STEMI. The primary PCI rate after STEMI among Caucasians was 29.1%, African Americans-23.3% and Hispanics-28.3% [P < 0.001] On multivariate regression, compared to Caucasians, African Americans and Hispanics respectively were 26% (IRR = 0.74) and 16% (IRR = 0.84) less likely to receive PCI (both with P < 0.001) during the entire study period.

CONCLUSION

Ethnic disparities in primary PCI after STEMI persist despite the 2002 IOM report.

Trends in Racial/Ethnic and Nativity Disparities in Cardiovascular Health Among Adults Without Prevalent Cardiovascular Disease in the United States, 1988 to 2014

BACKGROUND

Trends in cardiovascular disparities are poorly understood, even as diversity increases in the United States.

OBJECTIVE

To examine U.S. trends in racial/ethnic and nativity disparities in cardiovascular health.

DESIGN

Repeated cross-sectional study.

SETTING

NHANES (National Health and Nutrition Examination Survey), 1988 to 2014.

PARTICIPANTS

Adults aged 25 years or older who did not report cardiovascular disease.

MEASUREMENTS

Racial/ethnic, nativity, and period differences in Life's Simple 7 (LS7) health factors and behaviors (blood pressure, cholesterol, hemoglobin A1c, body mass index, physical activity, diet, and smoking) and optimal composite scores for cardiovascular health (LS7 score ≥10).

RESULTS

Rates of optimal cardiovascular health remain below 40% among whites, 25% among Mexican Americans, and 15% among African Americans. Disparities in optimal cardiovascular health between whites and African Americans persisted but decreased over time. In 1988 to 1994, the percentage of African Americans with optimal LS7 scores was 22.8 percentage points (95% CI, 19.3 to 26.4 percentage points) lower than that of whites in persons aged 25 to 44 years and 8.0 percentage points (CI, 6.4 to 9.7 percentage points) lower in those aged 65 years or older. By 2011 to 2014, differences decreased to 10.6 percentage points (CI, 7.4 to 13.9 percentage points) and 3.8 percentage points (CI, 2.5 to 5.0 percentage points), respectively. Disparities in optimal LS7 scores between whites and Mexican Americans were smaller but also decreased. These decreases were due to reductions in optimal cardiovascular health among whites over all age groups and periods: Between 1988 to 1994 and 2011 to 2014, the percentage of whites with optimal cardiovascular health decreased 15.3 percentage points (CI, 11.1 to 19.4 percentage points) for those aged 25 to 44 years and 4.6 percentage points (CI, 2.7 to 6.5 percentage points) for those aged 65 years or older.

LIMITATION

Only whites, African Americans, and Mexican Americans were studied.

CONCLUSION

Cardiovascular health has declined in the United States, racial/ethnic and nativity disparities persist, and decreased disparities seem to be due to worsening cardiovascular health among whites rather than gains among African Americans and Mexican Americans. Multifaceted interventions are needed to address declining population health and persistent health disparities.

PRIMARY FUNDING SOURCE

National Institute of Neurological Disorders and Stroke and National Center for Advancing Translational Sciences of the National Institutes of Health.

Effect of a Quality Improvement Intervention on Clinical Outcomes in Patients in India With Acute Myocardial Infarction: The ACS QUIK Randomized Clinical Trial

IMPORTANCE

Wide heterogeneity exists in acute myocardial infarction treatment and outcomes in India.

OBJECTIVE

To evaluate the effect of a locally adapted quality improvement tool kit on clinical outcomes and process measures in Kerala, a southern Indian state.

DESIGN, SETTING, AND PARTICIPANTS

Cluster randomized, stepped-wedge clinical trial conducted between November 10, 2014, and November 9, 2016, in 63 hospitals in Kerala, India, with a last date of follow-up of December 31, 2016. During 5 predefined steps over the study period, hospitals were randomly selected to move in a 1-way crossover from the control group to the intervention group. Consecutively presenting patients with acute myocardial infarction were offered participation.

INTERVENTIONS

Hospitals provided either usual care (control group; n = 10 066 participants [step 0: n = 2915; step 1: n = 2649; step 2: n = 2251; step 3: n = 1422; step 4; n = 829; step 5: n = 0]) or care using a quality improvement tool kit (intervention group; n = 11 308 participants [step 0: n = 0; step 1: n = 662; step 2: n = 1265; step 3: n = 2432; step 4: n = 3214; step 5: n = 3735]) that consisted of audit and feedback, checklists, patient education materials, and linkage to emergency cardiovascular care and quality improvement training.

MAIN OUTCOMES AND MEASURES

The primary outcome was the composite of all-cause death, reinfarction, stroke, or major bleeding using standardized definitions at 30 days. Secondary outcomes included the primary outcome's individual components, 30-day cardiovascular death, medication use, and tobacco cessation counseling. Mixed-effects logistic regression models were used to account for clustering and temporal trends.

RESULTS

Among 21 374 eligible randomized participants (mean age, 60.6 [SD, 12.0] years; n = 16 183 men [76%] ; n = 13 689 [64%] with ST-segment elevation myocardial infarction), 21 079 (99%) completed the trial. The primary composite outcome was observed in 5.3% of the intervention participants and 6.4% of the control participants. The observed difference in 30-day major adverse cardiovascular event rates between the groups was not statistically significant after adjustment (adjusted risk difference, -0.09% [95% CI, -1.32% to 1.14%]; adjusted odds ratio, 0.98 [95% CI, 0.80-1.21]). The intervention group had a higher rate of medication use including reperfusion but no effect on tobacco cessation counseling. There were no unexpected adverse events reported.

CONCLUSIONS AND RELEVANCE

Among patients with acute myocardial infarction in Kerala, India, use of a quality improvement intervention compared with usual care did not decrease a composite of 30-day major adverse cardiovascular events. Further research is needed to understand the lack of efficacy.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02256657.

Racial/Ethnic Disparities in Quality of Care for Cardiovascular Disease in Ambulatory Settings: A Review

Racial and ethnic disparities in cardiovascular disease (CVD) outcomes are widely reported, but research has largely focused on differences in quality of inpatient and urgent care to explain these disparate outcomes. The objective of this review is to synthesize recent evidence on racial and ethnic disparities in management of CVD in the ambulatory setting. Database searches yielded 550 articles of which 25 studies met the inclusion criteria. Reviewed studies were categorized into non-interventional studies examining the association between race and receipt of ambulatory CVD services with observational designs, and interventional studies evaluating specific clinical courses of action intended to ameliorate disparities. Based on the Donabedian framework, this review demonstrates that significant racial/ethnic disparities persist in process and outcome measures of quality of ambulatory CVD care. Multimodal interventions were most effective in reducing disparities in CVD outcomes.

Update on quality of care in Hispanics and other racial-ethnic groups in the United States discharged with the diagnosis of Acute Myocardial Infarction in 2013

BACKGROUND

Disparities in Acute Myocardial Infarction (AMI) care and outcomes have been frequently reported in racial-ethnic minorities in the U.S. Some studies have attributed disparities in Hispanics and other minorities to lower quality of services at hospitals where they seek care. Current information from hospitals with large Hispanic representations and updated quality resources is needed.

METHODS

Retrospective observational study of 839 AMI patients discharged in 2013 from three Southern California Hospitals (A, B, C) with tertiary cardiac care level. Non-Hispanic Whites (NHW) and Hispanics (H) were the larger racial-ethnic groups (68.3%), and the comparison of these two groups constitutes the focus of the study. Mortality, 30day readmissions, medication/performance measures (PRx); aspirin, statins/anti-lipids, beta-blockers, ACEI/ARB for LV systolic dysfunction, <90min door-balloon time, and revascularization procedures were compared between hospitals, NHW and H, using Chi-squared tests (χ²), Odds Ratios (OR) with 95% confidence intervals (CI), and Z tests for proportions - independent groups.

RESULTS

No significant differences in hospital, 30day mortality, PRx or procedures were observed between NHW, H and other racial-ethnic minority groups, or hospitals. Hospital C had 47.3% H and Hospitals A+B 14.6% (p<0.001, effect size=0.430). AMI performance measures exceeded 2013 national rates across all facilities. NHW had more private/commercial insurance (52.5% vs. 25.4%, OR 3.24, 95% CI 2.19-4.80, p<0.001) than H.

CONCLUSIONS

Equitable access to quality hospital services in three Southern California hospitals offset previously reported disparities in AMI management in Hispanics. These results may not necessarily reflect the reality of AMI care for Hispanics in other U.S. regions.

Comparison of Delay Times from Symptom Onset to Medical Contact in Blacks Versus Whites With Acute Myocardial Infarction

Clinical outcomes in acute myocardial infarction (AMI) worsen with increasing delay between symptom onset and clinical presentation. Previous studies have shown that black patients with AMI have longer presentation delays. The objective of this analysis is to explore the potential contribution of community factors to presentation delays in black patients with AMI. We linked clinical data for 346,499 consecutive patients with AMI from Acute Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines™ (2007-2014) to socioeconomic and community information from the American Community Survey. Black patients with AMI had longer symptom onset to first medical contact times than white patients (114 vs 101 minutes, p <0.0001) regardless of ambulance versus self-transport. Compared with white patients, black patients were younger and more likely to have clinical co-morbidities such as hypertension, diabetes, previous heart failure, and stroke. They were also more likely to live in urban communities with lower socioeconomic status, lower rates of long-term residence, and higher proportion of single-person households than white patients. In sequential linear regression models adjusting for patient demographic and clinical characteristics, logistic barriers to prompt presentation, and community socioeconomic and composition factors, black patients had a persistent 9% greater time from symptom onset to presentation compared with white patients (95% CI 8% to 11%, p <0.0001). In conclusion, the longer delay in time to presentation in black patients with AMI compared with white patients persists after accounting for a number of both patient and community factors.

Temporal Trends in Care and Outcomes of Patients Receiving Fibrinolytic Therapy Compared to Primary Percutaneous Coronary Intervention: Insights From the Get With The Guidelines Coronary Artery Disease (GWTG-CAD) Registry

Background

Timely reperfusion after ST‐elevation myocardial infarction (STEMI) improves survival. Guidelines recommend primary percutaneous coronary intervention (PPCI) within 90 minutes of arrival at a PCI‐capable hospital. The alternative is fibrinolysis within 30 minutes for those in those for whom timely transfer to a PCI‐capable hospital is not feasible.

Methods and Results

We identified STEMI patients receiving reperfusion therapy at 229 hospitals participating in the Get With the Guidelines—Coronary Artery Disease (GWTG‐CAD) database (January 1, 2003 through December 31, 2008). Temporal trends in the use of fibrinolysis and PPCI, its timeliness, and in‐hospital mortality outcomes were assessed. We also assessed predictors of fibrinolysis versus PPCI and compliance with performance measures. Defect‐free care was defined as 100% compliance with all performance measures. We identified 29 190 STEMI patients, of whom 2441 (8.4%) received fibrinolysis; 38.2% of these patients achieved door‐to‐needle times ≤30 minutes. Median door‐to‐needle times increased from 36 to 60 minutes (P=0.005) over the study period. Among PPCI patients, median door‐to‐balloon times decreased from 94 to 64 minutes (P<0.0001) over the same period. In‐hospital mortality was higher with fibrinolysis than with PPCI (4.6% vs 3.3%, P=0.001) and did not change significantly over time. Patients receiving fibrinolysis were less likely to receive defect‐free care compared with their PPCI counterparts.

Conclusions

Use of fibrinolysis for STEMI has decreased over time with concomitant worsening of door‐to‐needle times. Over the same time period, use of PPCI increased with improvement in door‐to‐balloon times. In‐hospital mortality was higher with fibrinolysis than with PPCI. As reperfusion for STEMI continues to shift from fibrinolysis to PPCI, it will be critical to ensure that door‐to‐needle times and outcomes do not worsen.

Age, Race and Cardiovascular Outcomes in African American Veterans

BACKGROUND

In the general population, compared wtih their White peers, African Americans suffer premature all-cause and cardiovascular (CV) deaths, attributed in part to reduced access to care and lower socioeconomic status. Prior reports indicated younger (aged 35 to 44 years) African Americans had a signficantly greater age-adjusted risk of death. Recent studies suggest that in a more egalitarian health care structure than typical United States (US) health care structures, African Americans may have similar or even better CV outcomes, but the impact of age is less well-known.

METHODS

We examined age stratified all-cause mortality, and incident coronary heart disease (CHD) and ischemic stroke in 3,072,966 patients (547,441 African American and 2,525,525 White) with an estimated glomerular filtration rate (eGFR)>60 mL/min/1.73m(2) receiving care from the US Veterans Health Administration. Outcomes were examined in Cox models adjusted for demographics, comorbidities, kidney function, blood pressure, socioeconomics and indicators of the quality of health care delivery.

RESULTS

African Americans had an overall 30% lower all-cause mortality (P<.001) and 29% lower incidence of CHD (P<.001) and higher incidence of ischemic stroke (aHR, 95%CI: 1.16, 1.13-1.18, P<.001). The lower rates of mortality and CHD were strongest in younger African Americans and attenuated across patients aged ≥70 years. Stroke rates did not differ by race in persons aged <70 years.

CONCLUSIONS

Among patients with normal eGFR and receiving care in the Veterans Health Administration, younger African Americans had lower all-cause mortality and incidence of CHD and similar rates of stroke, independent of demographic, comorbidity and socioeconomic differences. The lower all-cause mortality persisted but attenuated with increasing age and the lower incidence of CHD ended at aged ≥80 years. The higher incidence of ischemic stroke in African Americans was driven by increasing risk in patients aged ≥70 years suggesting that the improved cardiovascular outcomes were most dramatic for younger African Americans.

Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association

Cardiovascular disease is the leading cause of mortality in American women. Since 1984, the annual cardiovascular disease mortality rate has remained greater for women than men; however, over the last decade, there have been marked reductions in cardiovascular disease mortality in women. The dramatic decline in mortality rates for women is attributed partly to an increase in awareness, a greater focus on women and cardiovascular disease risk, and the increased application of evidence-based treatments for established coronary heart disease. This is the first scientific statement from the American Heart Association on acute myocardial infarction in women. Sex-specific differences exist in the presentation, pathophysiological mechanisms, and outcomes in patients with acute myocardial infarction. This statement provides a comprehensive review of the current evidence of the clinical presentation, pathophysiology, treatment, and outcomes of women with acute myocardial infarction.

Eliminating Health Care Disparities With Mandatory Clinical Decision Support: The Venous Thromboembolism (VTE) Example

BACKGROUND

All hospitalized patients should be assessed for venous thromboembolism (VTE) risk factors and prescribed appropriate prophylaxis. To improve best-practice VTE prophylaxis prescription for all hospitalized patients, we implemented a mandatory computerized clinical decision support (CCDS) tool. The tool requires completion of checklists to evaluate VTE risk factors and contraindications to pharmacological prophylaxis, and then recommends the risk-appropriate VTE prophylaxis regimen.

OBJECTIVES

The objective of the study was to examine the effect of a quality improvement intervention on race-based and sex-based health care disparities across 2 distinct clinical services.

RESEARCH DESIGN

This was a retrospective cohort study of a quality improvement intervention.

SUBJECTS

The study included 1942 hospitalized medical patients and 1599 hospitalized adult trauma patients.

MEASURES

In this study, the proportion of patients prescribed risk-appropriate, best-practice VTE prophylaxis was evaluated.

RESULTS

Racial disparities existed in prescription of best-practice VTE prophylaxis in the preimplementation period between black and white patients on both the trauma (70.1% vs. 56.6%, P=0.025) and medicine (69.5% vs. 61.7%, P=0.015) services. After implementation of the CCDS tool, compliance improved for all patients, and disparities in best-practice prophylaxis prescription between black and white patients were eliminated on both services: trauma (84.5% vs. 85.5%, P=0.99) and medicine (91.8% vs. 88.0%, P=0.082). Similar findings were noted for sex disparities in the trauma cohort.

CONCLUSIONS

Despite the fact that risk-appropriate prophylaxis should be prescribed equally to all hospitalized patients regardless of race and sex, practice varied widely before our quality improvement intervention. Our CCDS tool eliminated racial disparities in VTE prophylaxis prescription across 2 distinct clinical services. Health information technology approaches to care standardization are effective to eliminate health care disparities.

Informing Policy for Reducing Stroke Health Disparities from the Experience of African-American Male Stroke Survivors

BACKGROUND

The burden of stroke is severe among African-Americans. Despite overall declines in the rate of stroke since 2000, outcomes are largely unimproved or have worsened for African-American men. Adverse psychosocial challenges may hinder adherence to a regimen of risk factor reduction.

METHODS AND RESULTS

Focus group analysis was combined with a review of current published guidelines and epidemiologic evidence on risk factors to better understand stroke health disparities and potential policy solutions. Transcripts from three focus groups with ten African-American male stroke survivors under age 65 and their care partners (N = 7) were analyzed and compared with existing published data on (a) the burden of stroke (b) trends in clinical risk factors, and (c) trends in behavioral risk factors. Participants described myriad psychosocial barriers that impede reduction of risk indicators, including low trust in providers, poor social support, access difficulties, depression, and distress.

CONCLUSIONS

In order to be effective, policies and programs must target mechanisms consistent with the challenges faced by African-American men. Infrastructure is needed to better identify and share practices effective for improving cardiovascular outcomes within specific racial and ethnic groups.

Racial Differences in Treatment Approaches and Mortality Following Arterial Trauma

Objectives:

We sought to evaluate the impact of race on treatment approaches and mortality following arterial trauma.

Methods:

The National Trauma Data Bank (version 7.2, American College of Surgeons) was queried from 2002 to 2012 to identify patients aged 18 to 65 years with arterial trauma. The association between race (white, black, and Hispanic) and mortality following arterial injury was assessed, stratified by penetrating or blunt injury. Temporal trends in the use of open and endovascular procedures were evaluated across the racial groups. Multivariable regression models adjusting for patient demographics, injury severity, hospital characteristics, insurance status, and type of intervention performed were used to evaluate potential contributors to the association of race with mortality.

Results:

The study cohort consisted of 58 626 patients (52% white, 31% black, and 17% Hispanic). A majority (57%) of patients had penetrating injuries, with black and Hispanic patients being more likely to sustain penetrating injuries (80% and 65%, respectively) compared to white patients (41%, P < .001). Overall, black patients had higher mortality for penetrating injuries (16.8% vs 13.0% vs 7.8%, P < .001) when compared to Hispanic and white patients, correspondingly. Over the study period, there was increasing use of endovascular and decreasing open surgical procedures for treatment of arterial trauma. This finding was similar across all groups studied. In multivariable analysis, black race was found to be associated with higher mortality compared to white for both penetrating (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.33-1.75, P < .001) and blunt (OR 1.27 95%CI 1.09-1.47, P = .002) arterial trauma.

Conclusion:

Even after adjusting for potential confounders, minority patients had increased odds of mortality following arterial trauma compared to their white counterparts. Further studies are needed to understand and to eliminate these observed disparities in outcome.

Worldwide disparities in cardiovascular disease: Challenges and solutions

The 20th century saw cardiovascular disease ascend as the leading cause of death in the world. In response to the new challenge that heart disease imposed, the cardiovascular community responded with ground breaking innovations in the form of evidence based medications that have improved survival, imaging modalities that allow for precise diagnosis and guide treatment; revascularization strategies that have not only reduced morbidity, but also improved survival following an acute myocardial infarction. However the benefits have not been distributed equitably and as a result disparities have arisen in cardiovascular care. There is tremendous data from the United States demonstrating the many phenotypical forms of disparities. This paper takes a global view of disparities and highlights that disparate care is not limited to the United States and it is another challenge that the medical community should rise and face head on.

Ethnicity and coronary artery disease: the role of high-density lipoprotein - a change in paradigm

Cardiovascular disease (CVD) is the number one killer of men and women across ethnic groups in the USA. Health disparities in CVD, especially coronary artery disease (CAD), are well documented in the diverse American population. Despite efforts taken toward reducing cardiovascular health disparities, there are still gaps in its diagnosis and management. Current risk assessment guidelines consider high high-density lipoprotein (HDL) levels a protective factor against CAD, although its significance across races remains poorly understood. Recent clinical trials focused on increasing HDL levels have been disappointing. In this article, the authors have explored the role of HDL in CAD, have analyzed its significance across gender and ethnic groups and have challenged the broad application of widely used HDL level cutoffs in CAD risk assessment tools across these vulnerable groups. The current evidence suggests a paradigm change from HDL quantity to quality and function in future CVD risk research. This may better explain why some ethnic minority groups with a seemingly more benign lipid profile experience a higher CAD burden.