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Fishkin T, Wang A, Frishman WH, Aronow WS. Healthcare Disparities in Cardiovascular Medicine. Cardiol Rev 2024; 32:328-333. [PMID: 36511638 DOI: 10.1097/crd.0000000000000507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
There are significant healthcare disparities in cardiovascular medicine that represent a challenge for cardiologists and healthcare policy-makers who wish to provide equitable care. Disparities exist in both the management and outcomes of hypertension, coronary artery disease and its sequelae, and heart failure. These disparities are present along the lines of race, gender, and socioeconomic status. Despite recent efforts to reduce disparity, there are knowledge and research gaps among cardiologists with regards to both the scope of the problem and how to solve it. Solutions include increasing awareness of disparities in cardiovascular health, increasing research for optimal treatment of underserved communities, and public policy changes that reduce disparities in social determinants of health.
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Affiliation(s)
- Tzvi Fishkin
- From the Departments of Medicine, and Cardiology, Westchester Medical Center and New York Medical College, Vaslhalla, NY
| | - Andy Wang
- From the Departments of Medicine, and Cardiology, Westchester Medical Center and New York Medical College, Vaslhalla, NY
| | - William H Frishman
- From the Departments of Medicine, and Cardiology, Westchester Medical Center and New York Medical College, Vaslhalla, NY
| | - Wilbert S Aronow
- From the Departments of Medicine, and Cardiology, Westchester Medical Center and New York Medical College, Vaslhalla, NY
- Westchester Medical Center and New York Medical College, Vaslhalla, NY
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Folk J, McGurk K, Au L, Imas P, Dhake S, Haag A. The COVID-19 impact on STEMI disparities. Heliyon 2024; 10:e32218. [PMID: 38868039 PMCID: PMC11168440 DOI: 10.1016/j.heliyon.2024.e32218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 05/28/2024] [Accepted: 05/29/2024] [Indexed: 06/14/2024] Open
Abstract
ST-segment elevation myocardial infarction (STEMI) is a significant source of morbidity and mortality. Despite guideline-driven management and increased awareness of social determinants of health, there are persistent disparities in diagnosis, management, and outcomes. The coronavirus disease 2019 (COVID-19) pandemic has greatly affected emergency department visitation, conditions and throughput. The aim of this study was to find any potential health disparities in patients who presented with STEMI during the COVID-19 pandemic by reviewing STEMI care data from April to September 2019 (pre-pandemic) and April to September 2020 (during the pandemic) for our hospital system. Patients with STEMI within 12 h of presentation were included in this study, and subdivided by age, gender, and race/ethnicity. We compared the turnaround times between emergency department arrival to intervention (electrocardiogram or catheterization) within the patient subgroups to find any notable differences. No statistically significant changes in turnaround times during either study period were found based on age, gender, or race/ethnicity for the STEMI interventions despite shifts in emergency department resources during the pandemic. This study helped assess the status quo in STEMI intervention for our health system and serves as a baseline for us to monitor gaps in care or areas of improvement. As healthcare systems institute new measures to promote equitable care, such as improving the accuracy of demographic data capture, establishing a baseline is an essential first step in evaluating the impact of these measures.
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Affiliation(s)
- Jessica Folk
- Division of Emergency Medicine, NorthShore University HealthSystem, USA
- University of Chicago Pritzker School of Medicine, USA
| | - Kevin McGurk
- Department of Emergency Medicine, Medical College of Wisconsin, USA
| | | | | | - Sarah Dhake
- Division of Emergency Medicine, NorthShore University HealthSystem, USA
- University of Chicago Pritzker School of Medicine, USA
| | - Adam Haag
- Division of Emergency Medicine, NorthShore University HealthSystem, USA
- University of Chicago Pritzker School of Medicine, USA
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3
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Zea-Vera R, Asokan S, Shah RM, Ryan CT, Chatterjee S, Wall MJ, Coselli JS, Rosengart TK, Kayani WT, Jneid H, Ghanta RK. Racial/ethnic differences persist in treatment choice and outcomes in isolated intervention for coronary artery disease. J Thorac Cardiovasc Surg 2023; 166:1087-1096.e5. [PMID: 35248359 PMCID: PMC11092967 DOI: 10.1016/j.jtcvs.2022.01.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 12/10/2021] [Accepted: 01/23/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Studies have noted racial/ethnic disparities in coronary artery disease intervention strategies. We investigated trends and outcomes of coronary artery disease treatment choice (coronary artery bypass grafting or percutaneous coronary intervention) stratified by race/ethnicity. METHODS We queried the National Inpatient Sample for patients who underwent isolated coronary artery bypass grafting or percutaneous coronary intervention (2002-2017). Outcomes were stratified by race/ethnicity (White, African American, Hispanic, Asian). Multivariable logistic regression evaluated associations between race/ethnicity and receiving coronary artery bypass grafting versus percutaneous coronary intervention, in-hospital mortality, and costs. RESULTS Over the 15-year period, 2,426,917 isolated coronary artery bypass grafting surgeries and 7,184,515 percutaneous coronary interventions were performed. Compared with White patients, African American patients were younger (62 [interquartile range, 53-70] vs 66 [interquartile range, 57-75] years), were more likely to have Medicaid insurance (12.2% vs 4.4%), and had more comorbidities (Charlson-Deyo index, 1.9 ± 1.6 vs 1.7 ± 1.6) (all P < .01). After adjustment for patient comorbidities, presence of acute myocardial infarction, insurance status, and geography, African Americans were the least likely of all racial/ethnic groups to undergo coronary artery bypass grafting (odds ratio, 0.76; P < .01), a consistent trend throughout the study. African American patients had higher risk-adjusted mortality after coronary artery bypass grafting (odds ratio, 1.09; P < .01). Race/ethnicity was not associated with increased mortality after percutaneous coronary intervention. African American patients had higher hospitalization costs for coronary artery bypass grafting (+$5816; P < .01) and percutaneous coronary intervention (+$856; P < .01) after controlling for confounders. CONCLUSIONS In this contemporary national analysis, risk-adjusted frequency of coronary artery bypass grafting versus percutaneous coronary intervention for coronary artery disease differed by race/ethnicity. African American patients had lower odds of undergoing coronary artery bypass grafting and worse outcomes. Reasons for these differences merit further investigation to identify opportunities to reduce potential disparities.
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Affiliation(s)
- Rodrigo Zea-Vera
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Sainath Asokan
- Department of Surgery, Boston University School of Medicine, Boston, Mass
| | - Rohan M Shah
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Christopher T Ryan
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - Matthew J Wall
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Joseph S Coselli
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - Todd K Rosengart
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - Waleed T Kayani
- Section of Cardiology, Department of Internal Medicine, Baylor College of Medicine, Houston, Tex
| | - Hani Jneid
- Section of Cardiology, Department of Internal Medicine, Baylor College of Medicine, Houston, Tex
| | - Ravi K Ghanta
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex.
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Issa TZ, Lambrechts MJ, Canseco JA, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Reporting demographics in randomized control trials in spine surgery - we must do better. Spine J 2023; 23:642-650. [PMID: 36400397 DOI: 10.1016/j.spinee.2022.11.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/07/2022] [Accepted: 11/08/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND CONTEXT Demographic factors contribute significantly to spine surgery outcomes. Although race and ethnicity are not proxies for disease states, the intersection between these patient characteristics and socioeconomic status significantly impact patient outcomes. PURPOSE The purpose of this study is to investigate the frequency of demographic reporting and analysis in randomized controlled clinical trials (RCTs) published in the three highest impact spine journals. STUDY DESIGN Systematic review. PATIENT SAMPLE We analyzed 278 randomized control trials published in The Spine Journal, Spine, and Journal of Neurosurgery: Spine between January 2012 - January 2022. OUTCOME MEASURES Extracted manuscript characteristics included the frequency of demographic reporting, sample size, and demographic composition of studies. METHODS We conducted a systematic review of RCTs published between January 2012 - January 2022 in the three highest impact factor spine journals in 2021: The Spine Journal, Spine, and Journal of Neurosurgery: Spine. We determined if age, gender, BMI, race, and ethnicity were reported and analyzed for each study. The overall frequency of demographic reporting was assessed, and the reporting trends were analyzed for each individual year and journal. Among studies that did report demographics, the populations were analyzed in comparison to the national population per United States (US) census reports. Studies were evaluated for bias using Cochrane risk-of-bias. RESULTS Our search identified 278 RCTs for inclusion. 166 were published in Spine, 65 in The Spine Journal, and 47 in Journal of Neurosurgery: Spine. Only 9.35% (N=26) and 3.9% (N=11) of studies reported race and ethnicity, respectively. Demographic reporting frequency did not vary based on the publishing journal. Reporting of age and BMI increased over time, but reporting of race and ethnicity did not. Among RCTs that reported race, 88% were conducted in the US, and 85.71% of the patients in these US studies were White. White subjects were overly represented compared to the US population (85.71% vs. 61.63%, p<.001), and non-White or Black patients were most underrepresented (2.89% vs. 25.96%, p<.001). CONCLUSIONS RCTs published in the three highest impact factor spine journals failed to frequently report patient race or ethnicity. Among studies published in the US, study populations are increasingly represented by non-Hispanic White patients. As we strive to care for an increasingly diverse population and reduce disparities to care, spine surgeons must do a better job reporting these variables to increase the external validity and generalizability of RCTs.
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Affiliation(s)
- Tariq Ziad Issa
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, 925 Chestnut St., Philadelphia, MO19107, USA
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, 925 Chestnut St., Philadelphia, MO19107, USA.
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, 925 Chestnut St., Philadelphia, MO19107, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, 925 Chestnut St., Philadelphia, MO19107, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, 925 Chestnut St., Philadelphia, MO19107, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, 925 Chestnut St., Philadelphia, MO19107, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, 925 Chestnut St., Philadelphia, MO19107, USA
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Albert MA. Economic Adversity and Health Care: Synopsis of American Heart Association Presidential Address. Circulation 2023; 147:1115-1117. [PMID: 37011076 DOI: 10.1161/circulationaha.122.063726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
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Farmakis IT, Valerio L, Giannakoulas G, Hobohm L, Cushman M, Piazza G, Konstantinides SV, Barco S. Social determinants of health in pulmonary embolism management and outcome in hospitals: Insights from the United States nationwide inpatient sample. Res Pract Thromb Haemost 2023; 7:100147. [PMID: 37181280 PMCID: PMC10173008 DOI: 10.1016/j.rpth.2023.100147] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 03/08/2023] [Accepted: 03/26/2023] [Indexed: 05/16/2023] Open
Abstract
Background The role of social determinants in the treatment and course of acute pulmonary embolism (PE) is understudied. Objective To investigate the association between social determinants of health with in-hospital management and early clinical outcomes following acute PE. Methods We identified hospitalizations of adults with acute PE discharge diagnosis from the nationwide inpatient sample (2016-2018). Multivariable regression was used to investigate the association between race/ethnicity, type of expected primary payer, and income with the use of advanced PE therapies (thrombolysis, catheter-directed treatment, surgical embolectomy, extracorporeal membrane oxygenation), length of stay, hospitalization charges, and in-hospital death. Results A total of 1,124,204 hospitalizations with a PE diagnosis were estimated from the 2016-2018 nationwide inpatient sample, corresponding to a hospitalization rate of 14.9/10,000 adult persons-year. The use of advanced therapies was lower in Black and Asian/Pacific Islander (vs. White patients: adjusted odds ratio [ORadjusted], 0.87; 95% confidence interval [CI], 0.81-0.92 and ORadjusted 0.76; 95% CI, 0.59-0.98) and in Medicare- or Medicaid-insured (vs. privately-insured; ORadjusted, 0.73; 95% CI, 0.69-0.77 and ORadjusted, 0.68; 95% CI, 0.63-0.74), although they had the greatest length of stay and hospitalization charges. In-hospital mortality was higher in the lowest income quartile (vs. highest quartile; ORadjusted, 1.09; 95% CI, 1.02-1.17). Among high-risk PE, patients of other than the White race had the highest in-hospital mortality. Conclusion We observed inequalities in advanced therapies used for acute PE and higher in-hospital mortality in races other than White. Low socioeconomic status was also associated with lesser use of advanced treatment modalities and greater in-hospital mortality. Future studies should further explore and consider the long-term impact of social inequities in PE management.
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Affiliation(s)
- Ioannis T. Farmakis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Luca Valerio
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - George Giannakoulas
- Department of Cardiology, AHEPA University General Hospital of Thessaloniki, Aristotle University of Thessaloniki, Greece
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Mary Cushman
- Division of Hematology and Oncology, Department of Medicine, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Gregory Piazza
- Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Stavros V. Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Greece
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
- Correspondence Stefano Barco, Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langebeckstrasse 1, 55131, Mainz, Germany. @stebarco
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Tien M, Saddic LA, Neelankavil JP, Shemin RJ, Williams TM. The Impact of COVID-19 on Racial and Ethnic Disparities in Cardiac Procedural Care. J Cardiothorac Vasc Anesth 2023; 37:732-747. [PMID: 36863983 PMCID: PMC9827732 DOI: 10.1053/j.jvca.2023.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/17/2022] [Accepted: 01/05/2023] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The primary objective of this study was to evaluate whether the COVID-19 pandemic altered the racial and ethnic composition of patients receiving cardiac procedural care. DESIGN This was a retrospective observational study. SETTING This study was conducted at a single tertiary-care university hospital. PARTICIPANTS A total of 1,704 adult patients undergoing transcatheter aortic valve replacement (TAVR) (n = 413), coronary artery bypass grafting (CABG) (n = 506), or atrial fibrillation (AF) ablation (n = 785) from March 2019 through March 2022 were included in this study. INTERVENTIONS No interventions were performed as this was a retrospective observational study. MEASUREMENTS AND MAIN RESULTS Patients were grouped based on the date of their procedure: pre-COVID (March 2019 to February 2020), COVID Year 1 (March 2020 to February 2021), and COVID Year 2 (March 2021 to March 2022). Population-adjusted procedural incidence rates during each period were examined and stratified based on race and ethnicity. The procedural incidence rate was higher for White patients versus Black, and non-Hispanic patients versus Hispanic patients for every procedure and every period. For TAVR, the difference in procedural rates between White patients versus Black patients decreased between the pre-COVID and COVID Year 1 (12.05-6.34 per 1,000,000 persons). For CABG, the difference in procedural rates between White patients versus Black, and non-Hispanic patients versus Hispanic patients did not change significantly. For AF ablations, the difference in procedural rates between White patients versus Black patients increased over time (13.06 to 21.55 to 29.64 per 1,000,000 persons in the pre-COVID, COVID Year 1, and COVID Year 2, respectively). CONCLUSION Racial and ethnic disparities in access to cardiac procedural care were present throughout all study time periods at the authors' institution. Their findings reinforce the continuing need for initiatives to reduce racial and ethnic disparities in healthcare. Further studies are needed to fully elucidate the effects of the COVID-19 pandemic on healthcare access and delivery.
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Affiliation(s)
- Michael Tien
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, CA
| | - Louis A. Saddic
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, CA
| | - Jacques P. Neelankavil
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, CA
| | - Richard J. Shemin
- Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, CA
| | - Tiffany M. Williams
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, CA,Address correspondence to Tiffany M. Williams, MD, PhD, Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, 757 Westwood Plaza, Suite 3304, Los Angeles, CA 90095
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Bullock-Palmer RP, Bravo-Jaimes K, Mamas MA, Grines CL. Socioeconomic Factors and their Impact on Access and Use of Coronary and Structural Interventions. Eur Cardiol 2022; 17:e19. [PMID: 36643068 PMCID: PMC9820075 DOI: 10.15420/ecr.2022.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 06/28/2022] [Indexed: 01/18/2023] Open
Abstract
In the past few decades, the accelerated improvement in technology has allowed the development of new and effective coronary and structural heart disease interventions. There has been inequitable patient access to these advanced therapies and significant disparities have affected patients from low socioeconomic positions. In the US, these disparities mostly affect women, black and hispanic communities who are overrepresented in low socioeconomic. Other adverse social determinants of health influenced by structural racism have also contributed to these disparities. In this article, we review the literature on disparities in access and use of coronary and structural interventions; delineate the possible reasons underlying these disparities; and highlight potential solutions at the government, healthcare system, community and individual levels.
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Affiliation(s)
| | - Katia Bravo-Jaimes
- Division of Cardiology, Department of Internal Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center, University of CaliforniaLos Angeles, CA, US
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele UniversityKeele, UK
| | - Cindy L Grines
- Division of Cardiology, Department of Internal Medicine, Northside Cardiovascular Institute, Northside HospitalAtlanta, GA, US
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Roumeliotis A, Claessen B, Sartori S, Cao D, Koh WJ, Qiu H, Nicolas J, Chandiramani R, Goel R, Chiarito M, Sweeny J, Barman N, Krishnan P, Kini A, Sharma SK, Dangas G, Mehran R. Impact of Race/Ethnicity on Long Term Outcomes After Percutaneous Coronary Intervention with Drug-Eluting Stents. Am J Cardiol 2022; 167:1-8. [PMID: 35031109 DOI: 10.1016/j.amjcard.2021.11.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/17/2021] [Accepted: 11/22/2021] [Indexed: 11/01/2022]
Abstract
Cardiovascular disease constitutes the leading cause of mortality worldwide, irrespective of race/ethnicity. Previous studies have shown that minority patients with acute coronary syndrome have distinct clinical, anatomic, and socioeconomic characteristics which may affect clinical outcomes. We included patients who underwent percutaneous coronary intervention with drug-eluting stents for ST-segment elevation myocardial infarction (STEMI), non-STEMI, or unstable angina in a single center. Patients were stratified into Caucasian, African-American, Hispanic, and Asian. Caucasians were the reference group. The primary end point was major adverse cardiac and cerebrovascular events, composite of death, spontaneous myocardial infarction, or stroke at 1 year. Of 6,800 patients included, 49.7% were Caucasian, 20.7% Hispanic, 17.0% Asian and 12.6% African-American. Caucasians were the oldest, Hispanics and Asians had the highest prevalence of diabetes mellitus whereas African-Americans had more chronic kidney disease. Hispanics and African-Americans had the highest STEMI rates, whereas Asians were more likely to present with unstable angina. Compared with Caucasians, Asians had a lower rate of major adverse cardiac and cerebrovascular events at 1 year (3.9% vs 7.1%; p <0.01) whereas Hispanics (6.2% vs 7.1%; p = 0.17) and African-Americans (8.0% vs 7.1%; p = 0.38) had comparable outcomes. Differences were driven by mortality. Findings remained unchanged after adjustment. In conclusion, in acute coronary syndrome patients who underwent percutaneous coronary intervention, Asian race/ethnicity was associated with favorable cardiovascular outcomes compared with Caucasians. No significant differences were observed for Hispanics and African-Americans.
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Abstract
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.
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Mital R, Bayne J, Rodriguez F, Ovbiagele B, Bhatt DL, Albert MA. Race and Ethnicity Considerations in Patients With Coronary Artery Disease and Stroke: JACC Focus Seminar 3/9. J Am Coll Cardiol 2021; 78:2483-2492. [PMID: 34886970 DOI: 10.1016/j.jacc.2021.05.051] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/26/2021] [Accepted: 05/18/2021] [Indexed: 01/29/2023]
Abstract
Notable racial and ethnic differences and disparities exist in coronary artery disease (CAD) and stroke epidemiology and outcomes despite substantial advances in these fields. Racial and ethnic minority subgroups remain underrepresented in population data and clinical trials contributing to incomplete understanding of these disparities. Differences in traditional cardiovascular risk factors such as hypertension and diabetes play a role; however, disparities in care provision and process, social determinants of health including socioeconomic position, neighborhood environment, sociocultural factors, and racial discrimination within and outside of the health care system also drive racial and ethnic CAD and stroke disparities. Improved culturally congruent and competent communication about risk factors and symptoms is also needed. Opportunities to achieve improved and equitable outcomes in CAD and stroke must be identified and pursued.
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Affiliation(s)
- Rohit Mital
- Center for the Study of Adversity and Cardiovascular Disease (NURTURE Center), Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Joseph Bayne
- Center for the Study of Adversity and Cardiovascular Disease (NURTURE Center), Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine, Stanford University, Stanford, California, USA
| | - Bruce Ovbiagele
- Department of Neurology, University of California-San Francisco, San Francisco, California, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Michelle A Albert
- Center for the Study of Adversity and Cardiovascular Disease (NURTURE Center), Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA.
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Uzendu AI, Boudoulas KD, Capers Q. Black lives matter … in the cath lab, too! A proposal for the interventional cardiology community to counteract bias and racism. Catheter Cardiovasc Interv 2021; 99:213-218. [PMID: 34037303 PMCID: PMC9545946 DOI: 10.1002/ccd.29751] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 04/23/2021] [Accepted: 04/25/2021] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Anezi I Uzendu
- Section of Interventional Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Quinn Capers
- Division of Cardiology, University of Texas Southwestern, Dallas, Texas, USA
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Golomb M, Redfors B, Crowley A, Smits PC, Serruys PW, von Birgelen C, Madhavan MV, Ben-Yehuda O, Mehran R, Leon MB, Stone GW. Prognostic Impact of Race in Patients Undergoing PCI: Analysis From 10 Randomized Coronary Stent Trials. JACC Cardiovasc Interv 2021; 13:1586-1595. [PMID: 32646701 DOI: 10.1016/j.jcin.2020.04.020] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/26/2020] [Accepted: 04/14/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The aim of this study was to assess race-based differences in patients undergoing percutaneous coronary intervention from a large pooled database of randomized controlled trials. BACKGROUND Data on race-based outcomes after percutaneous coronary intervention are limited, deriving mainly from registries and single-center studies. METHODS Baseline characteristics and outcomes at 30 days, 1 year, and 5 years were assessed across different races, from an individual patient data pooled analysis from 10 randomized trials. Endpoints of interest included death, myocardial infarction, and major adverse cardiac events (defined as cardiac death, myocardial infarction, or ischemia-driven target lesion revascularization). Multivariate Cox proportional hazards regression was performed to assess associations between race and outcomes, controlling for differences in 12 baseline covariates. RESULTS Among 22,638 patients, 20,585 (90.9%) were white, 918 (4.1%) were black, 404 (1.8%) were Asian, and 473 (2.1%) were Hispanic. Baseline and angiographic characteristics differed among groups. Five-year major adverse cardiac event rates were 18.8% in white patients (reference group), compared with 23.9% in black patients (p = 0.0009), 11.2% in Asian patients (p = 0.0007), and 21.5% in Hispanic patients (p = 0.07). Multivariate analysis demonstrated an independent association between black race and 5-year risk for major adverse cardiac events (hazard ratio: 1.28; 95% confidence interval: 1.05 to 1.57; p = 0.01). CONCLUSIONS In the present large-scale individual patient data pooled analysis, comorbidities were significantly more frequent in minority-group patients than in white patients enrolled in coronary stent randomized controlled trials. After accounting for these differences, black race was an independent predictor of worse outcomes, whereas Hispanic ethnicity and Asian race were not. Further research examining race-based outcomes after percutaneous coronary intervention is warranted to understand these differences.
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Affiliation(s)
- Mordechai Golomb
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | - Björn Redfors
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York; Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Aaron Crowley
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | | | - Patrick W Serruys
- Department of Cardiology, NUIG, National University of Ireland, Galway, Ireland; Imperial College of Science, Technology and Medicine, London, United Kingdom
| | - Clemens von Birgelen
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands; Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Mahesh V Madhavan
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Ori Ben-Yehuda
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Roxana Mehran
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Martin B Leon
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Gregg W Stone
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
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14
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Hoyler MM, Abramovitz MD, Ma X, Khatib D, Thalappillil R, Tam CW, Samuels JD, White RS. Social determinants of health affect unplanned readmissions following acute myocardial infarction. J Comp Eff Res 2021; 10:39-54. [PMID: 33438461 DOI: 10.2217/cer-2020-0135] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: Low socioeconomic status predicts inferior clinical outcomes in many patient populations. The effects of patient insurance status and hospital safety-net status on readmission rates following acute myocardial infarction are unclear. Materials & methods: A retrospective review of State Inpatient Databases for New York, California, Florida and Maryland, 2007-2014. Results: A total of 1,055,162 patients were included. Medicaid status was associated with 37.7 and 44.0% increases in risk-adjusted readmission odds at 30 and 90 days (p < 0.0001). Uninsured status was associated with reduced odds of readmission at both time points. High-burden safety-net status was associated with 9.6 and 9.5% increased odds of readmission at 30 and 90 days (p < 0.0003). Conclusion: Insurance status and hospital safety-net burden affect readmission odds following acute myocardial infarction.
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Affiliation(s)
- Marguerite M Hoyler
- Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center, 525 East 68th Street, Box 124, NY 10065, USA
| | - Mark D Abramovitz
- Department of Electrical Engineering, Princeton University, Engineering Quadrangle, 41 Olden Street, Princeton, NJ 08544, USA
| | - Xiaoyue Ma
- Department of Healthcare Policy & Research, Weill Cornell Medicine, 428 East 72nd St., Suite 800A, NY 10021, USA
| | - Diana Khatib
- Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center, 525 East 68th Street, Box 124, NY 10065, USA
| | - Richard Thalappillil
- Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center, 525 East 68th Street, Box 124, NY 10065, USA
| | - Christopher W Tam
- Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center, 525 East 68th Street, Box 124, NY 10065, USA
| | - Jon D Samuels
- Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center, 525 East 68th Street, Box 124, NY 10065, USA
| | - Robert S White
- Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center, 525 East 68th Street, Box 124, NY 10065, USA
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15
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The Impact of Race on Outcomes of Revascularization for Multivessel Coronary Artery Disease. Ann Thorac Surg 2020; 111:1983-1990. [PMID: 33038339 DOI: 10.1016/j.athoracsur.2020.08.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 07/01/2020] [Accepted: 08/04/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Racial disparities exist between Black and White patients with coronary artery disease with regard to access to revascularization, preprocedural comorbidities, and postprocedural outcomes. This study investigated the differences in the treatment of multivessel coronary artery disease (MVCAD) and long-term outcomes between Black and White patients. METHODS This was a propensity-matched retrospective analysis that utilized pooled institutional data from a large, multihospital health care system. It included Black and White patients who underwent coronary revascularization for MVCAD between 2011 and 2018. RESULTS A total of 6005 patients were included (5689 White and 316 Black). In the unmatched cohort, Black patients had a higher incidence of preexisting comorbidities such as diabetes, dialysis dependence, peripheral arterial disease, heart failure, and underwent percutaneous coronary intervention (PCI) more frequently. Five-year overall survival was similar, but Black patients experienced higher rates of major adverse cardiac and cerebrovascular events and repeat revascularization. Propensity matching resulted in a sample of 926 (312 Black, 614 White) patients that were well matched. In the matched analysis, Black patients underwent PCI more frequently and a had higher rate of stoke. Five-year survival, major adverse cardiac and cerebrovascular events and repeat revascularization rates were comparable. CONCLUSIONS Black patients with MVCAD have a higher comorbidity burden and undergo PCI at higher rates. After adjusting for baseline differences, Black patients still had higher rates of PCI utilization and long-term stroke. It is possible that a significant portion of racial disparities in MVCAD are driven by differences in baseline risk; however, there is evidence of possible racial bias with regard to revascularization strategies.
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16
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Karnati SA, Wee A, Shirke MM, Harky A. Racial disparities and cardiovascular disease: One size fits all approach? J Card Surg 2020; 35:3530-3538. [PMID: 32949061 DOI: 10.1111/jocs.15047] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/06/2020] [Accepted: 09/08/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Despite recent advancements in prevention, treatment, and management options, cardiovascular diseases contribute to one of the leading causes of morbidity and mortality. Several studies highlight the compelling evidence for the existence of healthcare inequities and disparities in the treatment and management control of cardiovascular diseases. AIMS To explore the role of racial disparities in the treatment of various cardiovascular diseases, highlighting the role of socioeconomic and cultural factors, and ultimately postulate solutions to eliminate the disparities. METHODS A comprehensive review of the literature was conducted using appropriate keywords on search engines of SCOPUS, Wiley, PubMed, and SAGE Journals. CONCLUSION By continued research to eliminate healthcare inequalities, there exists a potential to improve health-related outcomes in minority populations.
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Affiliation(s)
- Santoshi A Karnati
- Department of Medicine, Queen's University Belfast School of Medicine, Belfast, UK
| | - Alexandra Wee
- Department of Medicine, Queen's University Belfast School of Medicine, Belfast, UK
| | - Manasi M Shirke
- Department of Medicine, Queen's University Belfast School of Medicine, Belfast, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
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17
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Abstract
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.
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18
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Ghomrawi H, Mushlin A, Kang R, Banerjee S, Singh J, Sharma L, Flink C, Nevitt M, Neogi T, Riddle D. Examining Timeliness of Total Knee Replacement Among Patients with Knee Osteoarthritis in the U.S.: Results from the OAI and MOST Longitudinal Cohorts. J Bone Joint Surg Am 2020; 102:468-476. [PMID: 31934894 PMCID: PMC7508265 DOI: 10.2106/jbjs.19.00432] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients with knee osteoarthritis may undergo total knee replacement too early or may delay or underuse this procedure. We quantified these categories of total knee replacement utilization in 2 cohorts of participants with knee osteoarthritis and investigated factors associated with each category. METHODS Data were pooled from 2 multicenter cohort studies that collected demographic, patient-reported, radiographic, clinical examination, and total knee replacement utilization information longitudinally on 8,002 participants who had or were at risk for knee osteoarthritis and were followed for up to 8 years. Validated total knee replacement appropriateness criteria were longitudinally applied to classify participants as either potentially appropriate or likely inappropriate for total knee replacement. Participants were further classified on the basis of total knee replacement utilization into 3 categories: timely (indicating that the patient had total knee replacement within 2 years after the procedure had become potentially appropriate), potentially appropriate but knee not replaced (indicating that the knee had remained unreplaced for >2 years after the procedure had become potentially appropriate), and premature (indicating that the procedure was likely inappropriate but had been performed). Utilization rates were calculated, and factors associated with each category were identified. RESULTS Among 8,002 participants, 3,417 knees fulfilled our inclusion and exclusion criteria and were classified into 1 of 3 utilization categories as follows: 290 knees (8% of the total and 9% of the knees for which replacement was potentially appropriate) were classified as "timely", 2,833 knees (83% of the total and 91% of those for which replacement was potentially appropriate) were classified as "potentially appropriate but not replaced", and 294 knees (comprising 9% of the total and 26% of the 1,114 total knee replacements performed) were considered to be "likely inappropriate" yet underwent total knee replacement and were classified as "premature". Of the knees that were potentially appropriate but were not replaced, 1,204 (42.5%) had severe symptoms. Compared with the patients who underwent timely total knee replacement, the likelihood of being classified as potentially appropriate but not undergoing total knee replacement was greater for black participants and the likelihood of having premature total knee replacement was lower among participants with a body mass index of >25 kg/m and those with depression. CONCLUSIONS In 2 multicenter cohorts of patients with knee osteoarthritis, we observed substantial numbers of patients who had premature total knee replacement as well as of patients for whom total knee replacement was potentially appropriate but had not been performed >2 years after it had become potentially appropriate. Further understanding of these observations is needed, especially among the latter group. CLINICAL RELEVANCE Undergoing total knee replacement too early may result in little or no benefit while exposing the patient to the risks of a major operation, whereas waiting too long may cause limitations in physical activity that in turn increase the risk of additional disability and chronic disease; however, little is known about timing of this surgery. We quantified the extent of premature, timely, and delayed use, and found a high prevalence of both premature and delayed use.
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Affiliation(s)
- H.M.K. Ghomrawi
- Departments of Surgery (H.M.K.G.), Pediatrics (H.M.K.G.), and Medicine (L.S.), Center for Health Services and Outcomes Research (H.M.K.G. and R.K.), Feinberg School of Medicine of Northwestern University, Chicago, Illinois,Email address for H.M.K. Ghomrawi:
| | - A.I. Mushlin
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY
| | - R. Kang
- Departments of Surgery (H.M.K.G.), Pediatrics (H.M.K.G.), and Medicine (L.S.), Center for Health Services and Outcomes Research (H.M.K.G. and R.K.), Feinberg School of Medicine of Northwestern University, Chicago, Illinois
| | - S. Banerjee
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY
| | - J.A. Singh
- Department of Medicine, University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | - L. Sharma
- Departments of Surgery (H.M.K.G.), Pediatrics (H.M.K.G.), and Medicine (L.S.), Center for Health Services and Outcomes Research (H.M.K.G. and R.K.), Feinberg School of Medicine of Northwestern University, Chicago, Illinois
| | - C. Flink
- Department of Radiology, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - M. Nevitt
- Medical School, University of California, San Francisco, San Francisco, California
| | - T. Neogi
- Clinical Epidemiology Unit, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - D.L. Riddle
- Departments of Physical Therapy, Orthopedics, and Rheumatology, Virginia Commonwealth University, Richmond, Virginia
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19
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Feng TR, Hoyler MM, Ma X, Rong LQ, White RS. Insurance Status and Socioeconomic Markers Affect Readmission Rates After Cardiac Valve Surgery. J Cardiothorac Vasc Anesth 2020; 34:668-678. [DOI: 10.1053/j.jvca.2019.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/29/2019] [Accepted: 08/02/2019] [Indexed: 11/11/2022]
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20
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de Jager E, Levine AA, Udyavar NR, Burstin HR, Bhulani N, Hoyt DB, Ko CY, Weissman JS, Britt LD, Haider AH, Maggard-Gibbons MA. Disparities in Surgical Access: A Systematic Literature Review, Conceptual Model, and Evidence Map. J Am Coll Surg 2020; 228:276-298. [PMID: 30803548 DOI: 10.1016/j.jamcollsurg.2018.12.028] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 12/13/2018] [Accepted: 12/13/2018] [Indexed: 01/17/2023]
Affiliation(s)
- Elzerie de Jager
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA; College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Adele A Levine
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | - N Rhea Udyavar
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | | | - Nizar Bhulani
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | | | - Clifford Y Ko
- American College of Surgeons, Chicago, IL; Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA; Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Joel S Weissman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | - L D Britt
- Department of Surgery, Eastern Virginia Medical School, Norfolk, VA
| | - Adil H Haider
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | - Melinda A Maggard-Gibbons
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA.
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21
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Shahu A, Herrin J, Dhruva SS, Desai NR, Davis BR, Krumholz HM, Spatz ES. Disparities in Socioeconomic Context and Association With Blood Pressure Control and Cardiovascular Outcomes in ALLHAT. J Am Heart Assoc 2019; 8:e012277. [PMID: 31362591 PMCID: PMC6761647 DOI: 10.1161/jaha.119.012277] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Observational studies demonstrate that communities of low socioeconomic status have higher blood pressure and worse cardiovascular outcomes. Yet, whether the clinical outcomes resulting from antihypertensive therapy vary by socioeconomic context in a randomized clinical trial, in which participants are treated under a standard protocol, is unknown. Methods and Results We used data from ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) to study the effect of socioeconomic context, defined as the county-level median household income, of study sites. We stratified sites into income quintiles and compared characteristics, blood pressure control, and cardiovascular outcomes among ALLHAT participants in the lowest- and highest-income quintiles. Among 27 862 qualifying participants, 2169 (7.8%) received care in the lowest-income sites (quintile 1) and 10 458 (37.6%) received care in the highest-income sites (quintile 5). Participants in quintile 1 were more likely to be women, to be black, to be Hispanic, to have fewer years of education, to live in the South, and to have fewer cardiovascular risk factors. After adjusting for baseline demographic and clinical characteristics, quintile 1 participants were less likely to achieve blood pressure control (<140/90 mm Hg) (odds ratio, 0.48; 95% CI, 0.37-0.63) and had greater all-cause mortality (hazard ratio [HR], 1.25; 95% CI, 1.10-1.41), heart failure hospitalizations/mortality (HR, 1.26; 95% CI, 1.03-1.55), and end-stage renal disease (HR, 1.86; 95% CI, 1.26-2.73), but lower angina hospitalizations (HR, 0.70; 95% CI, 0.59-0.83) and coronary revascularizations (HR, 0.71; 95% CI, 0.57-0.89). Conclusions Despite standardized treatment protocols, ALLHAT participants in the lowest-income sites experienced poorer blood pressure control and worse outcomes for some adverse cardiovascular events, emphasizing the importance of measuring and addressing socioeconomic context. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000542.
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Affiliation(s)
- Andi Shahu
- Department of Medicine Johns Hopkins Hospital Baltimore MD
| | - Jeph Herrin
- Section of Cardiovascular Medicine Department of Internal Medicine Yale School of Medicine New Haven CT.,Health Research & Educational Trust Chicago IL
| | - Sanket S Dhruva
- San Francisco Veterans Affairs Medical Center San Francisco CA.,University of California, San Francisco School of Medicine San Francisco CA
| | - Nihar R Desai
- Section of Cardiovascular Medicine Department of Internal Medicine Yale School of Medicine New Haven CT.,Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT
| | - Barry R Davis
- Coordinating Center for Clinical Trials University of Texas School of Public Health Houston TX
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine Department of Internal Medicine Yale School of Medicine New Haven CT.,Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT.,Department of Health Policy and Management Yale School of Public Health New Haven CT
| | - Erica S Spatz
- Section of Cardiovascular Medicine Department of Internal Medicine Yale School of Medicine New Haven CT.,Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT
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22
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Schofield D, Cunich M, Shrestha R, Passey M, Veerman L, Tanton R, Kelly S. The indirect costs of ischemic heart disease through lost productive life years for Australia from 2015 to 2030: results from a microsimulation model. BMC Public Health 2019; 19:802. [PMID: 31226965 PMCID: PMC6588908 DOI: 10.1186/s12889-019-7086-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 05/31/2019] [Indexed: 11/12/2022] Open
Abstract
Background Most studies measure the impact of ischemic heart disease (IHD) on individuals using quality of life metrics such as disability-adjusted life-years (DALYs); however, IHD also has an enormous impact on productive life years (PLYs). The objective of this study was to project the indirect costs of IHD resulting from lost PLYs to older Australian workers (45–64 years), government, and society 2015–2030. Methods Nationally representative data from the Surveys of Disability, Ageing and Carers (2003, 2009) were used to develop the base population in the microsimulation model (Health&WealthMOD2030), which integrated data from established microsimulation models (STINMOD, APPSIM), Treasury’s population and workforce projections, and chronic conditions trends. Results We projected that 6700 people aged 45–64 were out of the labour force due to IHD in 2015, increasing to 8100 in 2030 (21 increase). National costs consisted of a loss of AU$273 (US$263) million in income for people with IHD in 2015, increasing to AU$443 ($US426) million (62% increase). For the government, extra welfare payments increased from AU$106 (US$102) million in 2015 to AU$143 (US$138) million in 2030 (35% increase); and lost income tax revenue increased from AU$74 (US$71) million in 2015 to AU$117 (US$113) million in 2030 (58% increase). A loss of AU$785 (US$755) million in GDP was projected for 2015, increasing to AU$1125 (US$1082) million in 2030. Conclusions Significant costs of IHD through lost productivity are incurred by individuals, the government, and society. The benefits of IHD interventions include not only improved health but also potentially economic benefits as workforce capacity.
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Affiliation(s)
- Deborah Schofield
- Department of Economics, Faculty of Business and Economics, Centre for Economic Impacts of Genomic Medicine (GenIMPACT), Macquarie University, Sydney, NSW, 2109, Australia
| | - Michelle Cunich
- The Boden Institute of Obesity, Nutrition, Exercise & Eating Disorders, Charles Perkins Centre, The University of Sydney, and Sydney Health Economics, Sydney Local Health District, John Hopkins Drive, Camperdown, NSW, 2006, Australia.
| | - Rupendra Shrestha
- Department of Economics, Faculty of Business and Economics, Centre for Economic Impacts of Genomic Medicine (GenIMPACT), Macquarie University, Sydney, NSW, 2109, Australia.,Faculty of Pharmacy, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Megan Passey
- University Centre for Rural Health, School of Public Health, The University of Sydney, Lismore, NSW, 2480, Australia
| | - Lennert Veerman
- Cancer Council NSW, 153 Dowling Street, Woolloomooloo, NSW, 2011, Australia.,Griffith University, School of Medicine, Gold Coast campus, Southport, QLD, 4222, Australia
| | - Robert Tanton
- National Centre for Social and Economic Modelling, University of Canberra, Canberra, ACT, Australia
| | - Simon Kelly
- National Centre for Social and Economic Modelling, University of Canberra, Canberra, ACT, Australia
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23
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Pegus C, Duncan I, Greener J, Granada JF, Ahmed T. Achieving Health Equity by Normalizing Cardiac Care. Health Equity 2018; 2:404-411. [PMID: 30623169 PMCID: PMC6323589 DOI: 10.1089/heq.2018.0067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Purpose: It is well known that minority patients, and particularly African Americans undergo lower rates of cardiac procedures than the white population, even when covered by equivalent insurance. Methods: We analyzed the rates of percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction (AMI) and for intermediate coronary syndrome (ICS), and rates of transcatheter aortic valve replacement for aortic stenosis in the 2012–2013 Medicare Limited Data Set (5% sample) file. Results: Although blacks have similar prevalence rates for AMI and ICS, they experience lower PTCA rates when compared with that of white patients (10.57 vs. 19.40, −46%). “Normalizing” procedure rates in the African American community to match their disease prevalence will require education and participation of all stakeholders: patients, providers, manufacturers, insurers, and advocacy organizations. Beyond improved clinical outcomes, financial incentives to “normalize care” exist. We estimate “lost” revenue within the Medicare population as a result of the lower procedure rates, at ∼$90 million annually ($22.0 million AMI, $9.4 million ICS and $68.7 million aortic valve disease). Conclusions: Providing evidence-based care to all patients improves health equity and can lower downstream high-cost conditions such as heart failure and multiple repeat inpatient admissions. As we move toward value-based care, the opportunity to normalize treatment for everyone seeking care is within our data analytics, innovative and collective reach.
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Affiliation(s)
| | - Ian Duncan
- Department of Statistics and Applied Probability, University of California, Santa Barbara, Santa Barbara, California
| | | | - Juan F Granada
- Cardiovascular Research Foundation, Columbia University Medical Center, New York, New York
| | - Tamim Ahmed
- Santa Barbara Actuaries, Inc., Santa Barbara, California
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24
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Coronary artery bypass graft readmission rates and risk factors - A retrospective cohort study. Int J Surg 2018; 54:7-17. [PMID: 29678620 DOI: 10.1016/j.ijsu.2018.04.022] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 01/23/2018] [Accepted: 04/12/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Hospital readmissions contribute substantially to the overall healthcare cost. Coronary artery bypass graft (CABG) is of particular interest due to its relatively high short-term readmission rates and mean hospital charges. METHODS A retrospective review was performed on 2007-2011 data from California, Florida, and New York from the State Inpatient Databases, Healthcare Cost and Utilization Project. All patients ≥18 years of age who underwent isolated CABG and met inclusion/exclusion criteria were included. Insurance status was categorized by Medicaid, Medicare, Private Insurance, Uninsured, and Other. Primary outcomes were unadjusted rates and adjusted odds of readmission at 30- and 90-days. Secondary outcomes included diagnosis at readmission. RESULTS A total of 177,229 were included in the analyses after assessing for exclusion criteria. Overall 30-day readmission rate was 16.1%; rates were highest within Medicare (18.4%) and Medicaid (20.2%) groups and lowest in the private insurance group (11.7%; p < 0.0001). Similarly, 90-day rates were highest in Medicare (27.3%) and Medicaid (29.8%) groups and lowest in the private insurance group (17.6%), with an overall 90-day rate of 24.0% (p < 0.0001). The most common 30-day readmission diagnoses were atrial fibrillation (26.7%), pleural effusion (22.5%), and wound infection (17.7%). Medicare patients had the highest proportion of readmissions with atrial fibrillation (31.7%) and pleural effusions (23.3%), while Medicaid patients had the highest proportion of readmissions with wound infections (21.8%). Similar results were found at 90 days. Risk factors for readmission included non-private insurance, age, female sex, non-white race, low median household income, non-routine discharge, length of stay, and certain comorbidities and complications. CONCLUSIONS CABG readmission rates remain high and are associated with insurance status and racial and socioeconomic markers. Further investigation is necessary to better delineate the underlying factors that relate racial and socioeconomic disparities to CABG readmissions. Understanding these factors will be key to improving healthcare outcomes and expenditure.
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Stapleton SM, Bababekov YJ, Perez NP, Fong ZV, Hashimoto DA, Lillemoe KD, Watkins MT, Chang DC. Variation in Amputation Risk for Black Patients: Uncovering Potential Sources of Bias and Opportunities for Intervention. J Am Coll Surg 2018; 226:641-649.e1. [DOI: 10.1016/j.jamcollsurg.2017.12.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 12/19/2017] [Indexed: 10/18/2022]
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Abstract
On March 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (ACA) into law. This comprehensive health care reform legislation sought to expand health care coverage to millions of Americans, control health care costs, and improve the overall quality of the health care system. The ACA required that all US citizens and legal residents have qualifying health insurance by 2014. In this paper we give readers a brief overview of the effects of the ACA based on recent research. We then turn our attention to the possibility of using the ACA expansion to answer important underlying questions, such as: To what extent does the holding of insurance lead to improvements in access to care? To what extent does the holding of coverage lead to improvements in health? In mental health? Are there likely general equilibrium effects on labor force participation, hours worked, employment setting, and indeed even the probability of marrying? By necessity, researchers' ability to answer these questions depends on the availability of data, so we discuss current and potential data sources relevant for answering these questions. We also look to what has been studied about the health reform in Massachusetts and early Medicaid expansions to speculate what we can expect to learn about the effects of the ACA on these outcomes in the future.
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Affiliation(s)
- Maria Serakos
- La Follette School of Public Affairs, University of
Wisconsin-Madison, Madison, WI, USA
| | - Barbara Wolfe
- La Follette School of Public Affairs, University of
Wisconsin-Madison, Madison, WI, USA
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Purnell TS, Calhoun EA, Golden SH, Halladay JR, Krok-Schoen JL, Appelhans BM, Cooper LA. Achieving Health Equity: Closing The Gaps In Health Care Disparities, Interventions, And Research. Health Aff (Millwood) 2016; 35:1410-5. [DOI: 10.1377/hlthaff.2016.0158] [Citation(s) in RCA: 143] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Tanjala S. Purnell
- Tanjala S. Purnell is an assistant professor in the Department of Surgery and training director of the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, both at the Johns Hopkins University School of Medicine, in Baltimore, Maryland
| | - Elizabeth A. Calhoun
- Elizabeth A. Calhoun is a professor in the Department of Public Health Policy and Management at the University of Arizona, in Tucson. At the time this research was conducted, she was codirector of the Center for Population Health and Health Disparities at the University of Illinois at Chicago
| | - Sherita H. Golden
- Sherita H. Golden is the Hugh P. McCormick Family Professor in the Department of Medicine at the Johns Hopkins University School of Medicine and a core faculty member in the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities
| | - Jacqueline R. Halladay
- Jacqueline R. Halladay is an associate professor in the Department of Family Medicine and the Center to Reduce Cardiovascular Disparities, School of Medicine, at the University of North Carolina at Chapel Hill
| | - Jessica L. Krok-Schoen
- Jessica L. Krok-Schoen is a research specialist in the Comprehensive Cancer Center and the Center for Population Health and Health Disparities at the Ohio State University, in Columbus
| | - Bradley M. Appelhans
- Bradley M. Appelhans is an associate professor in the Department of Preventive Medicine and the Center for Urban Health Equity at Rush University, in Chicago
| | - Lisa A. Cooper
- Lisa A. Cooper (
) is the James F. Fries Professor in the Department of Medicine and director of the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, both at the Johns Hopkins University School of Medicine
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Schröder SL, Richter M, Schröder J, Frantz S, Fink A. Socioeconomic inequalities in access to treatment for coronary heart disease: A systematic review. Int J Cardiol 2016; 219:70-8. [PMID: 27288969 DOI: 10.1016/j.ijcard.2016.05.066] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 05/12/2016] [Indexed: 11/28/2022]
Abstract
Strong socioeconomic inequalities exist in cardiovascular mortality and morbidity. The current review aims to synthesize the current evidence on the association between socioeconomic status (SES) and access to treatment of coronary heart disease (CHD). We examined quantitative studies analyzing the relationship between SES and access to CHD treatment that were published between 1996 and 2015. Our data sources included Medline and Web of Science. Our search yielded a total of 2066 records, 57 of which met our inclusion criteria. Low SES was found to be associated with low access to coronary procedures and secondary prevention. Access to coronary procedures, especially coronary angiography, was mainly related to SES to the disadvantage of patients with low SES. However, access to drug treatment and cardiac rehabilitation was only associated with SES in about half of the studies. The association between SES and access to treatment for CHD was stronger when SES was measured based on individual-level compared to area level, and stronger for individuals living in countries without universal health coverage. Socioeconomic inequalities exist in access to CHD treatment, and universal health coverage shows only a minor effect on this relationship. Inequalities diminish along the treatment pathway for CHD from diagnostic procedures to secondary prevention. We therefore conclude that CHD might be underdiagnosed in patients with low SES. Our results indicate that there is an urgent need to improve access to CHD treatment, especially by increasing the supply of diagnostic angiographies, to reduce inequalities across different healthcare systems.
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Affiliation(s)
- Sara L Schröder
- Institute of Medical Sociology, Martin Luther University Halle-Wittenberg, Germany.
| | - Matthias Richter
- Institute of Medical Sociology, Martin Luther University Halle-Wittenberg, Germany
| | - Jochen Schröder
- Department of Internal Medicine III (Cardiology and Angiology), Martin Luther University Halle-Wittenberg, Germany
| | - Stefan Frantz
- Department of Internal Medicine III (Cardiology and Angiology), Martin Luther University Halle-Wittenberg, Germany
| | - Astrid Fink
- Institute of Medical Sociology, Martin Luther University Halle-Wittenberg, Germany
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30
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Loehrer AP, Hawkins AT, Auchincloss HG, Song Z, Hutter MM, Patel VI. Impact of Expanded Insurance Coverage on Racial Disparities in Vascular Disease: Insights From Massachusetts. Ann Surg 2016; 263:705-11. [PMID: 26587850 PMCID: PMC4777641 DOI: 10.1097/sla.0000000000001310] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To evaluate the impact of health insurance expansion on racial disparities in severity of peripheral arterial disease. BACKGROUND Lack of insurance and non-white race are associated with increased severity, increased amputation rates, and decreased revascularization rates in patients with peripheral artery disease (PAD). Little is known about how expanded insurance coverage affects disparities in presentation with and management of PAD. The 2006 Massachusetts health reform expanded coverage to 98% of residents and provided the framework for the Affordable Care Act. METHODS We conducted a retrospective cohort study of nonelderly, white and non-white patients admitted with PAD in Massachusetts (MA) and 4 control states. Risk-adjusted difference-in-differences models were used to evaluate changes in probability of presenting with severe disease. Multivariable linear regression models were used to evaluate disparities in disease severity before and after the 2006 health insurance expansion. RESULTS Before the 2006 MA insurance expansion, non-white patients in both MA and control states had a 12 to 13 percentage-point higher probability of presenting with severe disease (P < 0.001) than white patients. After the expansion, measured disparities in disease severity by patient race were no longer statistically significant in Massachusetts (+3.0 percentage-point difference, P = 0.385) whereas disparities persisted in control states (+10.0 percentage-point difference, P < 0.001). Overall, non-white patients in MA had an 11.2 percentage-point decreased probability of severe PAD (P = 0.042) relative to concurrent trends in control states. CONCLUSIONS The 2006 Massachusetts insurance expansion was associated with a decreased probability of patients presenting with severe PAD and resolution of measured racial disparities in severe PAD in MA.
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Affiliation(s)
- Andrew P. Loehrer
- Department of Surgery, Massachusetts General Hospital, Boston Massachusetts
| | | | | | - Zirui Song
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Matthew M. Hutter
- Department of Surgery, Massachusetts General Hospital, Boston Massachusetts
| | - Virendra I. Patel
- Department of Surgery, Massachusetts General Hospital, Boston Massachusetts
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Graham G. Racial and Ethnic Differences in Acute Coronary Syndrome and Myocardial Infarction Within the United States: From Demographics to Outcomes. Clin Cardiol 2016; 39:299-306. [PMID: 27028198 DOI: 10.1002/clc.22524] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 01/13/2016] [Indexed: 01/01/2023] Open
Abstract
In the United States, different races, ethnicities, and their subgroups experience disparities regarding acute coronary syndrome (ACS) and myocardial infarction (MI). This review highlights these differences across 4 stages that comprise the ACS/MI narrative: (1) patient demographics, (2) patient comorbidities and health risks, (3) treatments and their delays, and (4) outcomes. Overall, black and Hispanic ACS/MI patients are more likely to present with comorbidities, experience longer delays before treatment, and suffer worse outcomes when compared with non-Hispanic white patients. More specifically, across the studies analyzed, black and Hispanic ACS/MI patients were consistently more likely to be younger or female, or to have hypertension or diabetes, than non-Hispanic white patients. ACS/MI disparities also exist among Asian populations, and these are briefly outlined. However, black, Hispanic, and non-Hispanic white ACS/MI patients were the 3 most-studied racial and ethnic groups, indicating that additional studies of other minority groups, such as Native Americans, Asian populations, and black and Hispanic subgroups, are needed for their utility in reducing disparities. Despite notable improvement in ACS/MI treatment quality measures over recent decades, disparities persist. Causes are complex and extend beyond the healthcare system to culture and patients' personal characteristics; sophisticated solutions will be required. Continued research has the potential to further reduce or eliminate disparities in the comorbidities, delays, and treatments surrounding ACS and MI, extending healthy lifespans of many underserved and minority populations, while reducing healthcare costs.
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Affiliation(s)
- Garth Graham
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut.,Aetna Foundation, Aetna Inc., Hartford, Connecticut
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Graham G, Xiao YYK, Rappoport D, Siddiqi S. Population-level differences in revascularization treatment and outcomes among various United States subpopulations. World J Cardiol 2016; 8:24-40. [PMID: 26839655 PMCID: PMC4728105 DOI: 10.4330/wjc.v8.i1.24] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 08/29/2015] [Accepted: 11/04/2015] [Indexed: 02/06/2023] Open
Abstract
Despite recent general improvements in health care, significant disparities persist in the cardiovascular care of women and racial/ethnic minorities. This is true even when income, education level, and site of care are taken into consideration. Possible explanations for these disparities include socioeconomic considerations, elements of discrimination and racism that affect socioeconomic status, and access to adequate medical care. Coronary revascularization has become the accepted and recommended treatment for myocardial infarction (MI) today and is one of the most common major medical interventions in the United States, with more than 1 million procedures each year. This review discusses recent data on disparities in co-morbidities and presentation symptoms, care and access to medical resources, and outcomes in revascularization as treatment for acute coronary syndrome, looking especially at women and minority populations in the United States. The data show that revascularization is used less in both female and minority patients. We summarize recent data on disparities in co-morbidities and presentation symptoms related to MI; access to care, medical resources, and treatments; and outcomes in women, blacks, and Hispanics. The picture is complicated among the last group by the many Hispanic/Latino subgroups in the United States. Some differences in outcomes are partially explained by presentation symptoms and co-morbidities and external conditions such as local hospital capacity. Of particular note is the striking differential in both presentation co-morbidities and mortality rates seen in women, compared to men, especially in women ≤ 55 years of age. Surveillance data on other groups in the United States such as American Indians/Alaska Natives and the many Asian subpopulations show disparities in risk factors and co-morbidities, but revascularization as treatment for MI in these populations has not been adequately studied. Significant research is required to understand the extent of disparities in treatment in these subpopulations.
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Kramer MR, Valderrama AL, Casper ML. Decomposing Black-White Disparities in Heart Disease Mortality in the United States, 1973-2010: An Age-Period-Cohort Analysis. Am J Epidemiol 2015. [PMID: 26199382 DOI: 10.1093/aje/kwv050] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Against the backdrop of late 20th century declines in heart disease mortality in the United States, race-specific rates diverged because of slower declines among blacks compared with whites. To characterize the temporal dynamics of emerging black-white racial disparities in heart disease mortality, we decomposed race-sex-specific trends in an age-period-cohort (APC) analysis of US mortality data for all diseases of the heart among adults aged ≥35 years from 1973 to 2010. The black-white gap was largest among adults aged 35-59 years (rate ratios ranged from 1.2 to 2.7 for men and from 2.3 to 4.0 for women) and widened with successive birth cohorts, particularly for men. APC model estimates suggested strong independent trends across generations ("cohort effects") but only modest period changes. Among men, cohort-specific black-white racial differences emerged in the 1920-1960 birth cohorts. The apparent strength of the cohort trends raises questions about life-course inequalities in the social and health environments experienced by blacks and whites which could have affected their biomedical and behavioral risk factors for heart disease. The APC results suggest that the genesis of racial disparities is neither static nor restricted to a single time scale such as age or period, and they support the importance of equity in life-course exposures for reducing racial disparities in heart disease.
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Cardiovascular and Pulmonary Research. Cardiopulm Phys Ther J 2015. [DOI: 10.1097/cpt.0000000000000008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mochari-Greenberger H, Mosca L. Differential Outcomes by Race and Ethnicity in Patients with Coronary Heart Disease: A Contemporary Review. CURRENT CARDIOVASCULAR RISK REPORTS 2015; 9:20. [PMID: 25914758 PMCID: PMC4405256 DOI: 10.1007/s12170-015-0447-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Coronary heart disease (CHD) is a leading cause of death for people of most ethnicities in the USA. However, several racial and ethnic minority groups are disproportionately burdened by CHD and experience higher mortality rates and rehospitalization rates compared with whites. Contemporary CHD research has been dedicated in part to broadening our understanding of the root causes of racial and ethnic disparities in CHD outcomes. Several factors contribute, including socioeconomic and comorbid conditions. These factors may be amenable to change, and targets for initiatives to reduce disparities and improve CHD outcomes. In this article, we review the recently published research related to the distribution and determinants of racial and ethnic differences in CHD outcomes in the USA.
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Affiliation(s)
| | - Lori Mosca
- Columbia University Medical Center, 51 Audubon Avenue, Room 501, New York, NY 10032, USA
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36
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McCormick D, Hanchate AD, Lasser KE, Manze MG, Lin M, Chu C, Kressin NR. Effect of Massachusetts healthcare reform on racial and ethnic disparities in admissions to hospital for ambulatory care sensitive conditions: retrospective analysis of hospital episode statistics. BMJ 2015; 350:h1480. [PMID: 25833157 PMCID: PMC4382709 DOI: 10.1136/bmj.h1480] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2015] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To examine the impact of Massachusetts healthcare reform on changes in rates of admission to hospital for ambulatory care sensitive conditions (ACSCs), which are potentially preventable with good access to outpatient medical care, and racial and ethnic disparities in such rates, using complete inpatient discharge data (hospital episode statistics) from Massachusetts and three control states. DESIGN Difference in differences analysis to identify the change, overall and according to race/ethnicity, adjusted for secular changes unrelated to reform. SETTING Hospitals in Massachusetts, New York, New Jersey, and Pennsylvania, United States. PARTICIPANTS Adults aged 18-64 (those most likely to have been affected by the reform) admitted for any of 12 ACSCs in the 21 months before and after the period during which reform was implemented (July 2006 to December 2007). MAIN OUTCOME MEASURES Admission rates for a composite of all 12 ACSCs, and subgroup composites of acute and chronic ACSCs. RESULTS After adjustment for potential confounders, including age, race and ethnicity, sex, and county income, unemployment rate and physician supply, we found no evidence of a change in the admission rate for overall composite ACSC (1.2%, 95% confidence interval -1.6% to 4.1%) or for subgroup composites of acute and chronic ACSCs. Nor did we find a change in disparities in admission rates between black and white people (-1.9%, -8.5% to 5.1%) or white and Hispanic people (2.0%, -7.5% to 12.4%) for overall composite ACSC that existed in Massachusetts before reform. In analyses limited to Massachusetts only, we found no evidence of a change in admission rate for overall composite ACSC between counties with higher and lower rates of uninsurance at baseline (1.4%, -2.3% to 5.3%). CONCLUSIONS Massachusetts reform was not associated with significantly lower overall or racial and ethnic disparities in rates of admission to hospital for ACSCs. In the US, and Massachusetts in particular, additional efforts might be needed to improve access to outpatient care and reduce preventable admissions.
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Affiliation(s)
- Danny McCormick
- Harvard Medical School, Department of Medicine, Cambridge Health Alliance, 1493 Cambridge, MA 02139, USA
| | - Amresh D Hanchate
- Veterans Affairs Boston Healthcare System, Boston, MA 02130, USA Section of General Internal Medicine, Boston University School of Medicine, Boston, MA 02118, USA
| | - Karen E Lasser
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA 02118, USA
| | - Meredith G Manze
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA 02118, USA
| | - Mengyun Lin
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA 02118, USA
| | - Chieh Chu
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA 02118, USA
| | - Nancy R Kressin
- Veterans Affairs Boston Healthcare System, Boston, MA 02130, USA Section of General Internal Medicine, Boston University School of Medicine, Boston, MA 02118, USA
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Peykari N, Djalalinia S, Qorbani M, Sobhani S, Farzadfar F, Larijani B. Socioeconomic inequalities and diabetes: A systematic review from Iran. J Diabetes Metab Disord 2015; 14:8. [PMID: 25806357 PMCID: PMC4372329 DOI: 10.1186/s40200-015-0135-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 02/07/2015] [Indexed: 01/04/2023]
Abstract
Socioeconomic factor is a determinant of health may contribute to diabetes. We conducted a systematic review to summarizing evidences on associations between socioeconomic factors and diabetes in Iranian population. We systematically searched international databeses; ISI, PubMed/Medline, Scopus, and national databases Iranmedex, Irandoc, and Scientific Information Database (SID) to retrieve relevant articles to socioeconomic factors and diabetes without limitation on time. All identified articles were screened, quality assessed and data extracted by two authors independently. From 74 retrieved articles, 15 cases were relevant. We found increased diabetes prevalence among female sex, over 50 years' old age, illiterate population, retired status, unemployed, urban residents, and low economic status. There was a negative association between social capital and diabetes control. Diabetes complications were more frequent in upper age group, higher education levels and low income populations. Socioeconomic factors were associated with diabetes that leads to inequality. Improving modifiable factors through priority based interventions helps to diabetes prevention and control.
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Affiliation(s)
- Niloofar Peykari
- Non-communicable Diseases Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, 4th floor, No 4, Ostad Nejatollahi St, Enqelab Ave, Tehran, Iran.,Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, 5th floor, Shariati Hospital, Kargar St, Tehran, Iran.,Development of Research & Technology Center, Deputy of Research and Technology, Ministry of Health and Medical Education, Tehran, Iran
| | - Shirin Djalalinia
- Non-communicable Diseases Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, 4th floor, No 4, Ostad Nejatollahi St, Enqelab Ave, Tehran, Iran.,Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, 5th floor, Shariati Hospital, Kargar St, Tehran, Iran.,Development of Research & Technology Center, Deputy of Research and Technology, Ministry of Health and Medical Education, Tehran, Iran
| | - Mostafa Qorbani
- School of Medicine, Community Medicine Department, Alborz University of Medical Sciences, Karaj, Iran
| | - Sahar Sobhani
- Non-communicable Diseases Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, 4th floor, No 4, Ostad Nejatollahi St, Enqelab Ave, Tehran, Iran
| | - Farshad Farzadfar
- Non-communicable Diseases Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, 4th floor, No 4, Ostad Nejatollahi St, Enqelab Ave, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, 5th floor, Shariati Hospital, Kargar St, Tehran, Iran
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