The use of percutaneous coronary intervention in black and white veterans with acute myocardial infarction

Racial Disparities in In-Hospital Adverse Events Among Patients With Atrial Fibrillation Implanted With a Watchman Left Atrial Appendage Occlusion Device: A US National Perspective

[Figure: see text].

Racial/Ethnic Disparities in VA Services Utilization as a Partial Pathway to Mortality Differentials Among Veterans Diagnosed With TBI

Objective:

Primary: To examine Veterans Administration (VA) utilization and other potential mediators between racial/ethnic differentials and mortality in veterans diagnosed with traumatic brain injury (TBI).

Design:

A national cohort of veterans clinically diagnosed with TBI in 2006 was followed from January 1, 2006 through December 31, 2009 or until date of death. Utilization was tracked for 12 months. Differences in survival and potential mediators by race were examined via K-Wallis and chi-square tests. Potential mediation of utilization in the association between mortality and race/ethnicity was studied by fitting Cox models with and without adjustment for demographics and co-morbidities. Poisson regression was used to study the association of race/ethnicity with utilization of specialty services potentially important in the management of TBI.

Setting:

United States (US) Veterans Administration (VA) Hospitals and Clinics.

Participants:

14, 690 US veterans clinically diagnosed with TBI in 2006.

Interventions:

Not Applicable. The study is a secondary data analysis.

Main Outcome Measures:

Mortality, Utilization.

Results:

Hispanic veterans were found to have significantly higher unadjusted mortality (6.69%) than Non-Hispanic White veterans (2.93%). Hispanic veterans relative to Non-Hispanic White were found to have significantly lower utilization of all services examined, except imaging. Neurology was found to be the utilization mediator with the highest percent of excess risk (3.40%) while age was the non utilization confounder with the highest percent of excess risk (31.49%). In fully adjusted models for demographics and co-morbidities, Hispanic veterans relative to Non-Hispanic Whites were found to have less total visits (IRR 0.89), TBI clinic (IRR 0.43), neurology (IRR 0.35), rehabilitation (IRR 0.37), and other visits (IRR 0.85) with only higher mental health visits (IRR 1.53).

Conclusions:

We found evidence that utilization is a partial mediator between race/ethnicity and mortality, especially neurology utilization. We also found that Hispanic veterans receive significantly less TBI clinic, neurology, rehabilitation and other types of utilization. The use of innovative system factors (decision aids, information tools, patient activation, and adherence support interventions) could be valuable in enhancing utilization of specific TBI related services, especially among ethnic minorities.

Disparities in use of same-day percutaneous coronary intervention for patients with ST-elevation myocardial infarction in Florida, 2001-2005

Primary percutaneous coronary intervention (PCI) is the recommended treatment for ST-elevation myocardial infarction (STEMI), according to American College of Cardiology and American Heart Association guidelines published in 1999 and 2004. In this study, hospital and patient predictors of same-day primary PCI use for STEMI were examined across the period from 2001 to 2005. Inpatient discharge data for adults aged > or =18 years with primary diagnoses of STEMI who were admitted to Florida hospitals through emergency departments (ED) from 2001 to 2005 (n = 58,308) were analyzed. Hierarchical (multilevel) logistic regression models were used to assess hospital PCI volume and individual characteristics as predictors of same-day PCI use for patients at PCI-capable hospitals. The percentage of ED-admitted patients with a STEMI who received same-day PCI in Florida increased from 20% in early 2001 to 43% in late 2005. At PCI-capable hospitals, 50% of these patients received same-day PCI in late 2005. Patients admitted on weekends, women, patients aged > or = 75 years, patients with chronic obstructive pulmonary disease, and patients with end-stage renal disease were all significantly less likely to receive same-day PCI. Black patients were less likely to receive same-day PCI in early 2001 (adjusted odds ratio [OR] 0.7, 95% confidence interval 0.5 to 0.9, p <0.0001), but this racial disparity was not evident by late 2005 (adjusted OR 1.0). Men were more likely than women to receive same-day PCI, with a significant association remaining in late 2005 (adjusted OR 1.2, 95% confidence interval 1.1 to 1.4, p <0.0001). Throughout the study period, the strongest predictor of same-day PCI was admission to a high- or medium-volume PCI-capable hospital; the adjusted OR in late 2005 was 4.6 (95% confidence interval 2.8 to 7.6, p <0.0001). In conclusion, weekend admission, female gender, older age, and serious co-morbidities were all significant barriers to receiving same-day PCI. Among patients admitted to PCI-capable hospitals, total PCI volume (high or medium vs low) was associated with significantly greater odds of receiving primary PCI, independent of patient sociodemographics, risk factors, or co-morbidities. Statewide, despite an increase in the use of PCI over time, most ED-admitted patients with a STEMI in Florida did not receive primary PCI in late 2005.

Racial and ethnic disparities in the VA health care system: a systematic review

OBJECTIVES

To better understand the causes of racial disparities in health care, we reviewed and synthesized existing evidence related to disparities in the "equal access" Veterans Affairs (VA) health care system.

METHODS

We systematically reviewed and synthesized evidence from studies comparing health care utilization and quality by race within the VA.

RESULTS

Racial disparities in the VA exist across a wide range of clinical areas and service types. Disparities appear most prevalent for medication adherence and surgery and other invasive procedures, processes that are likely to be affected by the quantity and quality of patient-provider communication, shared decision making, and patient participation. Studies indicate a variety of likely root causes of disparities including: racial differences in patients' medical knowledge and information sources, trust and skepticism, levels of participation in health care interactions and decisions, and social support and resources; clinician judgment/bias; the racial/cultural milieu of health care settings; and differences in the quality of care at facilities attended by different racial groups.

CONCLUSIONS

Existing evidence from the VA indicates several promising targets for interventions to reduce racial disparities in the quality of health care.