Racial and ethnic disparities in the use of cardiovascular procedures: associations with type of health insurance

The effect of "failed" community mental health centers on non-white mortality

The Community Mental Health Act of 1963 established Community Mental Health Centers (CMHCs) across the country with the goal of providing continuous, comprehensive, community-oriented care to people suffering from mental illness. Despite this program being considered a failure by most contemporary accounts, the World Health Organization advocates for a transition from the institutionalization of the mentally ill to a system of community-centered care. In this paper, we construct a novel dataset documenting the rollout of CMHCs from 1971 to 1981 to identify the effect of establishing a CMHC on county level mortality rates, focusing on causes of death related to mental illness. Though we find little evidence that access to a CMHC impacted mortality rates in the white population, we find large and robust effects for the non-white population, with CMHCs reducing suicide and homicide rates by 8% and 14%, respectively. CMHCs also reduced deaths from alcohol in the female non-white population by 18%. These results suggest the historical narrative surrounding the failure of this program does not represent the non-white experience and that community care can be effective at reducing mental health related mortality in populations with the least access to alternative treatment options.

Addressing racial disparities in surgical care with machine learning

There is ample evidence to demonstrate that discrimination against several population subgroups interferes with their ability to receive optimal surgical care. This bias can take many forms, including limited access to medical services, poor quality of care, and inadequate insurance coverage. While such inequalities will require numerous cultural, ethical, and sociological solutions, artificial intelligence-based algorithms may help address the problem by detecting bias in the data sets currently being used to make medical decisions. However, such AI-based solutions are only in early development. The purpose of this commentary is to serve as a call to action to encourage investigators and funding agencies to invest in the development of these digital tools.

Racial and Ethnic Inequities in Use of Preventive Services Among Privately Insured Adults With a Pediatric-Onset Disability

PURPOSE

Cerebral palsy (CP) and spina bifida (SB) are pediatric-onset disabilities. Adults living with CP/SB are in a greater need of preventive care than the general population due to their increased risk for chronic diseases. Our objective was to compare White/Black and White/Hispanic inequities in the use of preventive services.

METHODS

Using 2007-2017 private claims data, we identified a total of 11,635 adults with CP/BS. Of these, 8,935 were White, 1,457 Black, and 1,243 Hispanic. We matched health-related variables (age, sex, comorbid conditions) between White adults and those in each minority subpopulation. Generalized estimating equations were used and all models were adjusted for age, sex, comorbidities, income, education, and US Census divisions. Outcomes of interest were: (1) any office visit; (2) any physical/occupational therapy; (3) wellness visit; (4) bone density screening; (5) cholesterol screening; and (6) diabetes screening.

RESULTS

The rate of recommended services for all subpopulations of adults with CP/SB was low. Compared with White adults, Hispanic adults had lower odds of wellness visits (odds ratio [OR] = 0.71, 95% CI, 0.53-0.96) but higher odds of diabetes screening (OR = 1.48, 95% CI, 1.13-1.93). Compared with White adults, Black adults had lower odds of wellness visits (OR = 0.50, 95% CI, 0.24-1.00) and bone density screening (OR = 0.54, 95% CI, 0.31-0.95).

CONCLUSIONS

Preventive service use among adults with CP/SB was low. Large White-minority disparities in wellness visits were observed. Interventions to address physical accessibility, adoption of telehealth, and increased clinician education may mitigate these disparities, particularly if initiatives target minority populations.

Resilience and Equity in a Time of Crises: Investing in Public Urban Greenspace Is Now More Essential Than Ever in the US and Beyond

The intersecting negative effects of structural racism, COVID-19, climate change, and chronic diseases disproportionately affect racial and ethnic minorities in the US and around the world. Urban populations of color are concentrated in historically redlined, segregated, disinvested, and marginalized neighborhoods with inadequate quality housing and limited access to resources, including quality greenspaces designed to support natural ecosystems and healthy outdoor activities while mitigating urban environmental challenges such as air pollution, heat island effects, combined sewer overflows and poor water quality. Disinvested urban environments thus contribute to health inequity via physical and social environmental exposures, resulting in disparities across numerous health outcomes, including COVID-19 and chronic diseases such as cancer and cardiovascular diseases (CVD). In this paper, we build off an existing conceptual framework and propose another conceptual framework for the role of greenspace in contributing to resilience and health equity in the US and beyond. We argue that strategic investments in public greenspaces in urban neighborhoods impacted by long term economic disinvestment are critically needed to adapt and build resilience in communities of color, with urgency due to immediate health threats of climate change, COVID-19, and endemic disparities in chronic diseases. We suggest that equity-focused investments in public urban greenspaces are needed to reduce social inequalities, expand economic opportunities with diversity in workforce initiatives, build resilient urban ecosystems, and improve health equity. We recommend key strategies and considerations to guide this investment, drawing upon a robust compilation of scientific literature along with decades of community-based work, using strategic partnerships from multiple efforts in Milwaukee Wisconsin as examples of success.

Impact of Economic Status on Utilization and Outcomes of Transcatheter Aortic Valve Implantation and Mitraclip

Data on the impact of economic status on Transcatheter aortic valve implantation (TAVI) and MitraClip (MC) is lacking. Patients who underwent TAVI and/or MC during 2012 to 2017 were identified in the Nationwide Readmission Database and divided by zip code estimated income quartile into 4 groups (Q1 to Q4). The utilization of TAVI and/or MC was defined as the number of TAVIs and/or MCs over all admissions with an aortic and/or mitral valve disease (AVD and/or MVD) and represented per 1,000 admissions. A total of 168,853 patients underwent TAVI; 20.6% in Q1, 26.3% in Q2, 27.3% in Q3, and 25.8% in Q4, while 15,387 patients underwent MC; 22% in Q1, 26.2% in Q2, 26.3% in Q3, and 25.5% in Q4. The annual utilization of TAVIs and/or MCs increased over the study period and was generally lower with lower income. In 2012, TAVI was performed for 8.2, 8.8, 10.8, and 11.3 per 1,000 AVD admissions in Q1, Q2, Q3, and Q4, respectively. In 2017, TAVI was performed for 54.1, 65.1, 68.6, and 71 per 1,000 AVD admissions in Q1, Q2, Q3, and Q4, respectively. In 2014, MC was performed for 1.6, 2.1, 1.8, and 1.9 per 1,000 MVD admissions in Q1, Q2, Q3, and Q4, respectively. In 2017, MC was performed for 5.6, 6.5, 8, and 8 per 1,000 MVD admissions in Q1, Q2, Q3, and Q4, respectively. In-hospital mortality, stroke, and 30-day readmissions were generally comparable across groups. Lower-income patients may be underrepresented among patients undergoing TAVI and MC despite comparable outcomes. Further studies are needed to examine the etiologies behind these disparities and identify targeted strategies for its mitigation.

The influence of patient race on the use of diagnostic imaging in United States emergency departments: data from the National Hospital Ambulatory Medical Care survey

BACKGROUND

An established body of literature has shown evidence of implicit bias in the health care system on the basis of patient race and ethnicity that contributes to well documented disparities in outcomes. However, little is known about the influence of patient race and ethnicity on the decision to order diagnostic radiology exams in the acute care setting. This study examines the role of patient race and ethnicity on the likelihood of diagnostic imaging exams being ordered during United States emergency department encounters.

METHODS

Publicly available data from the National Hospital Ambulatory Medical Care Survey Emergency Department sample for the years 2006-2016 was compiled. The proportion of patient encounters where diagnostic imaging was ordered was tabulated by race/ethnicity, sub-divided by imaging modality. A multivariable logistic regression model was used to evaluate the influence of patient race/ethnicity on the ordering of diagnostic imaging controlling for other patient and hospital characteristics. Survey weighting variables were used to formulate national-level estimates.

RESULTS

Using the weighted data, an average of 131,558,553 patient encounters were included each year for the 11-year study period. Imaging was used at 46% of all visits although this varied significantly by patient race and ethnicity with white patients receiving medical imaging at 49% of visits and non-white patients at 41% of visits (p < 0.001). This effect persisted in the controlled regression model and across all imaging modalities with the exception of ultrasound. Other factors with a significant influence on imaging use included patient age, gender, insurance status, number of co-morbidities, hospital setting (urban vs non-urban) and hospital region. There was no evidence to suggest that the disparate use of imaging by patient race and ethnicity changed over the 11-year study time period.

CONCLUSION

The likelihood that a diagnostic imaging exam will be ordered during United States emergency department encounters differs significantly by patient race and ethnicity even when controlling for other patient and hospital characteristics. Further work must be done to understand and mitigate what may represent systematic bias and ensure equitable use of health care resources.

Ethnic and Racial Disparities in Acute Myocardial Infarction

PURPOSE OF REVIEW

Significant racial and ethnic healthcare disparities exist in the management and outcomes of patients with acute myocardial infarction (AMI). This review will highlight the recent studies focusing on disparities in AMI care and how practice patterns have changed over time, and discuss solutions and future directions to overcome disparities in AMI care.

RECENT FINDINGS

AMI continues to be a leading cause of morbidity and mortality in the USA. Racial and ethnic disparities continue to be present in the care and outcomes associated with AMI. Non-white individuals continue to receive less guideline-concordant care and experience higher rates of adverse outcomes compared with white individuals. Health policy and quality improvement interventions have helped to narrow the gap; however, ongoing efforts are needed to continue to attempt to eliminate this disparity. Racial and ethnic disparities persist in the presentation, management, and outcomes of patients with AMI. Improvements in care have narrowed some of the inequalities. Ongoing research and efforts directed at improving access to care, eliminating bias in healthcare, and focusing on coronary heart disease prevention are needed to eliminate disparities.

Association Between Ambulatory Care Utilization and Coronary Artery Disease Outcomes by Race/Ethnicity

Background

Coronary artery disease is common, and there exist disparities in management and outcomes. The purpose of this study is to examine the association between ambulatory care utilizations and inpatient acute myocardial infarction (AMI) mortality.

Methods and Results

This is a retrospective analysis of a stratified national sample of Medicare fee‐for‐service enrollees aged 66 years and older from January 1, 2010 to December 31, 2011. We measured both number of ambulatory visits and presence of ambulatory cardiac tests. The primary outcome was inpatient AMI mortality. Using multivariate logistic regression models, we estimated the association between ambulatory care utilization and the main patient outcomes, adjusting for patient‐ and area‐level demographic, geographical, and clinical characteristics. We found that a significantly lower percentage of Hispanics and Asians, relative to whites, had frequent ambulatory care visits. Among the largest 4 race/ethnic groups, Asians had the highest observed inpatient mortality rate (15.9%). Overall, low ambulatory utilization was associated with higher odds (odds ratio=1.85 [95% confidence interval: 1.11‐3.08]), and ambulatory cardiac testing was associated with lower odds (odds ratio=0.73 [0.55‐0.95]) of inpatient AMI mortality, after adjustment for covariates. Asians had higher odds of inpatient AMI mortality even after adjustment for covariates.

Conclusions

Among Medicare fee‐for‐service enrollees, Hispanics and Asians had lower rates of ambulatory care visits, and all minority groups had higher odds of hospitalization for AMI. Ambulatory care utilization, including both ambulatory clinic visits and outpatient cardiac tests, were associated with AMI mortality. Further research is needed to understand the causal relationship between ambulatory care utilization and cardiovascular outcomes.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Exposure

Percutaneous coronary intervention at a VA hospital.

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Racial Disparities and Outcomes After Left Ventricular Assist Device Implantation as Bridge to Transplantation or Destination Therapy

OBJECTIVE

We sought to investigate outcomes after left ventricular assist device (LVAD) implantation in advanced heart failure patients stratified by race.

METHODS

Patients who had LVADs inserted at a single center as a bridge to transplant (BTT) or destination therapy (DT) were divided into 3 groups based on race: Caucasian, African American (AA), and Hispanic. Postoperative outcomes including complications, discharge disposition, and survival at defined time points were compared. Cox proportional hazards were used to identify factors associated with 1-year all-cause survival.

RESULTS

A total of 158 patients who had LVADs as BTT (n = 63) and DT (n = 95) were studied. Of these, 56% (n = 89) were Caucasians, 35% (n = 55) were AA, and 9% (n = 14) were Hispanics. AA patients had higher BMI and lower socioeconomic status and educational level, and were more likely to be single or divorced. Operative outcomes were similar among all 3 groups. Unadjusted 30-day, 6-month, 1-year, and 2-year survival rates for Caucasians versus AA versus Hispanics were 82% versus 89% versus 93%, P = 0.339; 74% versus 80% versus 71%, P = 0.596; 67% versus 76% versus 71%, P = 0.511; and 56% versus 62% versus 68%, P = 0.797. On multivariate analysis, device-related infection, malfunction, and abnormal rhythm were factors associated with overall all-cause mortality.

CONCLUSION

AA patients who undergo LVAD implantation as BTT or DT have lower socioeconomic status and educational level compared to their Caucasian or Hispanic counterparts. These differences, however, do not translate into postimplant survival outcomes.

Does Insurance Effect the Outcome in Patients With Acute Coronary Syndrome?: An Insight from the Most Recent National Inpatient Sample

Several studies have shown disparities in outcome in the patients with Acute coronary syndrome (ACS) based on several factors. Treatment might differ based on insurance type. Therefore, we retrospectively analyzed National Inpatient Sample (NIS 2016) data to identify the impact of different types of insurances on mortality outcome in patients admitted with ACS. ICD-CM-10 codes were used to identify hospital discharges with a principal diagnosis of ACS. Observations were stratified based on insurance (Medicare, Medicaid, Private, and No insurance). Primary and secondary outcomes were in-hospital mortality, length of stay and total cost. Any potential confounders were adjusted using multivariate logistic regression. STATA/IC 15.1 Stata Corp LLC was used for analysis. A total of 8,01,195 hospitalizations with the primary diagnosis of ACS were identified, of which 59.2% had Medicare, 9.72% had Medicaid, 26.8% had Private insurance, and 4.3% had no insurance. Higher odds of mortality were seen in the patients with Medicare, Medicaid, and Noninsured group. Adjusted Odds ratio for mortality in Medicare was 1.01 (confidence interval [CI]: 0.94-1.1; P = 0.65), in Medicaid was 1.16 (CI: 1.03-1.30; P = 0.01) and in uninsured group was 1.46 (CI: 1.26-1.69; P ≤ 0.01). However, the patients with private insurance adjusted odds ratio for mortality were 0.77 (CI: 0.70-0.84; P ≤ 0.01) compared to the patients with other insurance groups. Above results show that the disparity exists in the outcome of patients admitted with ACS based on their insurance types, particularly for Medicaid patients. We need further studies to understand the root cause of this disparity.

Racial/ethnic disparities among Asian Americans in inpatient acute myocardial infarction mortality in the United States

Background

Acute myocardial infarction (AMI) is a common high-risk disease with inpatient mortality of 5% nationally. But little is known about this outcome among Asian Americans (Asians), a fast growing racial/ethnic minority in the country. The objectives of the study are to obtain near-national estimates of differences in AMI inpatient mortality between minorities (including Asians) and non-Hispanic Whites and identify comorbidities and sociodemographic characteristics associated with these differences.

Method

This is a retrospective analysis of 2010–2011 state inpatient discharge data from 10 states with the largest share of Asian population. We identified hospitalization with a primary diagnosis of AMI using the ICD-9 code and used self-reported race/ethnicity to identify White, Black, Hispanic, and Asian. We performed descriptive analysis of sociodemographic characteristics, medical comorbidities, type of AMI, and receipt of cardiac procedures. Next, we examined overall inpatient AMI mortality rate based on patients’ race/ethnicity. We also examined the types of AMI and a receipt of invasive cardiac procedures by race/ethnicity. Lastly, we used sequential multivariate logistic regression models to study inpatient mortality for each minority group compared to Whites, adjusting for covariates.

Results

Over 70% of the national Asian population resides in the 10 states. There were 496,472 hospitalizations with a primary diagnosis of AMI; 75% of all cases were Whites, 10% were Blacks, 12% were Hispanics, and 3% were Asians. Asians had a higher prevalence of cardiac comorbidities, including hypertension, diabetes, and kidney failure compared to Whites (p-value< 0.01). There were 158,623 STEMI (ST-elevation AMI), and the proportion of hospitalizations for STEMI was the highest for Asians (35.2% for Asians, 32.7% for Whites, 25.3% for Blacks, and 32.1% for Hispanics). Asians had the highest rates of inpatient AMI mortality: 7.2% for Asians, 6.3% for Whites, 5.4% for Blacks, and 5.9% for Hispanics (ANOVA p-value < 0.01). In adjusted analyses, Asians (OR = 1.11 [95% CI: 1.04–1.19]) and Hispanics (OR = 1.14 [1.09–1.19]) had a higher likelihood of inpatient mortality compared to Whites.

Conclusions

Asians had a higher risk-adjusted likelihood of inpatient AMI mortality compared to Whites. Further research is needed to identify the underlying reasons for this finding to improve AMI disparities for Asians.

Race and Gender Differences in the Use of Direct Acting Antiviral Agents for Hepatitis C Virus

BACKGROUND

Direct acting antiviral agents (DAA) are highly effective yet expensive. Disparities by race and/or gender often exist in the use of costly medical advances as they become available.

METHODS

We examined a cohort of hepatitis C virus (HCV) patients who received care at the Veterans Administration facilities nationwide. We evaluated the effect of race and gender on DAA receipt after adjusting for socioeconomic status, liver disease severity, comorbidity, and propensity for healthcare use. To determine if disparities had changed over time, we conducted a similar analysis of HCV patients who were seen in the previous standard of care treatment era.

RESULTS

Of the 145 596 patients seen in the current DAA era, 17 791 (10.2%) received treatment during the first 16 months of DAA approval. Black patients had 21% lower odds of receiving DAA than whites (odds ratio [OR] = 0.79; 95% confidence interval [CI], .75, .84). Overall, women were as likely to receive treatment as men (OR = 0.99; 95% CI, .90-1.09). However, the odds of receiving DAAs were 29% lower for younger women compared with younger men (OR = 0.71, 95% CI, .54-.93). Similar to the DAA cohort, black patients had significantly lower odds of receiving treatment than whites (OR = 0.74, 95% CI, .69-.79) in the previous treatment era. The racial difference between the 2 eras did not reach statistical significance.

CONCLUSIONS

There were unexplained differences among HCV population subgroups in the receipt of new DAA treatment. Targeted interventions are needed for black patients and younger women.

Expanding research on the racial disparity in medical treatment with ideas from sociology

While hundreds of studies document racial differences in the use of medical procedures in the United States, by comparison little is known about the causes of these differences. This gap in knowledge should serve as a call to sociologists who, drawing on their disciplinary tradition of studying inequality, could improve understanding of the disparity. This article offers suggestions about how medical sociologists in the USA might bring sociology to the study of racial disparities in medical treatment. The article begins by reviewing the existing approaches to understanding the racial disparity in medical treatment. After considering the extant research and its limits, the article goes on to describe how a few specific concepts from sociology - cultural capital, social networks, self-presentation and social distance, all framed in a race critical framework - and more diverse methodological approaches can advance studies of the racial disparity in medical treatment

Immunization Rates and Beliefs among Elderly Patients of Inner City Neighborhood Health Centers

Although influenza and pneumonia are the sixth leading cause of death in the United States, immunization rates are modest and racial disparity occurs. To address this issue, the authors surveyed 220 of 261 contacted persons aged ≥ 66 years old who were randomly selected from inner city neighborhood health centers in Pittsburgh. The authors conducted computer assisted telephone interviewing using a standard questionnaire based on the theory of reasoned action. Influenza vaccination rates were 60% for Blacks and 79% for Whites, and varied from 59% to 81% by health center. Vaccination rates against pneumococcus were 59% for Blacks and 70% for Whites. No significant racial differences were found in report of experiencing influenza or in beliefs about the diseases and vaccines. Blacks were less likely than Whites to perceive that their doctor thought they should be vaccinated against influenza (83% vs. 93%, p = .02). Blacks were somewhat more likely than Whites to report that pneumococcal polysaccharide vaccination was more trouble than it was worth (21% vs. 10%, p = .02). Because factors related to social influences and facilitating conditions are associated with vaccination status and because immunization rates vary by medical center, the authors recommend enhancing immunization efforts within the health centers.

Clinical Characteristics, Oral Anticoagulation Patterns, and Outcomes of Medicaid Patients With Atrial Fibrillation: Insights From the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF I) Registry

Background

Whereas insurance status has been previously associated with care patterns, little is currently known about the association between Medicaid insurance and the clinical characteristics, treatment, or outcomes of patients with atrial fibrillation (AF).

Methods and Results

We used data from adults with AF enrolled in the Outcomes Registry for Better Informed Treatment of AF (ORBIT‐AF), a national outpatient registry conducted at 176 community, multispecialty sites. The primary outcome of interest was the proportion of patients prescribed any oral anticoagulation (OAC; warfarin or novel oral anticoagulants [NOAC]). Secondary outcomes of interest included the proportion of patients prescribed NOACs (dabigatran or rivaroxaban); time in therapeutic range (TTR) for warfarin users, all‐cause mortality, stroke/systemic embolism, and major bleed. Of 10 133 patients, N=470 (4.6%) had Medicaid insurance. Medicaid patients were similarly likely to receive OAC at baseline (72.8% vs 76.3%; unadjusted P=0.079), but less likely to receive NOAC at baseline or follow‐up (12.1% vs 16.3%; unadjusted P=0.019). After risk adjustment, Medicaid status was associated with lower use of OAC at baseline among patients with high stroke risk (odds ratio [OR]=0.68; 95% CI=0.49, 0.94), but was not associated with OAC use overall (OR=0.82; 95% CI=0.61, 1.09). Among warfarin users, median TTR was lower among Medicaid patients (60% vs 68%; P<0.0001; adjusted TTR difference, −2.9; 95% CI=−5.7, −0.2; P=0.04). Use of an NOAC over 2 years of follow‐up was not statistically different by insurance. Compared with non‐Medicaid patients, Medicaid patients had higher unadjusted rates of mortality, stroke/systemic embolism, and major bleeding; however, these differences were attenuated following adjustment for clinical characteristics.

Conclusions

In a contemporary AF cohort, use of OAC overall and use of NOACs were not significantly lower among Medicaid patients relative to others. However, among warfarin users, Medicaid patients spent less time in therapeutic range compared with those with other forms of insurance.

Limited impact on health and access to care for 19- to 25-year-olds following the Patient Protection and Affordable Care Act

IMPORTANCE

The Patient Protection and Affordable Care Act (PPACA) allowed young adults to remain on their parents' insurance until 26 years of age. Reports indicate that this has expanded health coverage.

OBJECTIVE

To evaluate coverage, access to care, and health care use among 19- to 25-year-olds compared with 26- to 34-year-olds following PPACA implementation.

DESIGN, SETTING, AND PARTICIPANTS

Data from the Behavior Risk Factor Surveillance System and the National Health Interview Survey, which provide nationally representative measures of coverage, access to care, and health care use, were used to conduct the study among participants aged 19 to 25 years (young adults) and 26 to 34 years (adults) in 2009 and 2012.

EXPOSURE

Self-reported health insurance coverage.

MAIN OUTCOMES AND MEASURES

Health status, presence of a usual source of care, and ability to afford medications, dental care, or physician visits.

RESULTS

Health coverage increased between 2009 and 2012 for 19- to 25-year-olds (68.3% to 71.7%). Using a difference-in-differences (DID) approach, after adjustment, the likelihood of having a usual source of care decreased in both groups but more significantly for 26- to 34-year-olds (DID, 2.8%; 95% CI, 0.45 to 5.15). There was no significant change in health status for 19- to 25-year-olds compared with 26- to 34-year-olds (DID, -0.5%; 95% CI, -1.87 to 0.87). There was no significant change for 19- to 25-year-olds compared with 26- to 34-year-olds in the percentage who reported receiving a routine checkup in the past year (DID, 0.3%; 95% CI, -2.25 to 2.85) or in the ability to afford prescription medications (DID, -0.4%; 95% CI, -2.93 to 1.93), dental care (DID, -2.6%; 95% CI, -5.61 to 0.61), or physician visits (DID, -1.7%; 95% CI, -3.66 to 0.26). There was also no change in the percentage who reported receiving a flu shot (DID, 1.9; 95% CI, -1.93 to 4.93). Insured individuals were more likely to report having a usual source of care and a recent routine checkup and were more likely to be able to afford health care than uninsured individuals.

CONCLUSIONS AND RELEVANCE

Implementation of the PPACA was associated with increased health insurance coverage for 19- to 25-year-olds without significant changes in perceived health care affordability or health status. Although the likelihood of having a usual source of care declined between 2009 and 2012 for all, this decrease was smaller among 19- to 25-year-olds, and younger adults were more likely than 26- to 34-year-olds to have a usual source of care.

Characteristics affecting oral anticoagulant therapy choice among patients with non-valvular atrial fibrillation: a retrospective claims analysis

Background

Dabigatran is one of the three newer oral anticoagulants (OACs) recently approved in the United States for stroke prevention in non-valvular atrial fibrillation (NVAF) patients. The objective of this study was to identify patient, healthcare provider, and health plan factors associated with dabigatran versus warfarin use among NVAF patients.

Methods

Administrative claims data from patients with ≥2 NVAF medical claims in the HealthCore Integrated Research Database between 10/1/2009 and 10/31/2011 were analyzed. During the study intake period (10/1/2010 - 10/31/2011), dabigatran patients had ≥2 dabigatran prescriptions, warfarin patients had ≥2 warfarin and no dabigatran prescriptions, and the first oral anticoagulant (OAC) prescription date was the index date. Continuous enrollment for 12 months preceding (“pre-index”) and ≥ 6 months following the index date was required. Patients without pre-index warfarin use were assigned to the ‘OAC-naïve’ subgroup. Separate analyses were performed for ‘all-patient’ and ‘OAC-naïve’ cohorts. Multivariable logistic regression (LR) identified factors associated with dabigatran versus warfarin use.

Results

Of 20,320 patients (3,019 dabigatran and 17,301 warfarin) who met study criteria, 27% of dabigatran and 13% of warfarin patients were OAC-naïve. Among all-patients, dabigatran patients were younger (mean 67 versus 73 years, p < 0.001), predominantly male (71% versus 61%, p < 0.001), and more frequently had a cardiologist prescriber (51% versus 30%, p < 0.001) than warfarin patients. Warfarin patients had higher pre-index Elixhauser Comorbidity Index (mean: 4.3 versus 4.0, p < 0.001) and higher ATRIA bleeding risk score (mean: 3.0 versus 2.3, p < 0.001). LR results were generally consistent between all- and OAC-naïve patients. Among OAC-naïve patients, strongest factors associated with dabigatran use were prescriber specialty (OR = 3.59, 95% CI 2.68-4.81 for cardiologist; OR = 2.22, 95% CI 1.65-2.97 for other specialist), health plan type (OR = 1.47 95% CI 1.10-1.96 for preferred provider organization), and prior ischemic stroke (OR = 1.42, 95% CI 1.06-1.90). Older age decreased the probability of dabigatran use.

Conclusions

Beside patient characteristics, cardiology specialty of the prescribing physician and health plan type were the strongest factors associated with dabigatran use.

Continuous-flow left ventricular assist device implantation as a bridge to transplantation or destination therapy: racial disparities in outcomes

BACKGROUND

There is a paucity of data assessing racial disparities in outcomes after left ventricular assist device (LVAD) implantation. This may be due to the relatively low percentage of African American (AA) patients at a given center. Given the high proportion of AAs in our patient population, we sought to evaluate outcomes of LVAD implantation in AAs vs Caucasians.

METHODS

We stratified 88 LVAD patients by AA or Caucasian race. Variables were compared using 2-sided t-tests, chi-square tests, Cox proportional hazards models, and log-rank tests to determine whether a difference existed between AAs and Caucasians and whether race was a significant independent predictor of outcome.

RESULTS

AAs represented 36.4% (32 of 88) of our LVAD patients. The two groups did not differ significantly in the incidence of hypertension, diabetes, or chronic renal insufficiency, reoperation rates, pre-operative body mass index, left ventricular ejection fraction, central venous pressure, pulmonary capillary wedge pressure, pulmonary artery pressure, or right ventricular function. Compared with Caucasians, AAs were significantly younger (48.6 vs 54.8 years, p = 0.019), and had a significantly higher mean body surface area (p = 0.009) and a higher rate of non-ischemic dilated cardiomyopathy (61% vs 39%, p = 0.008). No significant difference was found in 30-day (p = 0.12), 180-day (p = 0.166), or 360-day (p = 0.18) survival. Analysis by univariate Cox proportional hazard models (hazard ratio [95% confidence interval]) showed race was not an independent predictor of 30-day (4.5 [0.56-35.94], p = 0.157), 180-day (3.9 [0.48-31.95], p = 0.2), or 360-day survival (1.8 [0.6-5.71], p = 0.286). Age and pre-operative renal failure were the only independent predictors of survival at 30 days (1.1 [1.02-1.19], p = 0.019; 4.99 [1.24-20], p = 0.023, respectively), 180 days (1.09 [1-1.18], p = 0.041; 4.14 [0.99-17.39], p = 0.05), and 360 days (1.05 [1-1.1], p = 0.044; 2.52 [0.94-6.75], p = 0.05). Analysis by a multivariate logistic regression model showed age and chronic renal failure were no longer statistically significant for survival at 30, 180, and 360 days.

CONCLUSIONS

Although multiple studies have demonstrated that AAs experience worse outcomes after coronary artery bypass grafting, heart transplantation, and valve surgery, we did not find similar results in our LVAD population. More rigorous pre-operative LVAD workup, including an evaluation by a multidisciplinary team, along with more intense post-operative follow-up, may explain improved outcomes in AAs after LVAD implantation compared with other cardiac surgical procedures, although additional analysis is required.

Awareness, treatment and control of hypertension, diabetes and hyperlipidemia and area-level mortality regions in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study

BACKGROUND

Health Professional Shortage Areas (HPSA) receive extra federal resources, but recent reports suggest that HPSA may not consistently identify areas of need.

PURPOSE

To assess areas of need based on county-level ischemic heart disease (IHD) and stroke mortality regions.

METHODS

Need was defined by lack of awareness, treatment, or control of hypertension, diabetes, or hyperlipidemia. Counties were categorized into race-specific tertiles of IHD and stroke mortality using 1999-2006 CDC data. Multivariable logistic regression was used to model the relationships between IHD and stroke mortality region and each element of need.

RESULTS

Awareness and treatment of cardiovascular (CVD) risk factors were similar for residents in counties across IHD and stroke mortality tertiles, but control tended to be lower in counties with the highest mortality.

CONCLUSIONS

High stroke and IHD mortality identify distinct regions from current HPSA designations, and may be an additional criterion for designating areas of need.

Racial and Ethnic Patterns in the Utilization of Prehospital Emergency Transport Services in the United States

Introduction:

This descriptive research used a large, urban population-based data set for prehospital emergency medical transports to examine racial/ethnic patterns of access and utilization for several broad categories of emergency medical transport services.

Methods:

Fire department files of approximately 39,000 reports on service provision were used to establish rates of transport utilization per 1,000 population in 1990, the most recent year for which reliable citylevel census data were available. Data were categorized by three age groups (< 25 years 25–64years,≥ 65years), three racial/ethnic groups (non-Hispanic whites, African-Americans, Hispanics), and gender. Transport rates were computed for total utilization, trauma incidents, and incidents due to medical conditions. Racial/ethnic rates were analyzed for each age and gender group and age- and gender-standardized rates were analyzed and presented in a graphical comparison. Statistical analyses of racial/ethnic differences were conducted using Tukey-type tests of multiple comparisons of proportions, with significant differences evaluated at the p = 0.001 level of significance.

Results:

Significant differences between racial/ethnic groups in the utilization of emergency transport services existed for all pair-wise comparisons including comparisons by each of the three age groups and gender. For total utilization, unadjusted rates are highest for African-Americans (65.9/1,000) and lowest for Hispanics (25.8/1.000). Likewise, African-American rates were substantially higher for both gender groups and across all age groups. Categorized by gender and age group under age ≥ 65 years, non-Hispanic whites are observed to have the lowest rates for both males and females under the age 65 years, while Hispanics have the lowest rates in the group 65 years old However, when rates are age- and gender- standardized, compared to African-Americans and Hispanics, rates for non-Hispanic whites are significantly lower for total transports and for trauma and medically related transports (p = 0.001).

Conclusion:

Age- and gender- standardized rates for emergency medical transport were found to be lowest for non-Hispanic whites, moderately higher for Hispanics, and subsantially higher for African-Americans, who experienced transport rates nearly three times higher than were the rates for non-Hispanic whites. Further research is required to establish the extent to which racial/ethnic differences observed in this geographically restricted study reflect variations between racial/ethnic groups in the underlying need for services.

Lower extremity vascular injuries: increased mortality for minorities and the uninsured?

BACKGROUND

There is increasing evidence to suggest that racial disparities exist in outcomes for trauma. Minorities and the uninsured have been found to have higher mortality rates for blunt and penetrating trauma. However, mechanisms for these disparities are incompletely understood. Limiting the inquiry to a homogenous group, those with lower extremity vascular injuries (LEVIs), may clarify these disparities.

METHODS

The National Trauma Data Bank (NTDB; version 7.0, American College of Surgeons) was used for this study. LEVIs were identified using codes from the International Classification of Diseases, 9th revision. Univariate and multivariate analyses were performed using Stata software (version 11; StataCorp, LP, College Station, TX).

RESULTS

Records were reviewed for 4,928 LEVI patients. The mechanism of injury was blunt in 2,452 (49.8%), penetrating in 2,452 (49.8%), and unknown in 24 cases (0.5%). Mortality was similar by mechanism (7.6% overall). Regression analysis using mechanism as a covariate revealed a significantly worse mortality for people of color (POC; odds ratio [OR], 1.45; 95% confidence interval [CI], 1.03-2.02; P = .03) and the uninsured (UN; OR, 1.62; 95% CI, 1.15-2.23; P = .006). However, when separate analyses were performed stratifying by mechanism, no significant mortality disparities were found for blunt trauma (POC OR, 1.28; 95% CI, 0.85-1.96; P = .23; UN OR, 1.33; 95% CI, 0.78-2.22; P = .29), but disparities remained for penetrating trauma (POC OR, 1.81; 95% CI, 0.93-3.57; P = .08; UN OR, 1.85; 95% CI, 1.18-2.94; P = .009).

CONCLUSION

For patients with LEVI, mortality disparities based on race or insurance status were only observed for penetrating trauma. It is possible that injury heterogeneity or patient cohort differences may partly explain mortality disparities that have been observed between racial and socioeconomic groups.

Barriers to evaluation and wait listing for kidney transplantation

BACKGROUND AND OBJECTIVES

Many factors have been shown to be associated with ESRD patient placement on the waiting list and receipt of kidney transplantation. Our study aim was to evaluate factors and assess the interplay of patient characteristics associated with progression to transplantation in a large cohort of referred patients from a single institution.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We examined 3029 consecutive adult patients referred for transplantation from 2003 to 2008. Uni- and multivariable logistic models were used to assess factors associated with progress to transplantation including receipt of evaluations, waiting list placement, and receipt of a transplant.

RESULTS

A total of 56%, 27%, and 17% of referred patients were evaluated, were placed on the waiting list, and received a transplant over the study period, respectively. Older age, lower median income, and noncommercial insurance were associated with decreased likelihood to ascend steps to receive a transplant. There was no difference in the proportion of evaluations between African Americans (57%) and Caucasians (56%). Age-adjusted differences in waiting list placement by race were attenuated with further adjustment for income and insurance. There was no difference in the likelihood of waiting list placement between African Americans and Caucasians with commercial insurance.

CONCLUSIONS

Race/ethnicity, age, insurance status, and income are predominant factors associated with patient progress to transplantation. Disparities by race/ethnicity may be largely explained by insurance status and income, potentially suggesting that variable insurance coverage exacerbates disparities in access to transplantation in the ESRD population, despite Medicare entitlement.

Persistent racial disparities in survival after heart transplantation

BACKGROUND

Racial and ethnic disparities are well documented in many areas of health care, but have not been comprehensively evaluated among recipients of heart transplants.

METHODS AND RESULTS

We performed a retrospective cohort study of 39075 adult primary heart transplant recipients from 1987 to 2009 using national data from the United Network of Organ Sharing and compared mortality for nonwhite and white patients using the Cox proportional hazards model. During the study period, 8082 nonwhite and 30 993 white patients underwent heart transplantation. Nonwhite heart transplant recipients increased over time, comprising nearly 30% of transplantations since 2005. Nonwhite recipients had a higher clinical risk profile than white recipients at the time of transplantation, but had significantly higher posttransplantation mortality even after adjustment for baseline risk. Among the nonwhite group, only black recipients had an increased risk of death compared with white recipients after multivariable adjustment for recipient, transplant, and socioeconomic factors (hazard ratio, 1.34; 95% confidence interval, 1.21 to 1.47; P<0.001). Five-year mortality was 35.7% (95% confidence interval, 35.2 to 38.3) among black and 26.5% (95% confidence interval, 26.0 to 27.0) among white recipients. Black patients were more likely to die of graft failure or a cardiovascular cause than white patients, but less likely to die of infection or malignancy. Although mortality decreased over time for all transplant recipients, the disparity in mortality between blacks and whites remained essentially unchanged.

CONCLUSIONS

Black heart transplant recipients have had persistently higher mortality than whites recipients over the past 2 decades, perhaps because of a higher rate of graft failure.

Racial disparity in access to cardiac intensive care over 20 years

OBJECTIVES

The purposes of this article are: (1) to systematically examine racial disparities in access to and use of cardiac care units (CCUs) in acute-care hospitals; and (2) to assess racial differences in post-hospital mortality following CCU stays.

DESIGN

Data from the National Health and Nutrition Examination Survey I: Epidemiologic Follow-up Study of adults aged 25 and older at baseline are analyzed to track CCU use and survival after hospitalization over 20 years (N=4227). Estimates are derived from Cox proportional-hazards models with time-dependent covariates and from negative binomial and tobit regression analyses. All analyses adjust for disease severity, hospitalization history, and resources.

RESULTS

Black adults were less likely than White adults to be admitted to a CCU, even after adjusting for morbidities, health behaviors, previous hospitalization experience, and socioeconomic status. Comparing Black and White adults admitted to CCUs, Black adults spent fewer days and a smaller proportion of their hospital stay in CCUs. Black adults also had fewer CCU stays over the 20-year period and were more likely to die post-discharge, although the latter result was mediated by disease severity.

CONCLUSIONS

Higher morbidity, lower admission rates, fewer stays, and shorter stays reveal that racial inequality is far-reaching and exists even in such highly-specialized units as CCUs. The fact that Black individuals' greater post-discharge mortality was mediated by disease severity illustrated that even among high-risk individuals, the accumulation of morbidity factors (beyond cardiac problems) is a salient concern. Overall findings demonstrate that the accumulation of disadvantage for Black adults is not confined to discretionary medical measures, but also exists in critical care for serious health problems.

Relation of race, ethnicity and cardiac surgeons to operative mortality rates in primary coronary artery bypass grafting in California

The aim of this study was to evaluate whether African American, Hispanic, and Asian patients in California were more likely to undergo coronary artery bypass grafting (CABG) by cardiac surgeons with higher risk-adjusted mortality rates (RAMRs). Clinical data from the California CABG Outcomes Reporting Program were analyzed for all patients who underwent isolated CABG from 2003 to 2006 by surgeons who performed ≥ 10 operations. Surgeons were divided into quintiles on the basis of their RAMRs, with the top-performing surgeons in the first quintile and the lowest performing surgeons in the fifth quintile. There were 72,845 isolated CABG procedures performed by 303 surgeons, including 49,886 in white, 9,380 in Hispanic, 6,867 in Asian, and 2,750 in African American patients. African American and Asian patients underwent CABG by surgeons with higher mean RAMRs (2.90% and 2.99%, respectively) compared with the state average of 2.65% (p <0.001). Compared to white patients, Asian and Hispanic patients were more likely to be treated by surgeons in the lowest quintile (odds ratio [OR] 1.2, 95% confidence interval [CI] 1.11 to 1.3, and OR 1.38, 95% CI 1.30 to 1.48, respectively). African Americans and Hispanics were less likely to be operated on by surgeons in the top quintile compared to white patients (OR 0.80, 95% CI 0.71 to 0.90, and OR 0.81, 95% CI 0.76 to 0.87, respectively). Hispanics were less likely to be treated by surgeons in the top quintile than by surgeons in the lowest quintile (OR 0.65, 95% CI 0.60 to 0.75). In conclusion, racial and ethnic minority patients who undergo isolated CABG in California may be more likely to be operated on by cardiac surgeons with higher RAMRs.

Exploring the role of the built and social neighborhood environment in moderating stress and health

BACKGROUND

Health researchers have explored how different aspects of neighborhood characteristics contribute to health and well-being, but current understanding of built environment factors is limited.

PURPOSE

This study explores whether the association between stress and health varies by residential neighborhood, and if yes, whether built and social neighborhood environment characteristics act as moderators.

METHODS

This study uses multilevel modeling and variables derived from geospatial data to explore the role of neighborhood environment in moderating the association of stress with health. Individual-level data (N = 4,093) were drawn from residents of 45 neighborhoods within Philadelphia County, PA, collected as part of the 2006 Philadelphia Health Management Corporation's Household Health Survey.

RESULTS

We find that the negative influence of high stress varied by neighborhood, that residential stability and affluence (social characteristics) attenuated the association of high stress with health, and that the presence of hazardous waste facilities (built environment characteristics) moderated health by enhancing the association with stress.

CONCLUSIONS

Our findings suggest that neighborhood environment has both direct and moderating associations with health, after adjusting for individual characteristics. The use of geospatial data could broaden the scope of stress-health research and advance knowledge by untangling the intertwined relationship between built and social environments, stress, and health. In particular, future studies should integrate built environment characteristics in health-related research; these characteristics are modifiable and can facilitate health promotion policies.

Cardiac procedures among American Indians and Alaska Natives compared to non-Hispanic whites hospitalized with ischemic heart disease in California

BACKGROUND

American Indians/Alaska Natives (AIAN) experience a high burden of cardiovascular disease with rates for fatal and nonfatal heart disease approximately twofold higher than the U.S. population.

OBJECTIVE

To determine if disparities exist in cardiac procedure rates among AIAN compared to non-Hispanic whites hospitalized in California for ischemic heart disease defined as acute myocardial infarction or unstable angina.

DESIGN

Cross-sectional study. EVENTS: A total of 796 ischemic heart disease hospitalizations among AIAN and 90971 among non-Hispanic whites in 37 of 58 counties in California from 1998-2002.

MEASUREMENTS

Cardiac catheterization, percutaneous cardiac intervention, and coronary artery bypass graft surgery procedure rates from hospitalization administrative data.

MAIN RESULTS

AIAN did not have lower cardiac procedure rates for cardiac catheterization and percutaneous cardiac intervention compared to non-Hispanic whites (unadjusted OR 1.00, 95% CI 0.87-1.16 and OR 1.04, 95% CI 0.90-1.20, respectively). Adjustment for age, sex, comorbidities, and payer source did not alter the results (adjusted OR 0.95, 95% CI 0.82-1.10 and OR 0.98, 95% CI 0.85-1.14, respectively). We found higher odds (unadjusted OR 1.36, 95% CI 1.09-1.70) for receipt of coronary artery bypass graft surgery among AIAN hospitalized for ischemic heart disease compared to non-Hispanic whites which after adjustment attenuated some and was no longer statistically significant (adjusted OR 1.26, 95% CI 1.00-1.58).

CONCLUSION

AIAN were not less likely to receive cardiac procedures as non-Hispanic whites during hospitalizations for ischemic heart disease. Additional research is needed to determine whether differences in specialty referral patterns, patients' treatment preferences, or outpatient management may explain some of the health disparities due to cardiovascular disease that is found among AIAN.

Predictors of resuming therapy within four weeks after discharge from inpatient rehabilitation

PURPOSE

To identify the percentage of persons with stroke resuming therapy within 4 weeks of inpatient rehabilitation discharge, to compare the characteristics of those who did and did not resume therapy, and to determine the predictors of resuming physical (PT), occupational (OT), and speech (ST) therapy.

METHOD

Sociodemographic, stroke-related, and therapy data for persons with stroke (N = 131) were abstracted from inpatient rehabilitation charts. FIM, Stroke Impact Scale, Geriatric Depression Scale, and data on therapy received after discharge were also collected.

RESULTS

Logistic regression models demonstrated that minorities were less likely to resume PT (odds ratio [OR] = 0.30) and OT (OR = 0.25). Survivors with neglect/visual-field cut/spatial-perceptual loss were 2-3 times more likely to resume PT, OT, and ST. Survivors with higher scores on the SIS Physical domain subscale were less likely to resume PT (OR = 0.98) and OT (OR = 0.97). Men were 3.3 times more likely to have OT than women. Those with comprehensive health insurance were 11.2 times more likely to receive ST.

CONCLUSIONS

The benefits of outpatient therapy are not universally available to all persons with stroke. Further research needs to explore the factors that hinder the prompt resumption of therapy for minority and female persons with stroke and to test appropriate interventions.

Racial and ethnic disparities in access to higher and lower quality cardiac surgeons for coronary artery bypass grafting

To determine whether Hispanic and African-American patients are treated by cardiac surgeons with better or worse risk-standardized outcomes than surgeons of white patients, clinical data from the Massachusetts Data Analysis Center Registry were analyzed on all patients who underwent isolated coronary artery bypass grafting (CABG) from 2002 to 2004 by surgeons who performed >or=10 operations. Surgeons were divided into 4 groups based on their risk-standardized 30-day all-cause mortality incidence rates (top decile, top quartile, bottom quartile, and bottom decile). A total of 12,973 isolated CABGs were performed by 56 surgeons for 11,800 whites (91%), 413 Hispanics (3.2%), and 251 African-Americans (1.9%). White patients were more likely to be treated by surgeons in the top decile than by surgeons in the bottom decile (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.07 to 1.76). In contrast, Hispanic patients were almost 3 times more likely to be treated by surgeons in the bottom decile compared with the top decile (OR 2.85, 95% CI 1.82 to 4.47). Compared with whites, Hispanic patients were about 1/2 as less likely to be treated by surgeons in the top decile (OR 0.51, 95% CI 0.35 to 0.75). African-American and white patients were similarly likely to be treated by surgeons in the top- and bottom-quality performance groups. In conclusion, Hispanics undergoing isolated CABG in Massachusetts were more likely to be operated on by cardiac surgeons with higher risk-standardized mortality rates than by surgeons with lower rates.

Pain and prejudice

BACKGROUND

The primary objective of this pilot study is to understand the relationship between physicians' characteristics and physicians' management decisions about pain. The secondary aim is to understand how patient characteristics, including race/ethnicity and socioeconomic status (SES) may affect these treatment decisions in chronic low back pain.

METHODS

We conducted a double-blinded randomized controlled study using a survey instrument. Ninety physicians were randomly allocated one of two scenarios of a patient with chronic low back and lower extremity pain. In one version, the patient is a Caucasian male with Blue Cross health insurance. In the other version, the patient is an African American male with Medicaid. All other aspects of the survey scenarios are identical. The physicians were subsequently presented with questionnaires about their treatment plans. We analyzed the physician demographic variables in addition to patient ethnicity and SES to differentiate which variables affected treatment preferences.

RESULTS

Based on bivariate analysis, physician specialty, gender, ethnicity, and professional status significantly affected treatment plans, including analgesic prescription and referrals for invasive therapy. Patient ethnicity/SES trended toward significance for the prescription of opioids.

CONCLUSION

Our study is the first randomized controlled study assessing patient and treatment variables in the management of chronic pain. It suggests that physicians' demographic variables and perhaps patient demographic variables influence pain management decisions.

Acute myocardial infarction and race, sex, and insurance types: unequal processes of care

Cardiovascular disease is the leading cause of death among men and women in the United States. Georgia's death rate from cardiovascular disease is higher than the national rate. Previous studies have suggested that whites and African Americans do not receive the same processes of care for a first episode of acute myocardial infarction, one of many cardiovascular disease pathologies. Patient's insurance type, race, sex, and whether a patient lives in a rural or urban area have also been suggested as explanations for unequal processes of care for the treatment of acute myocardial infarction. Using diagnosis-related group reimbursement data from an academic medical center in Georgia, this study found independent effects for race (p < .001) and payer status (p = .004), after adjusting for fiscal year. Possible causes for these differences, as well as recommendations for further study, are explored.

Effects of regulation and competition on health care disparities: the case of cardiac angiography in New Jersey

This article evaluates a Certificate of Need (CON) reform in New Jersey that was designed to expand hospital capacity to provide cardiac angiography (CA) and reduce long-standing disparities in access to the procedure. Using data from 1995 to 2004, we find that expanded capacity increased CA utilization overall and did so more rapidly for blacks, leading to a large reduction in the disparity. However, this reduction was not attributable to services provided by new entrants to the CA market, since they were located in mostly white suburban areas. Instead, the new entrants cut into the incumbents' share of white CA patients who had previously traveled from the suburbs to receive the procedure at inner-city incumbent hospitals. As a result, it appears that incumbents were forced to serve more black patients in their local area to maintain their CA volume. These findings suggest that prior restrictions on CA capacity contributed to the historical disparity in access to the procedure.

How to engage the Latino or African American patient with benign prostatic hyperplasia: crossing socioeconomic and cultural barriers

Disparities based on race and ethnicity still exist in the US healthcare system. Such disparities are reflected in the diagnosis and treatment of benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) among African Americans and Latinos. The prevalence of risk factors for BPH and LUTS and symptom progression are higher in these populations, but treatment is less common. African American men and Latinos frequently have other serious comorbidities, such as cardiovascular disease, diabetes mellitus, and metabolic syndrome. Health plan constraints and variabilities, race/ethnicity, socioeconomic status, language, healthcare-seeking behaviors, and cultural beliefs and practices influence the treatment of BPH and LUTS, oftentimes resulting in unequal access to care or inferior quality of care. The provision of nondiscriminatory treatment poses a challenge to clinicians that can partially be addressed by improving the cultural competence of practitioners in minority communities. An awareness of the customs and healing traditions of African Americans and Latinos may also facilitate culturally appropriate care and improve outcomes, and the participation of clinicians in continuing education/professional development programs to increase knowledge about minority health issues is recommended. Conversely, improving the health literacy of African American and Latino patients with BPH and LUTS can help avoid ineffective nontraditional methods of treatment.

Health disparities and health-seeking behavior among Latino men: a review of the literature

Many studies examining Latino health-seeking behavior have focused on comparing Latinos with other ethnic groups, primarily with Whites and African Americans. However, without the benefit of intragroup or intracultural comparisons, such studies fail to identify the subtle variation in health-seeking strategies and the range of needs within the Latino ethnic group, and thus are compromised in their capacity to guide and improve practice and policy. This article reviews the literature regarding health-seeking behavior and Latino men. Important factors identified include gender, occupation, and responsiveness of the health care system along with characteristics of the individual.

Is lower 30-day mortality posthospital admission among blacks unique to the Veterans Affairs health care system?

BACKGROUND

Several studies have reported lower risk-adjusted mortality for blacks than whites within the Veterans Affairs (VA) health care system, particularly for those age 65 and older. This finding may be a result of the VA's integrated health care system, which reduces barriers to care through subsidized comprehensive health care services. However, no studies have directly compared racial differences in mortality within 30 days of hospitalization between the VA and non-VA facilities in the US health care system.

OBJECTIVE

To compare risk-adjusted 30-day mortality for black and white males after hospital admission to VA and non-VA hospitals, with separate comparisons for patients younger than age 65 and those age 65 and older.

RESEARCH DESIGN

Retrospective observational study using hospital claims data from the national VA system and all non-VA hospitals in Pennsylvania and California.

SUBJECTS

A total of 369,155 VA and 1,509,891 non-VA hospitalizations for a principal diagnosis of pneumonia, congestive heart failure, gastrointestinal bleeding, hip fracture, stroke, or acute myocardial infarction between 1996 and 2001.

MEASURES

Mortality within 30 days of hospital admission.

RESULTS

Among those under age 65, blacks in VA and non-VA hospitals had similar odds ratios of 30-day mortality relative to whites for gastrointestinal bleeding, hip fracture, stroke, and acute myocardial infarction. Among those age 65 and older, blacks in both VA and non-VA hospitals had significantly reduced odds of 30-day mortality compared with whites for all conditions except pneumonia in the VA. The differences in mortality by race are remarkably similar in VA and non-VA settings.

CONCLUSIONS

These findings suggest that factors associated with better short-term outcomes for blacks are not unique to the VA.

Is thirty-day hospital mortality really lower for black veterans compared with white veterans?

OBJECTIVE

To examine the source of observed lower risk-adjusted mortality for blacks than whites within the Veterans Affairs (VA) system by accounting for hospital site where treated, potential under-reporting of black deaths, discretion on hospital admission, quality improvement efforts, and interactions by age group.

DATA SOURCES

Data are from the VA Patient Treatment File on 406,550 hospitalizations of veterans admitted with a principal diagnosis of acute myocardial infarction, stroke, hip fracture, gastrointestinal bleeding, congestive heart failure, or pneumonia between 1996 and 2002. Information on deaths was obtained from the VA Beneficiary Identification Record Locator System and the National Death Index.

STUDY DESIGN

This was a retrospective observational study of hospitalizations throughout the VA system nationally. The primary outcome studied was all-location mortality within 30 days of hospital admission. The key study variable was whether a patient was black or white.

PRINCIPAL FINDINGS

For each of the six study conditions, unadjusted 30-day mortality rates were significantly lower for blacks than for whites (p<.01). These results did not vary after adjusting for hospital site where treated, more complete ascertainment of deaths, and in comparing results for conditions for which hospital admission is discretionary versus non-discretionary. There were also no significant changes in the degree of difference by race in mortality by race following quality improvement efforts within VA. Risk-adjusted mortality was consistently lower for blacks than for whites only within the population of veterans over age 65.

CONCLUSIONS

Black veterans have significantly lower 30-day mortality than white veterans for six common, high severity conditions, but this is generally limited to veterans over age 65. This differential by age suggests that it is unlikely that lower 30-day mortality rates among blacks within VA are driven by treatment differences by race.

Racial and ethnic disparities in mortality following congenital heart surgery

Our objective was to assess risk-adjusted racial and ethnic disparities in mortality following congenital heart surgery. We studied 8483 congenital heart surgical cases from the Kids' Inpatient Database 2000. Black sub-analysis was performed using predetermined regional categories. For our Hispanic sub-analyses, we categorized Hispanics into state groups according to a state's predominant Hispanic group: West (Mexican-American), Southeast (Cuban-American), Northeast (Puerto Rican), and Mixed/Heterogeneous. Risk adjustment was performed using the Risk Adjustment for Congenital Heart Surgery method. Multivariate analyses assessed the effect of race/ethnicity and Hispanic state group on mortality and explored the effects of gender, income, insurance type, and region. Black children had a higher risk for death than Whites odds ratio (OR), [1.65; p = 0.003]. Hispanics and the Cuban-American state group showed a trend toward a higher death risk (Hispanic: OR, 1.24; p = 0.16; Southeast Cuban-American: OR 1.55; p = 0.08). Disparities were not influenced by insurance. Among Blacks, disparities were greatest in the Northeast region (OR, 2.25; p = 0.007). After adjusting for gender, income, and region, Blacks (OR, 1.76; p = 0.002) and Hispanics (OR, 1.34; p = 0.05) had a higher death risk. Racial and ethnic disparities in risk-adjusted mortality following congenital heart disease exist for Blacks and Hispanics. These disparities are not due to insurance but are partially explained by gender and region.

Racial/ethnic variations in veterans' ambulatory care use

OBJECTIVES

We assessed racial/ethnic variations in patterns of ambulatory care use among Department of Veterans Affairs (VA) health care-eligible veterans to determine if racial/ethnic differences in health care use persist in equal-access systems.

METHODS

We surveyed 3227 male veterans about their health and ambulatory care use.

RESULTS

Thirty-eight percent of respondents had not had a health care visit in the previous 12 months. Black (odds ratio [OR] = 0.5), Hispanic (OR = 0.4), and Asian/Pacific Islander veterans (OR=0.4) were less likely than White veterans to report any ambulatory care use. Alternately, Whites (OR=2.2) were more likely than other groups to report ambulatory care use. Being White was a greater predictor of health care use than was having fair or poor health (OR=1.4) or functional limitations (OR=1.5). In non-VA settings, racial/ethnic minorities were less likely to have a usual provider of health care. There was no VA racial/ethnic variation in this parameter.

CONCLUSIONS

Racial/ethnic disparities in health and health care use are present among VA health care-eligible veterans. Although the VA plays an important role in health care delivery to ethnic minority veterans, barriers to VA ambulatory care use and additional facilitators for reducing unmet need still need to be investigated.

Mortality after acute myocardial infarction in hospitals that disproportionately treat black patients

BACKGROUND

African Americans are more likely to be seen by physicians with less clinical training or to be treated at hospitals with longer average times to acute reperfusion therapies. Less is known about differences in health outcomes. This report compares risk-adjusted mortality after acute myocardial infarction (AMI) between US hospitals with high and low fractions of elderly black AMI patients.

METHODS AND RESULTS

A prospective cohort study was performed for fee-for-service Medicare patients hospitalized for AMI during 1997 to 2001 (n=1,136,736). Hospitals (n=4289) were classified into approximate deciles depending on the extent to which the hospital served the black population. Decile 1 (12.5% of AMI patients) included hospitals without any black AMI admissions during 1997 to 2001. Decile 10 (10% of AMI patients) included hospitals with the highest fraction of black AMI patients (33.6%). The main outcome measures were 90-day and 30-day mortality after AMI. Patients admitted to hospitals disproportionately serving blacks experienced no greater level of morbidities or severity of the infarction, yet hospitals in decile 10 experienced a risk-adjusted 90-day mortality rate of 23.7% (95% CI 23.2% to 24.2%) compared with 20.1% (95% CI 19.7% to 20.4%) in decile 1 hospitals. Differences in outcomes between hospitals were not explained by income, hospital ownership status, hospital volume, census region, urban status, or hospital surgical treatment intensity.

CONCLUSIONS

Risk-adjusted mortality after AMI is significantly higher in US hospitals that disproportionately serve blacks. A reduction in overall mortality at these hospitals could dramatically reduce black-white disparities in healthcare outcomes.

Operative and late coronary artery bypass grafting outcomes in matched African-American versus Caucasian patients: evidence of a late survival-Medicaid association

OBJECTIVES

This study sought to determine whether African-American versus Caucasian race is a determinant of early or late coronary artery bypass surgery (CABG) outcomes.

BACKGROUND

African Americans are referred to CABG less frequently than Caucasians and Medicaid coverage is disproportionately common among those who are referred. How these factors affect the relative early and late CABG outcomes in these groups is incompletely elucidated.

METHODS

A retrospective cohort comparison of operative and 12-year outcomes for 304 African-American and 6,073 Caucasian consecutive patients who underwent isolated CABG (1991 to 2003) at an urban community hospital was used. Results were further confirmed in propensity-matched subgroups (n = 301 each).

RESULTS

African Americans were younger (62 vs. 64 years, median), more were female (46% vs. 30%), more were on Medicaid (29% vs. 6.3%) and had more comorbidities. These differences were eliminated after matching. A total of 161 operative and 1,080 late deaths have been documented. Operative mortality was similar (African American versus Caucasian: 3.0% vs. 2.5%; p = 0.81). Unadjusted Kaplan-Meier survival at 1, 5, and 10 years (93.4%, 80.3%, and 66.1% vs. 94.8%, 86.5%, and 71.7%) was worse in African Americans (hazard ratio [HR] = 1.38; p = 0.004), but similar for matched groups (HR = 1.03; p = 0.97). After risk adjustment, race did not predict operative (odds ratio = 1.17; p = 0.69) or late (HR = 1.15; p = 0.28) mortality. However, Medicaid status (HR = 1.54; p < 0.005) predicted worse survival, which was verified in a case-matched Medicaid (n = 469) versus non-Medicaid analysis. The latter showed that in younger Medicaid patients without companion Medicare coverage, late mortality was nearly doubled (HR = 1.96; p = 0.003) with systematically increasing death hazard after the second year.

CONCLUSIONS

African-American race per se is not associated with worse operative or late outcomes underscoring that CABG should be based on clinical characteristics only. Alternatively, Medicaid status, which is more prevalent among African Americans, is associated with worse late survival, especially in non-Medicare patients. Studies are needed to elucidate this late Medicaid-CABG outcome association.

Carotid endarterectomy in older women and men in the United States: trends in ethnic disparities

Trends in utilization of carotid endarterectomy (CEA) among elderly ethnic minorities have received little attention. Data from the U.S. Centers for Medicare and Medicaid Services were examined for the years 1990 through 2000. In women and men, the rate of CEA per 100,000 non-HMO beneficiaries aged > or = 65 years increased in African Americans and in European Americans between 1990 and 1995, with only small changes thereafter. Between 1990 and 2000, the ratio of rates in European Americans to those in African Americans have decreased slightly, i.e., in women from 2.63 in 1990 to 2.24 (15%) in 2000 and in men from 3.94 to 3.39 (14%). Large ethnic differences in utilization of CEA persist in the elderly requiring further evaluation.

Perceived discrimination and reported delay of pharmacy prescriptions and medical tests

BACKGROUND

Access to health care varies according to a person's race and ethnicity. Delaying treatment is one measure of access with important health consequences.

OBJECTIVE

Determine whether perceptions of unfair treatment because of race or ethnicity are associated with reported treatment delays, controlling for economic constraints, self-reported health, depression, and demographics.

DESIGN

Cross-sectional, observational study.

PARTICIPANTS

A randomly selected community sample of 181 blacks, 148 Latinos, and 193 whites in Durham County, NC.

MEASUREMENTS

A phone survey conducted in 2002 to assess discrimination, trust in medical care, quality of care, and access to care. Treatment delays were measured by whether or not a person reported delaying or forgoing filling a prescription and delaying or forgoing having a medical test/treatment in the past 12 months. Perceived discrimination was measured as unfair treatment in health care and as racism in local health care institutions.

RESULTS

The odds of delaying filling prescriptions were significantly higher (odds ratio (OR)=2.02) for persons who perceived unfair treatment, whereas the odds of delaying tests or treatments were significantly higher (OR=2.42) for persons who thought racism was a problem in health care locally. People with self-reported depression and people who reported not working had greater odds of delaying both types of care.

CONCLUSIONS

A prospective cohort study with both personal and macro measures of discrimination, as well as more refined measures of treatment delays, would help us better understand the relationship between perceived discrimination and treatment delays.

Racial and ethnic disparities in cardiac catheterization for acute myocardial infarction in the United States, 1995--2001

OBJECTIVE

To examine recent trends in racial and ethnic disparities in cardiac catheterization for acute myocardial infarction (AMI) to determine whether disparities documented from the 1980s through mid-1990s persist, and evaluate whether patient and hospital characteristics are associated with any observed disparities

METHODS

Cross-sectional analyses of 585,710 white, 51,369 black and 31,923 Hispanic discharges from hospitals in the Nationwide Inpatient Sample (which includes data on all discharges from 951 representative hospitals in 23 states) that had performed cardiac catheterization from 1995--2001 with a primary diagnosis of AMI. Adjusted procedure rates and prevalence ratios (PR) were computed to compare catheterization rates by race and ethnicity.

MEASUREMENTS AND MAIN RESULTS

Catheterization rates were higher for whites than blacks for all years examined; rates among Hispanics increased during this period and approached the rate among whites. After adjustment for age, demographics, comorbidity, year and hospital characteristics, rates (per 100 discharges) were 58.4 for whites, 50.1 for blacks (PR 0.87; 95% CI 0.84-0.91) and 55.2 for Hispanics (PR 0.95; 95% CI 0.90-0.99).

CONCLUSIONS

These nationwide data suggest blacks remain less likely than whites and Hispanics to undergo catheterization during a hospitalization for AMI. Whether this disparity stems from patient or provider factors remains to be determined.

Hematopoietic stem cell transplantation among patients with leukemia of all ages in Texas

BACKGROUND

Hematopoietic stem cell transplantation (HSCT) is an effective but expensive medical procedure to which some ethnic minorities, the elderly, and those without insurance have been shown to have limited access. The purpose of the current study was to determine whether socioeconomic factors were associated with HSCT usage rates in patients with leukemia.

METHODS

The authors identified 6574 patients with acute lymphocytic leukemia, chronic lymphocytic leukemia, acute myelogenous leukemia, chronic myelogenous leukemia, or other leukemias from the 1999 Texas Hospital Inpatient Discharge Public Use Data File. Of these patients, 1604 received an autologous or allogeneic HSCT. The authors assessed patients' ethnicity, payer status, age, gender, and comorbid medical conditions. Logistic regression was used to control for patient characteristics and to evaluate associations among payer status, ethnicity, and HSCT use. P < or = 0.05 indicated statistical significance.

RESULTS

Patients who self-paid had the highest rate of HSCT use in all age groups (32%; P < or = 0.01) and in the adult group (36%; P = 0.11). Elderly patients with Medicare had a low rate of HSCT use (17%; P = 0.13). Logistic regression showed no statistically significant associations between payer status or ethnicity and HSCT use. However, elderly women were significantly less likely to undergo HSCT than elderly men (odds ratio, 0.34; P < or = 0.01).

CONCLUSIONS

The lack of statistically significant differences in HSCT use among adult patients with leukemia was surprising because previous studies had shown differences in HSCT by ethnicity and insurance.

Effects of Race on Mortality and Use of Hospital Services in Maryland, 1998

This study analyzes administrative data from the Maryland Health Services Cost Review Commission to compare differences by race in the use of 17 major procedures performed in hospitals and the corresponding mortality rates. African Americans discharged from Maryland hospitals were less likely than whites to have received most of these procedures while hospitalized. The largest differences were seen for "referral sensitive surgeries" such as percutaneous transluminal coronary angioplasty, coronary artery bypass graft surgery, total knee replacement, and total hip replacement. In contrast, African Americans were found to have substantially higher rates than white patients in the use of four procedures performed in the hospital: amputation of part of the lower limb, surgical debridement, arteriovenostomy, and bilateral orchiectomy. The types of procedures for which African American hospital patients have higher rates raise questions about whether there is a need for more comprehensive and continuous follow-up care with primary care physicians for the underlying health conditions associated with these procedures.

Race and patient refusal of invasive cardiac procedures

OBJECTIVE

To determine whether patients' decisions are an important determinant of nonuse of invasive cardiac procedures and whether decisions vary by race.

DESIGN

Observational prospective cohort.

PARTICIPANTS

Patients (N= 681) enrolled at the exercise treadmill or the cardiac catheterization laboratories at a large Veterans Affairs hospital.

MEASURES

Doctors' recommendations and patients' decisions were determined by both direct observation of doctor and patient verbal behavior and by review of medical charts. Performance of coronary angiography, angioplasty, and bypass surgery were determined by chart review for a minimum of 3 months follow-up.

RESULTS

Coronary angiography was recommended after treadmill testing for 83 of 375 patients and 72 patients underwent angiography. Among 306 patients undergoing angiography, recommendations for coronary angioplasty or bypass surgery were given to 113 and 45 patients and were completed for 98 and 33 patients, respectively. Recommendations were not significantly different by race. However, 4 of 83 (4.8%) patients declined or did not return for recommended angiograms and this was somewhat more likely among black and Hispanic patients, compared with white patients (13% and 33% vs 2%; P =.05). No patients declined angioplasty and 2 of 45 (4.4%) patients declined or did not return for recommended bypass surgery. Other recommended procedures were not completed after further medical evaluation (n = 32). There was no difference (P >.05) by race/ethnicity in doctor-level reasons for nonreceipt of recommended invasive cardiac procedures.

CONCLUSIONS

Patient decisions to decline recommended invasive cardiac procedures were infrequent and may explain only a small fraction of racial disparities in the use of invasive cardiac procedures.

Are there race/ethnicity differences in outpatient congestive heart failure management, hospital use, and mortality among an insured population?

OBJECTIVE

The objective of this study was to assess the quality of outpatient care received by patients with congestive heart failure (CHF) and whether differences in care and outcomes exist by race/ethnicity.

BACKGROUND

Appropriate outpatient CHF management can improve patient well-being and reduce the need for costly inpatient care. Yet, little is known regarding outpatient CHF management or whether differences in this care exist by race/ethnicity.

METHODS

Using automated data sources, we identified a cohort of insured patients seen in an outpatient setting for CHF between September 1992 and August 1993. Medical record abstraction was used to confirm diagnosis of CHF. Patients (N = 566) were followed until September 1998. Race/ethnicity differences in outpatient management and medical care utilization were assessed using generalized estimating equations. Differences in mortality and hospitalization for CHF, controlling for patient characteristics and outpatient management, were assessed using Cox and Andersen-Gill models, respectively.

RESULTS

With the exception of beta blocker use and primary care visit frequency, few differences by race/ethnicity in patient characteristics and CHF management were found. However, older black patients had more hospital use both at baseline and during follow up. These differences persisted after adjusting for patient characteristics and clinical management. No race/ethnicity differences were found in mortality.

CONCLUSIONS

In an insured population, older black patients with CHF have substantially more hospital use than older white patients. This increased use was not explained by differences in CHF outpatient management. Further research is needed to understand why race/ethnicity differences in hospital use are observed among older patients with CHF.