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Factors Associated With Racial Differences in Myocardial Infarction Outcomes

John A. Spertus, MD, MPH; Philip G. Jones, MS; Frederick A. Masoudi, MD, MSPH; John S. Rumsfeld, MD, PhD; and Harlan M. Krumholz, MD, SM
[+] Article and Author Information

For a list of members of the Cardiovascular Outcomes Research Consortium who participated in this study, see the Appendix.


From the Mid America Heart Institute of Saint Luke's Hospital and University of Missouri–Kansas City, Kansas City, Missouri; Denver Health Medical Center, University of Colorado at Denver Health Sciences Center, and Denver Veterans Affairs Medical Center, Denver, Colorado; and Yale–New Haven Hospital and Yale University School of Medicine, New Haven, Connecticut.


Acknowledgment: The authors thank Peter Austin, PhD.

Grant Support: By the National Heart, Lung, and Blood Institute Specialized Center of Clinically Oriented Research in Cardiac Dysfunction and Disease (grant no. P50 HL077113); CV Therapeutics, Palo Alto, California; and Cardiovascular Outcomes, Kansas City, Missouri.

Potential Financial Conflicts of Interest:Honoraria: F.A. Masoudi (United Healthcare). Other: J.A. Spertus (copyright holder, Seattle Angina Questionnaire).

Reproducible Research Statement:Study protocol, statistical code, and data set: Available from Dr. Spertus (Spertusj@umkc.edu).

Requests for Single Reprints: John A. Spertus, MD, MPH, Mid America Heart Institute, 4401 Wornall Road, 5th Floor, Kansas City, MO 64111; e-mail, Spertusj@umkc.edu.

Current Author Addresses: Dr. Spertus and Mr. Jones: Mid America Heart Institute, 4401 Wornall Road, 5th Floor, Kansas City, MO 64111.

Dr. Masoudi: Colorado Health Outcomes Program, 12477 East 19th Street, Building 406, 2nd Floor West Wing, Aurora, CO 80010.

Dr. Rumsfeld: Denver Veterans Affairs Medical Center, 1055 Clermont Street, Cardiology, Room 111 B, Denver, CO 80220.

Dr. Krumholz: 333 Cedar Street, Room IE-61SHM, New Haven, CT 06520.

Author Contributions: Conception and design: J.A. Spertus, P.G. Jones, J.S. Rumsfeld, H.M. Krumholz.

Analysis and interpretation of the data: J.A. Spertus, P.G. Jones, F.A. Masoudi, J.S. Rumsfeld, H.M. Krumholz.

Critical revision of the article for important intellectual content: J.A. Spertus, P.G. Jones, F.A. Masoudi, J.S. Rumsfeld, H.M. Krumholz.

Final approval of the article: J.A. Spertus, P.G. Jones, F.A. Masoudi, J.S. Rumsfeld, H.M. Krumholz.

Provision of study materials or patients: H.M. Krumholz.

Statistical expertise: P.G. Jones.

Obtaining of funding: H.M. Krumholz.

Administrative, technical, or logistic support: H.M. Krumholz.

Collection and assembly of data: J.A. Spertus, F.A. Masoudi, J.S. Rumsfeld, H.M. Krumholz.


Ann Intern Med. 2009;150(5):314-324. doi:10.7326/0003-4819-150-5-200903030-00007
Text Size: A A A

Background: Little information is available about factors associated with racial differences across a broad spectrum of post–myocardial infarction outcomes, including patients' symptoms and quality of life.

Objective: To determine racial differences in mortality, rehospitalization, angina, and quality of life after myocardial infarction and identify the factors associated with these differences.

Design: Prospective cohort study.

Setting: 10 hospitals in the United States.

Patients: 1849 patients who had myocardial infarction, 28% of whom were black.

Measurements: Demographic, economic, clinical, psychosocial, and treatment characteristics and outcomes were prospectively collected. Outcomes included time to 2-year all-cause mortality, 1-year rehospitalization, and Seattle Angina Questionnaire–assessed angina and quality of life.

Results: Black patients had higher unadjusted mortality (19.9% vs. 9.3%; P < 0.001) and rehospitalization rates (45.4% vs. 40.4%; P = 0.130), more angina (28.0% vs. 17.8%; P < 0.001), and worse mean quality of life (80.6 [SD, 22.5] vs. 85.9 [SD, 17.2]; P < 0.001). After adjustment for patient characteristics, black patients trended toward greater mortality (hazard ratio, 1.29 [95% CI, 0.92 to 1.81]; P = 0.142), fewer rehospitalizations (hazard ratio, 0.82 [CI, 0.66 to 1.02]; P = 0.071), and higher likelihood of angina at 1 year (odds ratio, 1.41 [CI, 1.03 to 1.94]; P = 0.032) but similar quality of life (mean difference, −0.6 [CI, −3.4 to 2.2]). Adjustment for site of care further attenuated mortality differences (hazard ratio, 1.04 [CI, 0.71 to 1.52]; P = 0.84). Adjustment for treatments had minimal effect on any association.

Limitation: Residual confounding and missing data may have introduced bias.

Conclusion: Although black patients with myocardial infarction have worse outcomes than white patients, these differences did not persist after adjustment for patient factors and site of care. Further adjustment for treatments received minimally influenced observed differences. Strategies that focus on improving baseline cardiac risk and hospital factors may do more than treatment-focused strategies to attenuate racial differences in myocardial infarction outcomes.

Funding: The National Heart, Lung, and Blood Institute Specialized Center of Clinically Oriented Research in Cardiac Dysfunction and Disease, CV Therapeutics, and Cardiovascular Outcomes.

Figures

Grahic Jump Location
Figure.
Racial differences in post–myocardial infarction outcomes.

SAQ = Seattle Angina Questionnaire.

Grahic Jump Location

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Comments

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Unequal Treatment
Posted on March 10, 2009
James R Webster
Feinberg School of Medicine of Northwestern University
Conflict of Interest: None Declared

To the Editor: Data in the paper by Spertus et. al. (1) confirms the findings of many other studies demonstrating that Black patients with heart disease receive lower quality care than Whites. The authors document major care disparities with Black patients getting significantly fewer diagnostic catheterizations and revascularizations and less discharge counseling regarding smoking cessation and exercise, all at P values of < 0.0001! Contrary to current dogma do the authors honestly believe that these interventions have no value and that the differences in health outcomes in the Black and White study populations were simply due to "cardiac risk factors"? If so we must seriously reconsider our approach to all our patients with myocardial infarction. In any case one of the conclusions of their research should be that there is still a great deal of unequal treatment (2) going on in the U.S. today.

References

1. Spertus JA, Jones PG, Masoudi FA et. al. Factors associated with racial differences in myocardial infarction outcomes. Ann Intern Med 2009;150:314-324.

2. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington DC: National Academies Pr. 2003

Conflict of Interest:

None declared

The causality of racial differences and myocardial infarction outcomes
Posted on March 15, 2009
Yu Han
Xijing Hospital, Fourth Military Medical University
Conflict of Interest: None Declared

To the editor:

We read with great interest the excellent paper by Dr Spertus JA and colleagues (1), in which the authors drew a conclusion that black patients with myocardial infarction have worse outcomes than white patients.

Although the study was potentially clinically directive, we would like to express 2 concerns. First, since the white patients were predominantly men, extrapolation of the findings to women must be done with caution. Furthermore, there might be enrollment bias for 2 groups due to different proportation of males. Second, the fundamental question of causality between racial differences and myocardial infarction outcomes could not be answered in this observational study. Thus, before one speculated about the putative mechanisms underlying the observed survival advantage of white race over black, perhaps one should firstly investigate the reason behind the unsignificant differences between 2 groups after adjustment for patient factors and site of care.

References:

1 Spertus JA, Jones PG, Masoudi FA, et al. Factors associated with racial differences in myocardial infarction outcomes. Ann Intern Med. 2009;150(5):314-24.

Conflict of Interest:

None declared

Re: Unequal Treatment
Posted on June 9, 2009
John A. Spertus
Mid America Heart Institute and the University of Missouri-Kansas City
Conflict of Interest: None Declared

Dr. Webster is correct that we found disparities in quality of care by race. The differences were, for the most part, modest in absolute terms and each measure is relevant to only a subset of the patients. For that reason we are not surprised that differences in the quality measures did not have a dominant effect in explaining differences in outcomes among the entire cohort. That observation does not suggest that the indicators are not important to the subset of patients to which they apply or that addressing that disparity is unimportant, but what we do find is that when considering the entire group and the differences in outcomes, that differences in the clinical characteristics of the patients on admission explain much of the difference in outcomes. Nevertheless, we emphatically do support the use of evidence-based therapies in all patients, regardless of race.

Dr. Rhan raised a concern about the representativeness of the enrolled patients and the inferred assumptions of causality between race, or its associated risk factors, and outcomes. With regard to recruitment bias, we previously reported the representativeness of the PREMIER patients by comparing their characteristics with those of the entire population of eligible myocardial infarction patients at our enrolling centers. While not previously described by race, 55.1% of black patients enrolled in our study were male, as compared with 54.1% of the entire black population. We thus feel that it is unlikely that enrollment bias contributed to the larger proportion of blacks who were female as compared with whites.

Conflict of Interest:

None declared

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Summary for Patients

Factors Associated With Differences in Outcomes of Black and White Patients After Heart Attack

The summary below is from the full report titled “Factors Associated With Racial Differences in Myocardial Infarction Outcomes.” It is in the 3 March 2009 issue of Annals of Internal Medicine (volume 150, pages 314-324). The authors are J.A. Spertus, P.G. Jones, F.A. Masoudi, J.S. Rumsfeld, and H.M. Krumholz.

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