Transcript Racial and Ethnic Differences in the Treatment of Acute Myocardial Infarction Findings From Get With The Guidelines®-CAD Program Mauricio G.

Racial and Ethnic Differences in the Treatment
of Acute Myocardial Infarction
Findings From Get With The Guidelines®-CAD
Program
Mauricio G. Cohen, MD; Gregg C. Fonarow, MD;
Eric D. Peterson, MD, MPH; Mauro Moscucci, MD, MBA;
David Dai, MHS; Adrian F. Hernandez, MD, MHS;
Robert O. Bonow, MD; Sidney C. Smith, Jr., MD
Cohen et al. Circulation . ePub May 17, 2010
Disclosures
The Get With The Guidelines– CAD (GWTG-CAD) program is provided
by the American Heart Association/American Stroke Association. The
data analyzed in this manuscript were collected while the GWTG
program was supported in part through an unrestricted educational
grant from Merck.
The individual author disclosures are listed in the manuscript.
Cohen et al. Circulation . ePub May 17, 2010
Background
• The elimination of disparate health care is one of the
principal goals of Healthy People 2010.1
• Research suggests that there are differences in the use
of evidence-based process performance among
racial/ethnic groups.
• The GWTG-CAD quality improvement program may
enhance hospital adherence to quality of care guidelines
whereby improving ethnic and racial disparities.
1. Lillie-Blanton M, Maddox TM, Rushing O, Mensah GA. Disparities in cardiac care: rising to the challenge of Healthy People 2010. J Am Coll
Cardiol. 2004;44:503-508.
Cohen et al. Circulation . ePub May 17, 2010
Introduction
Research has shown that racial and ethnic differences
exist in cardiovascular care. Among patients with acute
coronary syndromes (ACS), minorities are:
• less likely than Caucasians to receive evidencebased care
• more likely to be treated at facilities with lower
adherence to composite measures.1
1. Skinner J, Chandra A, Staiger D, Lee J, McClellan M. Mortality after acute myocardial infarction in hospitals that
disproportionately treat black patients. Circulation. 2005;112:2634-2641.
Cohen et al. Circulation . ePub May 17, 2010
Objectives
• The major goals of the study were to assess the
racial/ethnic differences in individual and
composite core CAD performance measures
and to assess whether a QI program is
associated with decreasing health disparities
over time.
• Also examined was the temporal trend of the
summary “defect-free care” performance
measure in hospitals that treated a greater
proportion of Black or Hispanic patients.
Cohen et al. Circulation . ePub May 17, 2010
Methods
• Data collected: Jan. 2002 and June 2007
• 443 GWTG-CAD- participating hospitals
• 142,593 AMI patients were analyzed (discharge
diagnosis of AMI)
– 121,528 Caucasians
– 10,882 African Americans
– 10,183 Hispanics
• Outcome Sciences, Inc. served as the data collection
and coordination center.
• Duke Clinical Research Institute served as the data
analysis and coordination center.
Cohen et al. Circulation . ePub May 17, 2010
Methods
Areas Examined
• The overall racial/ethnic differences in individual
and composite core CAD performance
measures
• Whether a QI program is associated with
decreasing health disparities over time
• Examine the temporal trend of the summary
“defect-free care”1 performance measure in
hospitals that treat a greater proportion of
African American or Hispanic patients.
1. “defect-free care”, was defined as the proportion of patients that received all interventions for which they were eligible.
Cohen et al. Circulation . ePub May 17, 2010
Core Performance Measures
Assessed
•
Use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin
receptor blockers (ARB) in patients with documented left ventricular systolic
dysfunction
•
Use of aspirin within 24 hours of admission
•
Use of aspirin at discharge
•
Use of beta-blockers at discharge
•
Use of lipid-lowering therapy in patients with low-density lipoprotein (LDL)
cholesterol greater than 100 mg/dL
•
Smoking cessation counseling
•
Composite measure “defect-free care”
•
In addition, the following “quality metrics” were analyzed in eligible patients
presenting with ST-elevation myocardial infarction (STEMI)
– Door-to-balloon time of less or equal than 90 minutes
– Door-to-thrombolysis time of less or equal than 30 minutes
Cohen et al. Circulation . ePub May 17, 2010
Methods:
Statistical Analysis
• Descriptive analyses included comparisons according to
race/ethnicity (Caucasians, African Americans, and Hispanics) for
– demographics, comorbidities, baseline clinical characteristics, clinical
performance measures, invasive procedures, and in-hospital mortality.
• Trends in racial/ethnic differences according to the overall duration
of the program (calendar quarters)
– Each quarter enrolled ≥ 1000 pts to support steadiness of statistical
conclusions
• To examine the association between time, race/ethnicity and
performance measures, multivariable logistic regression was used to
estimate the marginal effects of time and race/ethnicity.
• GEE with exchangeable working correlation structure was used to
account for within-hospital clustering
• To analyze the temporal trend of “defect-free care” in hospitals that
treated a greater proportion of African Americans or Hispanics, we
further divided the study population into quintiles according the
percent of Hispanic and African Americans treated at the site-level
Cohen et al. Circulation . ePub May 17, 2010
Baseline
Characteristics
White
Black
Hispanic
(n=121,528 )
(n=10,882)
(n=10,183)
68 (56,79)
61 (51, 73)
65 (54, 75)
37
45
35
28 (24, 32)
28 (24, 33)
28 (25, 31)
Diabetes (%)
21.7
31.6
37.1
Hypertension (%)
58.9
72.6
64.4
Hyperlipidemia (%)
39.5
34.8
38.9
Smoking (%)
31.0
37.7
27.5
PVD (%)
8.6
8.9
7.5
Prior MI (%)
19.4
19.0
16.6
Prior Stroke (%)
7.4
10.2
7.6
Renal Failure (%)
8.6
14.1
10.2
CHF (%)
13.8
16.8
14.0
Age (yrs)
Female (%)
BMI (%)
N = 142,593
Cohen et al. Circulation . ePub May 17, 2010
Results
• When compared with Caucasian and Hispanic patients, African
Americans were younger, more likely female, and had a higher
prevalence of hypertension, smoking, prior history of stroke, and
renal insufficiency.
• African American and Hispanic patients were significantly more
likely to be uninsured or covered by Medicaid in comparison with
Caucasian patients.
• The geographic distribution of recruitment for the three racial/ethnic
group somewhat paralleled the US census distribution. A large
proportion of African American patients were recruited in the South,
while Hispanic patients were mostly recruited in the Southwest.
• African American patients sought care at facilities that had more
beds, were more likely academic, and had similar interventional and
surgical capabilities compared to the other racial/ethnic groups.
Cohen et al. Circulation . ePub May 17, 2010
Results
• Percutaneous coronary intervention (PCI) was used in
74.3% of the 40,843 ST-elevation myocardial infarction
patients
– 74.7% of whites, 69.5% of blacks, and 73.7% of Hispanics
• Delays in performing primary PCI were significantly
longer in minority patients than in white patients.
– The median door-to-balloon time in minutes was 91 in white
patients, 105 in black patients,102 in Hispanic patients.
• As a consequence of these delays, a lower proportion of
Hispanic and black patients had a door-to-balloon time of
90 minutes than white patients, even after adjustment for
patient and hospital variables
Cohen et al. Circulation . ePub May 17, 2010
Results
• Use of thrombolytic therapy was low and
comparable
– 3.5% in white, 3.4% in black, and 3.9% in Hispanic
patients
• Black patients had greater delays in
thrombolysis administration
– Blacks - median door-to-thrombolysis time - 52
minutes
– Whites - 38 min
– Hispanics - 35 min.
Cohen et al. Circulation . ePub May 17, 2010
STEMI Reperfusion
Quality Metrics
Cohen et al. Circulation . ePub May 17, 2010
Results
• All racial/ethnic groups had a similar median length of
stay of 4 days
• Unadjusted hospital mortality rates were 5.7% for
Caucasian, 5.0% for African American, and 5.5% for
Hispanic patients
• Aspirin (admission & discharge) and Beta Blockers use
was greater than 90% in the three groups
• Black patients had significantly lower use of aspirin at
discharge and of smoking cessation counseling, and
they were less likely to receive defect-free care than
white patients.
Cohen et al. Circulation . ePub May 17, 2010
Individual Performance
Measures
Aspirin within 24 hours
Lipid Lowering Therapy
ACE/ARB for LVSD
Aspirin at Discharge
100
2007q2
Smoking Cessation Advice
100
100
90
90
95
80
80
70
70
90
60
Cohen et al. Circulation . ePub May 17, 2010
2007q2
2006q3
2005q4
2005q1
2004q2
AA vs. C OR: 0.64 (0.36-1.11)
Hisp vs. C OR: 1.14 (0.69-1.86)
2003q3
30
Overall OR: 1.15 (1.11-1.20)
2002q4
2007q2
2006q3
2005q4
80
2005q1
40
2004q2
AA vs. C OR: 1.03 (0.68-1.58)
Hisp vs. C OR: 1.07 (0.69-1.68)
2003q3
50
2002q4
2007q2
2006q3
2005q4
2005q1
2004q2
2003q3
2002q1
40
AA vs. C OR: 1.44 (0.87-2.40)
Hisp vs. C OR: 0.72 (0.42-1.27)
2002q1
50
Overall OR: 1.08 (1.06-1.10)
85
Overall OR: 1.08 (1.06-1.10)
2002q1
60
2002q4
Patients (%)
70
AA vs. C OR: 0.82 (0.57-1.17)
Hisp vs. C OR: 1.47 (0.94-2.27)
2006q3
2002q4
2002q1
60
Overall OR: 1.07 (1.05-1.09)
75
AA vs. C OR: 1.40 (0.92-2.12)
Hisp vs. C OR: 1.16 (0.74-1.82)
65
2007q2
2006q3
2005q4
2005q1
2004q2
2003q3
2002q1
60
2002q4
AA vs. C OR: 1.02 (0.70-1.48)
Hisp vs. C OR: 1.69 (1.09-2.61)
65
80
Overall OR: 1.05 (1.03-1.06)
70
2005q4
Overall OR: 1.07 (1.03-1.12)
70
2005q1
75
2004q2
75
85
2003q3
80
2002q4
80
90
2002q1
85
2007q2
85
95
2006q3
90
2005q4
90
2005q1
95
2004q2
95
Beta-blocker at Discharge
100
2003q3
100
Patients (%)
100
Defect-Free Care
Patients (%)
100
Caucasian
African American
Hispanic
§
90
80
§
§
§
*
70
* *
§
* *
Overall, defect-free care was:
- 80.9% for Caucasians
- 79.5% for Hispanics
- 77.7% for African Americans
60
Overall OR: 1.08 (1.06-1.10)
50
African American vs. Caucasian OR: 0.98 (0.79-1.21)
Hispanic vs. Caucasian OR: 1.19 (0.93-1.53)
* p<0.01 for difference between African-American and Caucasian patients
§ p<0.01 for difference between Hispanic and Caucasian patients
The significance level of p was changed to less than 0.01 to adjust for the multiple comparisons.
Cohen et al. Circulation . ePub May 17, 2010
2007q1
2006q3
2006q1
2005q3
2005q1
2004q3
2004q1
2003q3
2003q1
2002q3
2002q1
40
Defect Free Care
According to Minority
Proportion per Hospital
Temporal trends in the hospital use of defect-free care according to quintiles of
the percent of patients of African American and Hispanic race/ethnicity
Hispanics
100
100
80
80
60
60
Quintile 1 (0% )
Quintile 1 (0% )
Quintile 2 (1.2% )
Quintile 2 (0.4% )
Quintile 3 (3.8% )
40
Quintile 3 (1.6% )
40
Quintile 4 (9.7% )
Quintile 4 (5.9% )
Quintile 5 (31.7% )
Quintile 5 (31.1% )
2007q1
2006q3
2006q1
2005q3
2005q1
2004q3
2004q1
2003q3
2003q1
2007q1
2006q3
2006q1
2005q3
2005q1
2004q3
2004q1
2003q3
2003q1
2002q3
2002q1
Cohen et al. Circulation . ePub May 17, 2010
2002q3
20
20
2002q1
Patients (%)
African-Americans
Results
• Progressive improvements in performance measures
and in defect-free care for all racial/ethnic groups.
• These positive trends were present even after
adjustments for patient baseline characteristics, and
patient baseline characteristics and hospital variables.
• Further analysis of temporal trends revealed that African
Americans received lower defect-free care during the
first year of the study. However, the care of African
Americans improved relative to that for the other groups
and the difference was no longer apparent during the
remainder of the study period.
Cohen et al. Circulation . ePub May 17, 2010
Limitations
– Observational, non-randomized study
– Findings are limited to the inpatient setting
– Sites are self-selected and interested in QI and may
not be representative of national care patterns.
– Minority patients were underrepresented in
comparison with census data
Cohen et al. Circulation . ePub May 17, 2010
Conclusions
• Among hospitals engaged in a national quality
monitoring and improvement program, evidencebased care for acute myocardial infarction
appeared to improve over time for patients
irrespective of race/ethnicity.
• Differences in care by race/ethnicity care were
reduced or eliminated.
• Small remaining gaps in care may be potentially
targeted by intervention programs addressing
the specific needs of each racial/ethnic group.
Cohen et al. Circulation . ePub May 17, 2010
Clinical Implications
• The elimination of disparate health care is one of
the principal goals of Healthy People 2010
• Participation in Get With The Guideline-CAD
was associated with a reduction or elimination of
disparities in care quality for acute myocardial
infarction regardless of race/ethnicity
Cohen et al. Circulation . ePub May 17, 2010