Differences between hospitals account for much of the racial/ethnic treatment differences

October 05, 2004

Differences between racial/ethnic groups for times to treatment for a heart attack may be largely attributable to the differences between hospitals to which the patients are admitted, according to a study in the October 6 issue of JAMA.

According to background information in the article, recent reports have indicated that patients identified as African American/black or as nonwhite minority experience significantly longer times to fibrinolytic (dissolving blood clots) therapy ("door-to-drug" times) and percutaneous coronary intervention ("door-to-balloon" times) than patients identified as white, raising concerns of health care disparities. However, existing studies have not comprehensively investigated the factors that explain the observed racial and ethnic differences in time to reperfusion therapy (the restoration of blood flow to an organ or tissue). Understanding the sources of racial and ethnic differences in cardiovascular care is important to designing effective interventions to eliminate disparities.

Elizabeth H. Bradley, Ph.D., of the Yale University School of Medicine, New Haven, Conn., and colleagues estimated racial and ethnic differences in time between hospital arrival and receipt of reperfusion therapy, and examined the role of sociodemographic factors, insurance status, clinical characteristics, and health system factors in explaining these differences. The researchers used admission and treatment data from the National Registry of Myocardial Infarction (NRMI) for a large U.S. cohort of patients with ST-segment elevation (a certain measurement from an electrocardiograph) heart attack or left bundle branch block and receiving reperfusion therapy. Patients (73,032 receiving fibrinolytic therapy; 37,143 receiving primary percutaneous coronary intervention) were admitted to hospitals from January 1, 1999, through December 31, 2002.

The researchers found that door-to-drug times were significantly longer for patients identified as African American/black (41.1 minutes), Hispanic (36.1 minutes), and Asian/Pacific Islander (37.4 minutes), compared with patients identified as white (33.8 minutes). Door-to-balloon times for patients identified as African American/black (122.3 minutes) or Hispanic (114.8 minutes) also were significantly longer than for patients identified as white (103.4 minutes). Racial/ethnic differences were still significant but were substantially reduced after accounting for differences in average times to treatment for the hospitals in which patients were treated; significant racial/ethnic differences persisted after further adjustment for sociodemographic characteristics, insurance status, and clinical and hospital characteristics.

"... crude difference in door-to-balloon time between African American/black and white patients was reduced by 33 percent after accounting for differences between the hospitals in which patients were treated. More striking, the crude difference in door-to-balloon times between Hispanic patients and white patients was reduced by nearly 75 percent after accounting for differences between the hospitals in which they were treated," the authors write.

"Our study has important implications for efforts to eliminate disparities in time to acute reperfusion. Although efforts to increase awareness of racial/ethnic disparities inside the hospital are important, our findings suggest the need for parallel efforts directed toward improving the care in hospitals that are lagging in their quality and in which minority patients may be more likely to receive their care," the researchers write. "Interventions to eliminate racial/ethnic disparities are likely to fall short of their goals unless they are accompanied by systemic changes that can ensure all patients have access to high-quality hospitals."
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(JAMA. 2004; 292:1563-1572. Available post-embargo at www.jama.com)

Editor's note: This study was supported by a National Heart, Lung, and Blood Institute (NHLBI) grant. Dr. Bradley is supported by the Patrick & Catherine Weldon Donaghue Medical Research Foundation and by a grant from the Claude D. Pepper Older Americans Independence Center at Yale University.

Editorial: Measuring Race and Ethnicity - Why and How?
In an accompanying editorial, Margaret A. Winker, M.D., Deputy Editor, JAMA, Chicago, discusses issues surrounding measuring, reporting and analyzing race and ethnicity in medical studies.

"Determining race can be an important initial step in assessing quality of care delivery and outcomes, as the study by Bradley and colleagues illustrates. However, it is just a first step. By reporting race and ethnicity transparently and beginning to explore other important and related characteristics, biomedical research can move beyond race as a social construct in itself and explore other tangible components that can be affected to improve the public's health," Dr. Winker writes.

(JAMA. 2004; 292:1612-1614. Available post-embargo at www.jama.com)

The JAMA Network Journals

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