Neighborhood socioeconomic and racial disparities in angiography and coronary revascularization: the ARIC surveillance study

Racial and Ethnic Disparities in the Management of Chronic Coronary Disease

Chronic coronary disease (CCD) comprises a continuum of conditions that include obstructive and non-obstructive coronary artery disease with or without prior acute coronary syndrome. Racial and ethnic representation disparities are pervasive in CCD guideline-informing clinical trials and evidence-based management. These disparities manifest across the entire spectrum of CCD management, spanning from non-pharmacological lifestyle changes to guideline-directed medical therapy, and cardiac rehabilitation to invasive procedures. Recognizing and addressing the historical factors underlying these disparities is crucial for enhancing the quality and equity of CCD management within an increasingly diverse population.

Impact of Outcome Definitions on Cardiovascular Risk Prediction in a Contemporary Primary Prevention Population

BACKGROUND

Estimation of an individual's cardiovascular disease (CVD) risk may enhance risk discussion and treatment decisions. Yet, common cardiovascular outcomes such as heart failure or coronary revascularization are not included in the estimation of atherosclerotic cardiovascular disease (ASCVD) risk. Our objective was to determine the incidence of ASCVD in a contemporary primary prevention population with more than 10 years of follow-up, and how incidence estimates change when incorporating additional cardiovascular endpoints.

METHODS

We used the population-level CANHEART (Cardiovascular Health in Ambulatory Care Research Team) database of all Ontario residents alive January 1, 2008, aged 30-99 years, and with no prior history of cardiovascular disease. Individuals were followed to December 31, 2019 for incident first and recurrent cardiovascular events. ASCVD outcomes were defined by hospitalizations for myocardial infarction, stroke and circulatory death, while global CVD outcomes also included hospitalizations for unstable angina, transient ischemic attacks, peripheral arterial disease, out-of-hospital cardiac arrests, heart failure and coronary revascularization.

RESULTS

Among 7496 165 individuals free of cardiovascular disease, their mean age was 50 years (SD: 13.9 years) and 52.3% were women. After 11 years of follow-up, the rate of an incident ASCVD event was 3.95 per 1000 person-years while the rate of a global CVD event was almost doubled at 6.67 per 1000 person-years. The most common additional first manifestations of CVD were heart failure which accounted for 12.0% of additional events and coronary revascularization which accounted for 12.7%. When considering first and recurrent events, the rate of ASCVD was 5.20 per 1000 person-years while the rate of all global CVD events was more than double at 10.90 per 1000 person-years. This was mainly due to a higher proportion of recurrent heart failure (13.7%) and coronary revascularization (23.2%) events.

CONCLUSIONS

ASCVD accounts for just over half of all preventable first cardiovascular events and even fewer first and recurrent cardiovascular events in contemporary practice. Estimating broader CVD endpoints may enhance risk-discussions with patients and improve informed decision-making.

Life-Course Neighborhood Socioeconomic Status and Cardiovascular Events in Black and White Adults in the Atherosclerosis Risk in Communities Study

It has been reported that residents of low-socioeconomic-status (SES) neighborhoods have a higher risk of developing cardiovascular disease (CVD). However, most of the previous studies focused on 1-time measurement of neighborhood SES in middle-to-older adulthood and lacked demographic diversity to allow for comparisons across different race/ethnicity and sex groups. We examined neighborhood SES in childhood and young, middle, and older adulthood in association with CVD risk among Black and White men and women in the Atherosclerosis Risk in Communities Study (1996-2019). We found that lower neighborhood SES in young, middle, and older adulthood, but not in childhood, was associated with a higher risk of CVD later in life. When compared with the highest quartile, the lowest quartile of neighborhood SES in young, middle, and older adulthood was associated with 18% (hazard ratio (HR) = 1.18, 95% confidence interval (CI): 1.02, 1.36), 21% (HR = 1.21, 95% CI: 1.04, 1.39), and 12% (HR = 1.12, 95% CI: 0.99, 1.26) increases in the hazard of total CVD, respectively. The association between lower neighborhood SES in older adulthood and higher CVD hazard was particularly strong among Black women. Our study findings support the role of neighborhood SES in cardiovascular health in both Black and White adults.

Association of Race and Ethnicity on the Management of Acute Non-ST-Segment Elevation Myocardial Infarction

Background Prior studies have reported disparities by race in the management of acute myocardial infarction (MI), with many studies having limited covariates or now dated. We examined racial and ethnic differences in the management of MI, specifically non-ST-segment-elevation MI (NSTEMI), in a large, socially diverse cohort of insured patients. We hypothesized that the racial and ethnic disparities in the receipt of coronary angiography or percutaneous coronary intervention would persist in contemporary data. Methods and Results We identified individuals presenting with incident, type I NSTEMI from 2017 to 2019 captured by a health claims database. Race and ethnicity were categorized by the database as Asian, Black, Hispanic, or White. Covariates included demographics (age, sex, race, and ethnicity); Elixhauser variables, including cardiovascular risk factors and other comorbid conditions; and social factors of estimated annual household income and educational attainment. We examined rates of coronary angiography and percutaneous coronary intervention by race and ethnicity and income categories and in multivariable-adjusted models. We identified 87 094 individuals (age 73.8±11.6 years; 55.6% male; 2.6% Asian, 13.4% Black, 11.2% Hispanic, 72.7% White) with incident NSTEMI events from 2017 to 2019. Individuals of Black race were less likely to undergo coronary angiography (odds ratio [OR], 0.93; [95% CI, 0.89-0.98]) and percutaneous coronary intervention (OR, 0.86; [95% CI, 0.81-0.90]) than those of White race. Hispanic individuals were less likely (OR, 0.88; [95% CI, 0.84-0.93]) to undergo coronary angiography and percutaneous coronary intervention (OR, 0.85; [95% CI, 0.81-0.89]) than those of White race. Higher annual household income attenuated differences in the receipt of coronary angiography across all racial and ethnic groups. Conclusions We identified significant racial and ethnic differences in the management of individuals presenting with NSTEMI that were marginally attenuated by higher household income. Our findings suggest continued evidence of health inequities in contemporary NSTEMI treatment.

Association between race/ethnicity and income on the likelihood of coronary revascularization among postmenopausal women with acute myocardial infarction: Women's health initiative study

BACKGROUND

Historically, race, income, and gender were associated with likelihood of receipt of coronary revascularization for acute myocardial infarction (AMI). Given public health initiatives such as Healthy People 2010, it is unclear whether race and income remain associated with the likelihood of coronary revascularization among women with AMI.

METHODS

Using the Women's Health Initiative Study, hazards ratio (HR) of revascularization for AMI was compared for Black and Hispanic women vs White women and among women with annual income <$20,000/year vs ≥$20,000/year over median 9.5 years follow-up(1993-2019). Proportional hazards models were adjusted for demographics, comorbidities, and AMI type. Results were stratified by revascularization type: percutaneous coronary intervention and coronary artery bypass grafting(CABG). Trends by race and income were compared pre- and post-2010 using time-varying analysis.

RESULTS

Among 5,284 individuals with AMI (9.5% Black, 2.8% Hispanic, and 87.7% White; 23.2% <$20,000/year), Black race was associated with lower likelihood of receiving revascularization for AMI compared to White race in fully adjusted analyses [HR:0.79(95% Confidence Interval:[CI]0.66,0.95)]. When further stratified by type of revascularization, Black race was associated with lower likelihood of percutaneous coronary intervention for AMI compared to White race [HR:0.72(95% CI:0.59,0.90)] but not for CABG [HR:0.97(95%CI:0.72,1.32)]. Income was associated with lower likelihood of revascularization [HR:0.90(95%CI:0.82,0.99)] for AMI. No differences were observed for other racial/ethnic groups. Time periods (pre/post-2010) were not associated with change in revascularization rates.

CONCLUSION

Black race and income remain associated with lower likelihood of revascularization among patients presenting with AMI. There is a substantial need to disrupt the mechanisms contributing to race, sex, and income disparities in AMI management.

Outcomes of decreasing versus increasing cardiac troponin in patients admitted with non-ST-segment elevation myocardial infarction: the Atherosclerosis Risk in Communities Surveillance Study

BACKGROUND

The fourth universal definition of myocardial infarction requires an increase or decrease in cardiac troponin for the classification of non-ST-segment elevation myocardial infarction. We sought to determine whether the characteristics, management, and outcomes of patients admitted with non-ST-segment elevation myocardial infarction differ by the initial biomarker pattern.

METHODS

We identified patients in the Atherosclerosis Risk in Communities Surveillance Study admitted with chest pain and an initially elevated cardiac troponin I, who presented within 12 hours of symptom onset and were classified with non-ST-segment elevation myocardial infarction. A change in cardiac troponin I required an absolute difference of at least 0.02 ng/mL on the first day of hospitalization, prior to invasive cardiac procedures.

RESULTS

A total of 1926 hospitalizations met the inclusion criteria, with increasing cardiac troponin I more commonly observed (78%). Patients with decreasing cardiac troponin I were more often black (45% vs. 35%) and women (54% vs. 40%), and were less likely to receive non-aspirin antiplatelets (44% vs. 63%), lipid-lowering agents (62% vs. 80%), and invasive angiography (38% vs. 64%). Inhospital mortality was 3%, irrespective of the cardiac troponin I pattern. However, patients with decreasing cardiac troponin I had twice the 28-day mortality (12% vs. 5%; P=0.01). Fatalities within 28 days were more often attributable to non-cardiovascular causes in those with decreasing versus increasing cardiac troponin I (75% vs. 38%; P=0.01).

CONCLUSION

Patients presenting with chest pain and an initially elevated cardiac troponin I which subsequently decreases are less often managed by evidence-based therapies and have greater mortality, primarily driven by non-cardiovascular causes. Whether associations are attributable to type 2 myocardial infarction or a subacute presentation merits further investigation.

Outcomes of decreasing versus increasing cardiac troponin in patients admitted with non-ST-segment elevation myocardial infarction: the Atherosclerosis Risk in Communities Surveillance Study

BACKGROUND

The fourth universal definition of myocardial infarction requires an increase or decrease in cardiac troponin for the classification of non-ST-segment elevation myocardial infarction. We sought to determine whether the characteristics, management, and outcomes of patients admitted with non-ST-segment elevation myocardial infarction differ by the initial biomarker pattern.

METHODS

We identified patients in the Atherosclerosis Risk in Communities Surveillance Study admitted with chest pain and an initially elevated cardiac troponin I, who presented within 12 hours of symptom onset and were classified with non-ST-segment elevation myocardial infarction. A change in cardiac troponin I required an absolute difference of at least 0.02 ng/mL on the first day of hospitalization, prior to invasive cardiac procedures.

RESULTS

A total of 1926 hospitalizations met the inclusion criteria, with increasing cardiac troponin I more commonly observed (78%). Patients with decreasing cardiac troponin I were more often black (45% vs. 35%) and women (54% vs. 40%), and were less likely to receive non-aspirin antiplatelets (44% vs. 63%), lipid-lowering agents (62% vs. 80%), and invasive angiography (38% vs. 64%). Inhospital mortality was 3%, irrespective of the cardiac troponin I pattern. However, patients with decreasing cardiac troponin I had twice the 28-day mortality (12% vs. 5%; P=0.01). Fatalities within 28 days were more often attributable to non-cardiovascular causes in those with decreasing versus increasing cardiac troponin I (75% vs. 38%; P=0.01).

CONCLUSION

Patients presenting with chest pain and an initially elevated cardiac troponin I which subsequently decreases are less often managed by evidence-based therapies and have greater mortality, primarily driven by non-cardiovascular causes. Whether associations are attributable to type 2 myocardial infarction or a subacute presentation merits further investigation.

Assessing Health Resources Equipped with Hemodynamic Rooms in the Portuguese-Spanish Borderland: Cross-Border Cooperation Strategies as a Possible Solution

Portugal and Spain share one of the greatest European borderland areas. This fact has direct impacts on a large territory and consequently on the communities’ living in it. Still, even if the border areas represent an essential fraction of the territory, planning policies have not resulted in specific cooperation programs that could enable sharing general leisure and recreation assets and infrastructures and collaboration in critical domains—i.e., the case of the health sector. The present study aims to assess the territorial accessibility to the hemodynamic rooms by the potential population of the Spanish-Portuguese transition areas that may suffer an acute myocardial infarction. Contextually, this study employed a spatial interaction model based on the three-step floating catchment area method (method-3SFCA). By applying these methods, it was possible to develop a map of accessibility to health infrastructures equipped with hemodynamics rooms on both sides of the border that may answer the Spanish-Portuguese border populations’ needs. Besides, while granting valuable information for decision-makers regarding the need to develop new infrastructures to guarantee that even considering cross border cooperation, everyone gets access to a hemodynamics room within the critical intervention period.

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 Impact of Race on Outcomes of Revascularization for Multivessel Coronary Artery Disease

BACKGROUND

Racial disparities exist between Black and White patients with coronary artery disease with regard to access to revascularization, preprocedural comorbidities, and postprocedural outcomes. This study investigated the differences in the treatment of multivessel coronary artery disease (MVCAD) and long-term outcomes between Black and White patients.

METHODS

This was a propensity-matched retrospective analysis that utilized pooled institutional data from a large, multihospital health care system. It included Black and White patients who underwent coronary revascularization for MVCAD between 2011 and 2018.

RESULTS

A total of 6005 patients were included (5689 White and 316 Black). In the unmatched cohort, Black patients had a higher incidence of preexisting comorbidities such as diabetes, dialysis dependence, peripheral arterial disease, heart failure, and underwent percutaneous coronary intervention (PCI) more frequently. Five-year overall survival was similar, but Black patients experienced higher rates of major adverse cardiac and cerebrovascular events and repeat revascularization. Propensity matching resulted in a sample of 926 (312 Black, 614 White) patients that were well matched. In the matched analysis, Black patients underwent PCI more frequently and a had higher rate of stoke. Five-year survival, major adverse cardiac and cerebrovascular events and repeat revascularization rates were comparable.

CONCLUSIONS

Black patients with MVCAD have a higher comorbidity burden and undergo PCI at higher rates. After adjusting for baseline differences, Black patients still had higher rates of PCI utilization and long-term stroke. It is possible that a significant portion of racial disparities in MVCAD are driven by differences in baseline risk; however, there is evidence of possible racial bias with regard to revascularization strategies.

Distribution of Cardiovascular Health by Individual- and Neighborhood-Level Socioeconomic Status: Findings From the Jackson Heart Study

BACKGROUND

Data demonstrate a positive relationship between socioeconomic status (SES) and cardiovascular health (CVH).

OBJECTIVE

To assess the association between individual- and neighborhood-level SES and CVH among participants of the JHS (Jackson Heart Study), a community-based cohort of African Americans in Jackson, Mississippi.

METHODS

We included all JHS participants with complete SES and CVH information at the baseline study visit (n = 3,667). We characterized individual- and neighborhood-level SES according to income (primary analysis) and education (secondary analysis), respectively. The outcome of interest for these analyses was a CVH score, based on 7 modifiable behaviors and factors, summed to a total of 0 (worst) to 14 (best) points. We utilized generalized estimating equations to account for the clustering of participants within the same residential areas to estimate the linear association between SES and CVH.

RESULTS

The median age of the participants was 55 years, and 64% were women. Nearly one-third of eligible participants had individual incomes <$20,000 and close to 40% lived in the lowest neighborhood income category (<$25,480). Adjusted for age, sex, and neighborhood SES, there was an average increase in CVH score of 0.31 points associated with each 1-category increase in individual income. Similarly, each 1-category increase in neighborhood SES was associated with a 0.19-point increase in CVH score. These patterns held for our secondary analyses, which used educational attainment in place of income. These data did not suggest a synergistic effect of individual- and neighborhood-level SES on CVH.

CONCLUSIONS

Our findings suggest a potential causal pathway for disparities in CVH among vulnerable populations. These data can be useful to the JHS community to empower public health and clinical interventions and policies for the improvement of CVH.

Racial Differences in Quality of Care and Outcomes After Acute Coronary Syndrome

Guideline adherence and variation in acute coronary syndrome (ACS) outcomes by race in the modern era of drug-eluting stents (DES) are not well understood. Previous studies also fail to capture rapidly growing minority populations, such as Asians. A retrospective analysis of 689,238 hospitalizations for ACS across all insurance types from 2008 to 2011 from the Healthcare Cost and Utilization Project database was performed to determine whether quality of ACS care and mortality differ by race (white, black, Asian, Hispanic, or Native American), with adjustment for patient clinical and demographic characteristics and clustering by hospital. We found that black patients had the lowest in-hospital mortality rates (5% vs 6% to 7% for other races, p <0.0001, odds ratio [OR] 1.02, 95% confidence interval [CI] 0.97 to 1.07), despite low rates of timely angiography in ST-elevation myocardial infarction and non-ST-elevation myocardial infarction, and lower use of DES (30% vs 38% to 40% for other races, p <0.0001). In contrast, Asian patients had the highest in-hospital mortality rates (7% vs 5% to 7% for other races, p <0.0001, odds ratio 1.13, 95% CI 1.08 to 1.20, relative to white patients), despite higher rates of timely angiography in ST-elevation myocardial infarction and non-ST-elevation myocardial infarction, and the highest use of DES (74% vs 63% to 68% for other races, p <0.0001). Asian patients had the worst in-hospital mortality outcomes after ACS, despite high use of early invasive treatments. Black patients had better in-hospital outcomes despite receiving less guideline-driven care.

A review of racial disparities in transcatheter aortic valve replacement (TAVR): accessibility, referrals and implantation

Racial disparities in transcatheter aortic valve replacement (TAVR) implantation results from several factors, including socioeconomic disparities, inherent biases in healthcare provision, fewer referrals to specialists and language barriers in some minority populations. In this review article, we discuss the current data on the racial disparities in TAVR, explore the prevalence of aortic stenosis in different demographics in the United States and we proffer practical solutions to these problems.

Inequalities in care in patients with acute myocardial infarction

Coronary heart disease is the single largest cause of death in developed countries. Guidelines exist for the management of acute myocardial infarction (AMI), yet despite these, significant inequalities exist in the care of these patients. The elderly, deprived socioeconomic groups, females and non-caucasians are the patient populations where practice tends to deviate more frequently from the evidence base. Elderly patients often had higher mortality rates after having an AMI compared to younger patients. They also tended to present with symptoms that were not entirely consistent with an AMI, thus partially contributing to the inequalities in care that is seen between younger and older patients. Furthermore the lack of guidelines in the elderly age group presenting with AMI can often make decision making challenging and may account for the discrepancies in care that are prevalent between younger and older patients. Other patients such as those from a lower socioeconomic group, i.e., low income and less than high school education often had poorer health and reduced life expectancy compared to patients from a higher socioeconomic group after an AMI. Lower socioeconomic status was also seen to be contributing to racial and geographical variation is the care in AMI patients. Females with an AMI were treated less aggressively and had poorer outcomes when compared to males. However even when females were treated in the same way they continued to have higher in hospital mortality which suggests that gender may well account for differences in outcomes. The purpose of this review is to identify the inequalities in care for patients who present with an AMI and explore potential reasons for why these occur. Greater attention to the management and a better understanding of the root causes of these inequalities in care may help to reduce morbidity and mortality rates associated with AMI.

Is tree loss associated with cardiovascular-disease risk in the Women's Health Initiative? A natural experiment

Data from the Women's Health Initiative were used to quantify the relationship between the loss of trees to an invasive forest pest-the emerald ash borer-and cardiovascular disease. We estimated a semi-parametric Cox proportional hazards model of time to cardiovascular disease, adjusting for confounders. We defined the incidence of cardiovascular disease as acute myocardial infarction requiring overnight hospitalization, silent MI determined from serial electrocardiograms, ischemic or hemorrhagic stroke, or death from coronary heart disease. Women living in a county infested with emerald ash borer had an increased risk of cardiovascular disease (HR=1.25, 95% CI: 1.20-1.31).

Antiplatelet and Statin Use in US Patients With Coronary Artery Disease Categorized by Race/Ethnicity and Gender, 2003 to 2012

Antiplatelets and statins are efficacious for preventing future cardiovascular events in patients with coronary heart disease. Disparity in cardiovascular outcomes exists by race/ethnicity and gender; however, few studies have explored potential disparities in long-term antiplatelet and statin use by race/ethnicity and gender. We conducted a repeated cross-sectional analysis using the nationally representative Medical Expenditure Panel Survey from 2003 to 2012. The sample consisted of 14,334 men and women >29 years with coronary heart disease. We identified antiplatelet and statin use, medical conditions, and sociodemographic characteristics. Rates of use did not change for statins or the combination of statins and antiplatelets from 2003 to 2012 but decreased for antiplatelets (p = 0.015). Of the total sample, 70.9% (95% confidence interval [CI] 69.7 to 72.1) reported use of antiplatelets, 52.5% (95% CI 51.1 to 53.8) reported statin use, and 43.1% (95% CI 41.8 to 44.4) reported the combination. Use of antiplatelets and statins were associated with one another (odds ratio 3.22; 95% CI 2.87 to 3.62). From 2009 to 2012, black and Hispanic men along with all race/ethnicities of women were less likely to report use of statins, antiplatelets, and the combination of the 2 compared with white men, even after controlling for sociodemographics. Changing the definition of a medication use, inclusion of cardiovascular risk factors, or the inclusion of warfarin in the antiplatelet category did not substantially change the results. Future practice and policy goals should focus on increasing the number of high-risk patients on appropriate preventative medications while focusing particular attention on decreasing the identified disparity.

Medicare's Hospital Readmissions Reduction Program in Surgery May Disproportionately Affect Minority-serving Hospitals

OBJECTIVE

To project readmission penalties for hospitals performing cardiac surgery and examine how these penalties will affect minority-serving hospitals.

BACKGROUND

The Hospital Readmissions Reduction Program will potentially expand penalties for higher-than-predicted readmission rates to cardiac procedures in the near future. The impact of these penalties on minority-serving hospitals is unknown.

METHODS

We examined national Medicare beneficiaries undergoing coronary artery bypass grafting in 2008 to 2010 (N = 255,250 patients, 1186 hospitals). Using hierarchical logistic regression, we calculated hospital observed-to-expected readmission ratios. Hospital penalties were projected according to the Hospital Readmissions Reduction Program formula using only coronary artery bypass grafting readmissions with a 3% maximum penalty of total Medicare revenue. Hospitals were classified into quintiles according to proportion of black patients treated. Minority-serving hospitals were defined as hospitals in the top quintile whereas non-minority-serving hospitals were those in the bottom quintile. Projected readmission penalties were compared across quintiles.

RESULTS

Forty-seven percent of hospitals (559 of 1186) were projected to be assessed a penalty. Twenty-eight percent of hospitals (330 of 1186) would be penalized less than 1% of total Medicare revenue whereas 5% of hospitals (55 of 1186) would receive the maximum 3% penalty. Minority-serving hospitals were almost twice as likely to be penalized than non-minority-serving hospitals (61% vs 32%) and were projected almost triple the reductions in reimbursement ($112 million vs $41 million).

CONCLUSIONS

Minority-serving hospitals would disproportionately bear the burden of readmission penalties if expanded to include cardiac surgery. Given these hospitals' narrow profit margins, readmission penalties may have a profound impact on these hospitals' ability to care for disadvantaged patients.

Socioeconomic inequalities in quality of care and outcomes among patients with acute coronary syndrome in the modern era of drug eluting stents

BACKGROUND

The rapidly changing landscape of percutaneous coronary intervention provides a unique model for examining disparities over time. Previous studies have not examined socioeconomic inequalities in the current era of drug eluting stents (DES).

METHODS AND RESULTS

We analyzed 835 070 hospitalizations for acute coronary syndrome (ACS) from the Healthcare Cost and Utilization Project across all insurance types from 2008 to 2011, examining whether quality of care and outcomes for patients with ACS differed by income (based on zip code of residence) with adjustment for patient characteristics and clustering by hospital. We found that lower-income patients were less likely to receive an angiogram within 24 hours of a ST elevation myocardial infarction (STEMI) (69.5% for IQ1 versus 73.7% for IQ4, P<0.0001, OR 0.79 [0.68 to 0.91]) or within 48 hours of a Non-STEMI (47.6% for IQ1 versus 51.8% for IQ4, P<0.0001, OR 0.86 [0.75 to 0.99]). Lower income was associated with less use of a DES (64.7% for IQ1 versus 71.2% for IQ4, P<0.0001, OR 0.83 [0.74 to 0.93]). However, no differences were found for coronary artery bypass surgery. Among STEMI patients, lower-income patients also had slightly increased adjusted mortality rates (10.8% for IQ1 versus 9.4% for IQ4, P<0.0001, OR 1.17 [1.11 to 1.25]). After further adjusting for time to reperfusion among STEMI patients, mortality differences across income groups decreased.

CONCLUSIONS

For the most well accepted procedural treatments for ACS, income inequalities have faded. However, such inequalities have persisted for DES use, a relatively expensive and until recently, controversial revascularization procedure. Differences in mortality are significantly associated with differences in time to primary PCI, suggesting an important target for understanding why these inequalities persist.

Neighborhood socioeconomic status, race, and mortality in young adult dialysis patients

Young blacks receiving dialysis have an increased risk of death compared with whites in the United States. Factors influencing this disparity among the young adult dialysis population have not been well explored. Our study examined the relation of neighborhood socioeconomic status (SES) and racial differences in mortality in United States young adults receiving dialysis. We merged US Renal Data System patient-level data from 11,027 black and white patients ages 18-30 years old initiating dialysis between 2006 and 2009 with US Census data to obtain neighborhood poverty information for each patient. We defined low SES neighborhoods as those neighborhoods in U.S. Census zip codes with ≥20% of residents living below the federal poverty level and quantified race differences in mortality risk by level of neighborhood SES. Among patients residing in low SES neighborhoods, blacks had greater mortality than whites after adjusting for baseline demographics, clinical characteristics, rurality, and access to care factors. This difference in mortality between blacks and whites was significantly attenuated in higher SES neighborhoods. In the United States, survival between young adult blacks and whites receiving dialysis differs by neighborhood SES. Additional studies are needed to identify modifiable factors contributing to the greater mortality among young adult black dialysis patients residing in low SES neighborhoods.

Disparities in deep brain stimulation surgery among insured elders with Parkinson disease

OBJECTIVE

To identify sociodemographic, clinical, and physician/practice factors associated with deep brain stimulation (DBS). DBS is a proven surgical therapy for Parkinson disease (PD), but is recommended only for patients with excellent health, results in significant out-of-pocket costs, and requires substantial physician involvement.

METHODS

Retrospective cohort study of more than 657,000 Medicare beneficiaries with PD. Multivariable logistic regression models examined the association between demographic, clinical, socioeconomic status (SES), and physician/practice factors, and DBS therapy.

RESULTS

There were significant disparities in the use of DBS therapy among Medicare beneficiaries with PD. The greatest disparities were associated with race: black (adjusted odds ratio [AOR] 0.20, 95% confidence interval [CI] 0.16-0.25) and Asian (AOR 0.55, 95% CI 0.44-0.70) beneficiaries were considerably less likely to receive DBS than white beneficiaries. Women (AOR 0.79, 95% CI 0.75-0.83) also had lower odds of receiving DBS compared with men. Eighteen percent of procedures were performed on patients with PD who had cognitive impairment/dementia, a reported contraindication to DBS. Beneficiaries treated in minority-serving PD practices were less likely to receive DBS, regardless of individual race (AOR 0.76, 95% CI 0.66-0.87). Even after adjustment for demographic and clinical covariates, high neighborhood SES was associated with 1.4-fold higher odds of receiving DBS (AOR 1.42, 95% CI 1.33-1.53).

CONCLUSIONS

Among elderly Medicare beneficiaries with PD, race, sex, and neighborhood SES are strong independent predictors of DBS receipt. Racial disparities are amplified when adjusting for physician/clinic characteristics. Future investigations of the demographic differences in clinical need/usefulness of DBS, ease of DBS attainment, and actual/opportunity DBS costs are needed to inform policies to reduce DBS disparities and improve PD quality of care.