Quality of care by race and gender for congestive heart failure and pneumonia

Minority-Serving Hospitals Are Associated With Low Within-Hospital Disparity

BACKGROUND

Disparities in obstetric care have been well documented, but disparities in the within-hospital population have not been as extensively explored. The objective is to assess cesarean delivery rate disparities at the hospital level in a nationally recognized low risk of cesarean delivery group.

METHODS

An observational study using a national population-based database, Nationwide Inpatient Sample, from 2008 to 2011 was conducted. All patients with nulliparous, term, singleton, vertex pregnancies from Black and White patients were included. The primary outcome was delivery mode (cesarean vs vaginal). The primary independent variable was race (Black vs White).

RESULTS

A total of 1,064,351 patients were included and the overall nulliparous, term, singleton, and vertex pregnancies cesarean delivery rate was 14.1%. The within-hospital disparities of cesarean delivery rates were lower in minority-serving hospitals (OR: 1.20 95% CI: 1.12-1.28), rural hospitals (OR 1.11 95% CI: 1.02-1.20), and the South (OR 1.24 95% CI 1.19-1.30) compared to their respective counterparts. Non-minority serving hospitals (OR: 1.20 95% CI 0.12-1.25), and urban hospitals (OR1.32 95% CI 1.28-1.37), the Northeast (OR 1.41 95% CI 1.30-1.53) or West (OR 1.52 95% CI 1.38-1.67), had higher within-hospital racial disparities of cesarean delivery rates. The odds ratios reported are comparing within-hospital cesarean delivery rates in Black and White patients.

DISCUSSION

Significant within-hospital disparities of cesarean delivery rates across hospitals highlight the importance of facility-level factors. Policies aimed at advancing health equity must address hospital-level drivers of disparities in addition to structural racism.

Community Engagement Strategies for Underrepresented Racial and Ethnic Populations

The representation of racial and ethnic minority populations in clinical trials continues to be a challenge despite mandates, good intentions, and concerted efforts by funding agencies, regulatory bodies, and researchers to close the clinical trials gap. A lack of diversity in research results in both continued disparities and poorer health outcomes. It is thus imperative that investigators understand and effectively address the challenges of clinical trials participation by underrepresented populations. In this paper, we expound on best practices for participatory research by clearly defining the community, highlighting the importance of proper identification and engagement of strong community partners, and exploring patient- and provider-level barriers and facilitators that require consideration. A clearer understanding of the balance of power between researchers and community partners is needed for any approach that addresses clinical trials representation. Unintended biases in study design and methods may continue to prevent racial and ethnic minority participants from taking part, and significant organizational changes are necessary for efficient and transparent relationships. Comprehensive community engagement in research includes dissemination of clinical trial results within and in partnership with community partners. Through careful deliberation and honest reflection, investigators, institutions, and community partners can develop the tailored blueprints of research collaborations essential for true equity in clinical trials.

Health inequities and socioeconomic factors predicting the access to treatment for unruptured intracranial aneurysms in the USA in the last 20 years: interaction effect of race, gender, and insurance

BACKGROUND

The literature suggests that minority racial and ethnic groups have lower treatment rates for unruptured intracranial aneurysms (UIA). It is uncertain how these disparities have changed over time.

METHODS

A cross-sectional study using the National Inpatient Sample database covering 97% of the USA population was carried out.

RESULTS

A total of 213 350 treated patients with UIA were included in the final analysis and compared with 173 375 treated patients with aneurysmal subarachnoid hemorrhage (aSAH) over the years 2000-2019. The mean (SD) age of the UIA and aSAH groups was 56.8 (12.6) years and 54.3 (14.1) years, respectively. In the UIA group, 60.7% were white patients, 10.2% were black patients, 8.6% were Hispanic, 2% were Asian or Pacific Islander, 0.5% were Native Americans, and 2.8% were others. The aSAH group comprised 48.5% white patients, 13.6% black patients, 11.2% Hispanics, 3.6% Asian or Pacific Islanders, 0.4% Native Americans, and 3.7% others. After adjusting for covariates, black patients (OR 0.637, 95% CI 0.625 to 0.648) and Hispanic patients (OR 0.654, 95% CI 0.641 to 0.667) had lower odds of treatment compared with white patients. Medicare patients had higher odds of treatment than private patients, while Medicaid and uninsured patients had lower odds. Interaction analysis showed that non-white/Hispanic patients with any insurance/no insurance had lower treatment odds than white patients. Multivariable regression analysis showed that the treatment odds of black patients has improved slightly over time, while the odds for Hispanic patients and other minorities have remained the same over time.

CONCLUSION

This study from 2000 to 2019 shows that disparities in the treatment of UIA have persisted but have slightly improved over time for black patients while remaining constant for Hispanic patients and other minority groups.

Guideline-discordant inhaler regimens after COPD hospitalization: associations with rurality, drive time to care, and fragmented care - a United States cohort study

Background

Many patients receive guideline-discordant inhaler regimens after chronic obstructive pulmonary disease (COPD) hospitalization. Geography and fragmented care across multiple providers likely influence prescription of guideline-discordant inhaler regimens, but these have not been comprehensively studied. We assessed patient-level differences in guideline-discordant inhaler regimens by rurality, drive time to pulmonary specialty care, and fragmented care.

Methods

Retrospective cohort analysis using national Veterans Health Administration (VA) data among patients who received primary care and prescriptions from the VA. Patients hospitalized for COPD exacerbation between 2017 and 2020 were assessed for guideline-discordant inhaler regimens in the subsequent 3 months. Guideline-discordant inhaler regimens were defined as short-acting inhaler/s only, inhaled corticosteroid (ICS) monotherapy, long-acting beta-agonist (LABA) monotherapy, ICS + LABA, long-acting muscarinic antagonist (LAMA) monotherapy, or LAMA + ICS. Rural residence and drive time to the closest pulmonary specialty care were obtained from geocoded addresses. Fragmented care was defined as hospitalization outside the VA. We used multivariable logistic regression models to assess associations between rurality, drive time, fragmentated care, and guideline-discordant inhaler regimens. Models were adjusted for age, sex, race/ethnicity, Charlson Comorbidity Index, Area Deprivation Index, and region.

Findings

Of 33,785 patients, 16,398 (48.6%) received guideline-discordant inhaler regimens 3 months after hospitalization. Rural residents had higher odds of guideline-discordant inhalers regimens compared to their urban counterparts (adjusted odds ratio [aOR] 1.18 [95% CI: 1.12-1.23]). The odds of receiving guideline-discordant inhaler regimens increased with longer drive time to pulmonary specialty care (aOR 1.38 [95% CI: 1.30-1.46] for drive time >90 min compared to <30 min). Fragmented care was also associated with higher odds of guideline-discordant inhaler regimens (aOR 1.56 [95% CI: 1.48-1.63]).

Interpretation

Rurality, long drive time to care, and fragmented care were associated with greater prescription of guideline-discordant inhaler regimens after COPD hospitalization. These findings highlight the need to understand challenges in delivering evidence-based care.

Funding

NIHNCATS grants KL2TR002492 and UL1TR002494.

Analgesic use in ED patients with long-bone fractures: A national assessment of racial and ethnic disparities

BACKGROUND

It is vital to ensure equitable care is given to all patients and to eliminate any disparities in administration of analgesics and opioids in emergency department (ED) patients with long-bone fractures. Our objective was to determine whether sex, ethnic, or racial disparities still exist in administration and prescription of analgesics and opioids in ED patients with long-bone fractures using a current nationally representative database.

METHODS

This was a retrospective, cross-sectional analysis of ED patients ages 15-55 years with long-bone fractures included in the National Hospital and Medical Care Survey (NHAMCS) database from 2016 to 2019. Our primary and secondary outcomes were administration of analgesics and opioids in the ED and our exploratory outcomes were prescription of analgesics and opioids in discharged patients. Outcomes were adjusted for age, sex, race, insurance, fracture location, number of fractures, and pain severity.

RESULTS

Of the estimated 2.32 million ED patient visits analyzed, 65% received analgesics and 50% received opioids in the ED. On multivariable analyses, administration of analgesics was associated with female sex (OR 2.11; 95% CI 1.08-4.12) and Black race (OR 2.84; 95% CI 1.03-7.80), but not with Hispanic/Latino ethnicity (OR 2.09; 95% CI 0.72-6.04). No associations were found between opioid administration or analgesic or opioid prescription and female sex, Hispanic/Latino ethnicity, or Black race.

CONCLUSIONS

Between 2016 and 2019 there were no significant sex, ethnic, or racial disparities in administration or prescription of analgesics or opioids in ED adult patients with long-bone fractures.

Race, ethnicity, and gender representation in clinical case vignettes: a 20-year comparison between two institutions

BACKGROUND

The medical case vignette has long been used in medical student education and frequently includes demographic variables such as race, ethnicity and gender. However, inclusion of demographic variables without context may reinforce assumptions and biases. Yet, the absence of race, sexual orientation, and social determinants of health may reinforce a hidden curriculum that reflects cultural blindness. This replication study compared proportions of race, ethnicity, and gender with University of Minnesota (UMN) findings. This study sought to determine if there has been progress in the representation of demographic characteristics in case vignettes.

METHODS

University of North Carolina (UNC) case vignettes from 2015-2016 were analyzed and compared to UMN case vignettes from 1996-1998. Data included mentions of race, ethnicity, gender and social determinants of health.

RESULTS

In the 278 UNC vignettes, white race was noted in 19.7% of cases, black race was in 7.9% cases, and 76.6% of cases were unspecified. In the 983 UMN vignettes, white race was recorded in 2.85% cases, and black race in 0.41% cases. The institutions were significantly different in the proportion of their cases depicting race (0.20; 95% CI (0.15, 0.25)). Males were represented in the majority of vignettes.

DISCUSSION

Comparing case vignettes results from two medical schools suggests that reporting explicit demographic diversity was not significantly different. The findings illustrate that sex was the demographic characteristic consistently described, where males were over-represented. Based on these findings, greater cultural diversity as it intersects with social determinants of health is needed in medical student education.

White patients' physical responses to healthcare treatments are influenced by provider race and gender

The healthcare workforce in the United States is becoming increasingly diverse, gradually shifting society away from the historical overrepresentation of White men among physicians. However, given the long-standing underrepresentation of people of color and women in the medical field, patients may still associate the concept of doctors with White men and may be physiologically less responsive to treatment administered by providers from other backgrounds. To investigate this, we varied the race and gender of the provider from which White patients received identical treatment for allergic reactions and measured patients' improvement in response to this treatment, thus isolating how a provider's demographic characteristics shape physical responses to healthcare. A total of 187 White patients experiencing a laboratory-induced allergic reaction interacted with a healthcare provider who applied a treatment cream and told them it would relieve their allergic reaction. Unbeknownst to the patients, the cream was inert (an unscented lotion) and interactions were completely standardized except for the provider's race and gender. Patients were randomly assigned to interact with a provider who was a man or a woman and Asian, Black, or White. A fully blinded research assistant measured the change in the size of patients' allergic reaction after cream administration. Results indicated that White patients showed a weaker response to the standardized treatment over time when it was administered by women or Black providers. We explore several potential explanations for these varied physiological treatment responses and discuss the implications of problematic race and gender dynamics that can endure "under the skin," even for those who aim to be bias free.

Disparities in gynecologic cancer incidence, treatment, and survival: a narrative review of outcomes among black and white women in the United States

For patients diagnosed with ovarian, uterine, or cervical cancer, race impacts expected outcome, with black women suffering worse survival than white women for all three malignancies. Moreover, outcomes for black women have largely worsened since the 1970s. In this narrative review, we first provide an updated summary of the incidence and survival of ovarian, uterine, and cervical cancer, with attention paid to differences between white and black patients. We then offer a theoretical framework detailing how racial disparities in outcomes for each of the gynecologic malignancies can be explained as the sum result of smaller white-black differences in experience of preventive strategies, implementation of screening efforts, early detection of symptomatic disease, and appropriate treatment. Much research has been published regarding racial disparities in each of these domains, and with this review, we seek to curate the relevant literature and present an updated understanding of disparities between black and white women with gynecologic malignancies.

Disparities in acute decompensated heart failure

PURPOSE OF REVIEW

The aim of this review is to discuss racial and sex disparities in the management and outcomes of patients with acute decompensated heart failure (ADHF).

RECENT FINDINGS

Race and sex have a significant impact on in-hospital admissions and overall outcomes in patients with decompensated heart failure and cardiogenic shock. Black patients not only have a higher incidence of heart failure than other racial groups, but also higher admissions for ADHF and worse overall survival, while women receive less interventions for cardiogenic shock complicating acute myocardial infarction. Moreover, White patients are more likely than Black patients to be cared for by a cardiologist than a noncardiologist in the ICU, which has been linked to overall improved survival. In addition, recent data outline inherent racial and sex bias in the evaluation process for advanced heart failure therapies indicating that Black race negatively impacts referral for transplant, women are judged more harshly on their appearance, and that Black women are perceived to have less social support than others. This implicit bias in the evaluation process may impact appropriate timing of referral for advanced heart failure therapies.

SUMMARY

Though significant racial and sex disparities exist in the management and treatment of patients with decompensated heart failure, these disparities are minimized when therapies are properly utilized and patients are treated according to guidelines.

"The Tip of the Iceberg": Commentary on Sports, Health Inequity, and Trauma Exacerbated by COVID-19

OBJECTIVE

To discuss the relevance of system-level health inequities and their interplay with race in sports and athletic training, particularly during and after the coronavirus disease 2019 (COVID-19) pandemic.

BACKGROUND

Health inequity is a systemic and longstanding concern with dire consequences that can have marked effects on the lives of minority patients. As a result of the unequal consequences of the COVID-19 pandemic, the magnitude of the outcomes from health inequity in all spheres of American health care is being brought to the fore. The discourse within athletic training practice and policy must shift to intentionally creating strategies that acknowledge and account for systemic health inequities in order to facilitate an informed, evidence-based, and safe return to sport within the new normal.

CONCLUSIONS

To continue to evolve the profession and solidify athletic trainers' role in public health spaces post-COVID-19, professionals at all levels of athletic training practice and policy must intentionally create strategies that acknowledge and account for not only the social determinants of health but also the effects of racism and childhood trauma on overall health and well-being.

Association of Race and Major Adverse Cardiac Events (MACE): The Atherosclerosis Risk in Communities (ARIC) Cohort

Background and Aims

To evaluate the association of self-reported race with major adverse cardiac events (MACE) and modification of this association by paraoxonase gene (PON1, PON2, and PON3) single nucleotide polymorphisms (SNPs).

Methods

Included in this longitudinal study were 12,770 black or white participants from the Atherosclerosis Risk in Communities (ARIC) cohort who completed a baseline visit (1987–1989) with PON genotyping. Demographic, behavioral, and health information was obtained at baseline. MACE was defined as first occurrence of myocardial infarction, stroke, or CHD-related death through 2004. Cox proportional hazards regression was used to evaluate the association between race and MACE after adjustment for age, gender, and other demographic and cardiovascular risk factors such as diabetes and hypertension. Modification of the association between PON SNPs and MACE was also assessed.

Results

Blacks comprised 24.6% of the ARIC cohort; overall, 14.0% of participants developed MACE. Compared with whites, blacks had 1.24 times greater hazard of MACE (OR = 1.24,95%CI = 1.10,1.39) than whites after adjusting for age, gender, BMI, cigarette and alcohol use, educational and marital status, and aspirin use. This association became nonsignificant after further adjustment for high cholesterol, diabetes, and hypertension. None of the evaluated SNPs met the significance level (p < 0.001) after Bonferroni correction for multiple comparisons.

Conclusions

No association between race and MACE was identified after adjusting for high cholesterol, diabetes, and hypertension, suggesting that comorbidities are major determinants of MACE; medical intervention with focus on lifestyle and health management could ameliorate the development of MACE. Further studies are needed to confirm this observation.

Incorporating Sex and Gender-based Medical Education Into Residency Curricula

BACKGROUND

Emergency medicine (EM) residents do not generally receive sex- and gender-specific education. There will be increasing attention to this gap as undergraduate medical education integrates it within their curriculum.

METHODOLOGY

Members of the Sex and Gender in Emergency Medicine (SGEM) Interest Group set out to develop a SGEM toolkit and pilot integrating developed components at multiple residency sites. The curriculum initiative involved a pre- and posttraining assessment that included basic demographics and queries regarding previous training in sex-/gender-based medicine (SGBM). It was administered to PGY-1 to -4 residents who participated in a 3-hour training session that included one small group case-based discussion, two oral board cases, and one simulation and group debriefing.

ANALYSIS

Components of the developed toolkit (https://www.sexandgenderhealth.org) were implemented at four unique SGEM Interest Group member residency programs. Residents (n = 82/174, 47%) participated; 64% (n = 49) were male and 36% (n = 28) were female. Twenty-six percent (n = 21) of the residents reported that they had less than 1 hour of training in this domain during residency; 59% (n = 48) reported they had 1 to 6 hours and 16% (n = 13) reported they had >6 hours. The average preassessment score was 61% and postassessment was 88%. After training, 74% (n = 60) felt that their current practice would have benefited from further training in sex-/gender-based topics in medicine during medical school and 83% (n = 67) felt their clinical practice would have benefited from further training in this domain during residency.

IMPLICATIONS

The majority of EM residents who participated in this training program reported that they had limited instruction in this domain in medical school or residency. This initiative demonstrated a method that can be emulated for the incorporation of SGBM educational components into an EM residency training educational day. After training, the majority of residents who participated felt that their current practice would have benefited from further training in sex- and gender-based topics in residency.

Testing a somatization hypothesis to explain the Black-White depression paradox

PURPOSE

Epidemiologic studies document a lower prevalence of major depression in Blacks than Whites in the United States. This is paradoxical from the perspective of social stress theory. A long-standing claim in the (clinical) literature is that Blacks express depression more somatically than Whites. If true, the diagnostic algorithm may undercount depression in Blacks, since the screening symptoms privilege the psychological rather than somatic dimensions of depression. We test hypotheses that (1) Blacks express depression more somatically than Whites which (2) reduces their likelihood of endorsing screening symptoms, thereby undercounting Blacks' depression and explaining the Black-White depression paradox.

METHODS

We use cross-sectional data collected in 1991-92 from the National Longitudinal Alcohol Epidemiologic Survey (n = 42,862) among Blacks and Whites endorsing at least one past-12-month depression symptom. We compare groups on depression somatization and test whether greater somatization in Blacks leads to lower endorsement of psychological screening symptoms, and therefore under-diagnosis.

RESULTS

Blacks have higher mean depression somatization scores than Whites (0.28, SE 0.04 vs. 0.15, SE 0.02), t(122) = - 2.15, p = 0.03. This difference is small and driven by Blacks' higher endorsement of 1 somatic symptom (weight/appetite change) and Whites' greater propensity to endorse psychological symptoms. However, Blacks have the same odds as Whites of endorsing screening symptoms, before and after adjusting for somatization.

CONCLUSIONS

We find minimal evidence that Blacks express depression more somatically than Whites. Furthermore, this small difference does not appear to inhibit endorsement of diagnostic depression screening symptoms among Blacks, and therefore does not resolve the Black-White depression paradox.

Lack of Evidence for Racial Disparity in 30-Day All-Cause Readmission Rate for Older US Veterans Hospitalized with Heart Failure

BACKGROUND

Heart failure is the leading cause for 30-day all-cause readmission. Although racial disparities in health care are well documented, their impact on 30-day all-cause readmission rate is inconclusive.

OBJECTIVE

We examined the impact of racial disparity on 30-day readmission for hospitalized patients with heart failure.

METHODS

This is a retrospective secondary data analysis for a large veteran cohort in 130 Veterans Affairs Medical Centers. Propensity scores were used to reduce differences in age, gender, survival days, and comorbidities in index hospitalization among 46 524 whites and 14 124 African Americans (AA).

RESULTS

At index hospitalization, AA patients were younger (73.04 vs 67.10 years, t = -54.58, P < .000) and less likely to have myocardial infarcts (8.02% vs 9.80%, t = -6.36, P = .000), peripheral vascular disease (15.25% vs 22.51%, t = -18.68, P = .000), chronic obstructive pulmonary disease (39.59% vs 50.05%, t = -21.89, P < .000), and complicated diabetes (23.42% vs 26.24%, t = -6.73, P = .000). AA patients had lower mortality 30 days post-index hospitalization (3.51% vs 5.69%, t = -10.23, P = .000). In contrast, AA patients were more likely to have renal disease (44.03% vs 38.71%, t = 11.32, P < .000) and HIV/AIDS (1.56% vs 0.20%, t = 19.71, P < .000). The 30-day all-cause readmission rate before adjustments was 17.82% for AA patients versus 18.72% for white patients. There was no difference in the 2 rates after adjustments (18% vs 18%; odds of readmission = 1.002, z = 0.08, P = .937).

CONCLUSIONS

In a large Department of Veterans Affairs (VA) cohort, white and AA veterans hospitalized for heart failure had similar 30-day all-cause readmission rates after adjustments were made for age, gender, survival days, and comorbidities. However, the 30-day all-cause mortality rate was higher for white patients than for AA patients. Future prospective studies are needed to validate results and test generalizability outside the VA system of care.

Transthyretin Cardiac Amyloidosis in Black Americans

Transthyretin-related cardiac amyloidosis is a progressive infiltrative cardiomyopathy that mimics hypertensive and hypertrophic heart disease and often goes undiagnosed. In the United States, the hereditary form disproportionately afflicts black Americans, who when compared with whites with wild-type transthyretin amyloidosis, a phenotypically similar condition, present with more advanced disease despite having a noninvasive method for early identification (genetic testing). Although reasons for this are unclear, this begs to consider the inadequate access to care, societal factors, or a biological basis. In an effort to improve awareness and explore unique characteristics, we review the pathophysiology, epidemiology, and therapeutic strategies for transthyretin amyloidosis and highlight diagnostic pitfalls and clinical pearls for identifying patients with amyloid heart disease.

Gender Differences in Patients with Heart Failure

Aim: The aim of this literature review was to review and discuss the differences between men and women with heart failure with regard to epidemiology, aetiology, diagnostics, prognosis, pharmacological and non-pharmacological treatment, and the impact of heart failure on psychosocial factors and healthcare utilisation. Method: Two primary health care resources, MEDLINE and CINAHL, were selected to review the current literature. In MEDLINE, 234 abstracts dealing with heart failure and gender/sex were found and in CINAHL, 20 abstracts. Conclusion: Men have a higher incidence of heart failure, but the overall prevalence rate is similar in both sexes, since women survive longer after the onset of heart failure. Women tend to be older when diagnosed with heart failure and more often have diastolic dysfunction than men. The extent of sex differences in treatment, hospital cost and quality of care can partly be explained by age differences. The life situations for men and women with heart failure are different. Physical and social restrictions affecting daily life activities are experienced as most bothersome for men, whereas restrictions affecting the possibility to support family and friends are most difficult to accept for women. Women with heart failure ascribe more positive meanings to their illness. Despite this, women seem to experience a lower overall quality of life than men. The known gender differences in patients with heart failure need to be highlighted in guidelines as well as implemented in standard care.

Guideline-Appropriate Care and In-Hospital Outcomes in Patients With Heart Failure in Teaching and Nonteaching Hospitals: Findings From Get With The Guidelines-Heart Failure

BACKGROUND

Despite increasing awareness regarding evidence-based guidelines, considerable gaps exist for heart failure (HF) quality of care at teaching hospitals (TH) and nonteaching hospitals (NTH). We analyzed data from Get With The Guidelines (GWTG)-HF to compare the rates and trends of guideline-recommended care at TH and NTH for patients with HF.

METHOD AND RESULTS

Baseline patient characteristics, performance measures, and in-hospital outcomes were compared between 197 187 HF patients admitted to TH and 106 924 patients admitted to NTH between 2005 and 2014. Patients treated in TH were younger and were more likely to be black and uninsured. Defect-free care (defined as 100% compliance with performance measures) was similar in both group of hospitals (crude rates: 88% at TH versus 86% at NTH, adjusted odds ratio 0.99, 95% confidence interval 0.73-1.34) as were individual performance measures: discharge instruction, documentation of ejection fraction, use of angiotensin-converting enzyme inhibitors/angiotensin receptor antagonists, use of β-blocker, and smoking cessation counseling. During the study period, there was improvement in adherence with performance measures over time, with no significant difference at TH (adjusted odds ratio 1.20, 95% confidence interval 1.11-1.30; P<0.01) and NTH (adjusted odds ratio 1.09, 95% confidence interval 1.02-1.17; P=0.01; interaction P value 0.07).

CONCLUSIONS

Data from the GWTG-HF program suggest that there was improving and comparable adherence with HF performance measures and use of guideline-recommended therapies irrespective of hospital teaching status.

Overcoming Barriers to Access and Utilization of Hospice and Palliative Care Services in African-American Communities

While there is ample evidence to support the need for hospice and palliative care services for African Americans, only 8% of patients who utilize those services are from African-American communities. The underutilization of end-of-life and palliative care can be attributed to several barriers to service access including incompatibility between hospice philosophy and African-American religious, spiritual, and cultural beliefs; health care disparities; distrust of the medical establishment; physician influence; financial disincentives, and hospice admission criteria. Suggestions for dismantling barriers to care access include developing culturally competent professionals in the health and human services, expanding the philosophy of hospice to include spiritual advisors from client communities, and funding national initiatives to promote improved access to health care at all stages in the life cycle of members of all underserved communities.

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

Race Matters? Examining and Rethinking Race Portrayal in Preclinical Medical Education

Critical examination of "health disparities" is gaining consideration in medical schools across the United States, often as elective curricula that supplement required education. However, there is disconnect between discussions of race and disparities in these curricula and in core science courses. Specifically, required preclinical science lecturers often operationalize race as a biological concept, framing racialized disparities as inherent in bodies. A three- and five-month sampling of lecture slides at the authors' medical school demonstrated that race was almost always presented as a biological risk factor.This presentation of race as an essential component of epidemiology, risk, diagnosis, and treatment without social context is problematic, as a broad body of literature supports that race is not a robust biological category. The authors opine that current preclinical medical curricula inaccurately employ race as a definitive medical category without context, which may perpetuate misunderstanding of race as a bioscientific datum, increase bias among student-doctors, and ultimately contribute to worse patient outcomes.At the authors' institution, students approached the medical school administration with a letter addressing the current use of race, urging reform. The administration was receptive to proposals for further analysis of race in medical education and created a taskforce to examine curricular reform. Curricular changes were made as part of the construction of a longitudinal race-in-medicine curriculum. The authors seek to use their initiatives and this article to spark critical discussion on how to use teaching of race to work against racial inequality in health care.

Racial Differences in the Prevalence and Outcomes of Atrial Fibrillation in Patients Hospitalized With Heart Failure

Previous research has shown that roughly 15% to 30% of those with heart failure (HF) develop atrial fibrillation (AF). Although studies have shown variations in the incidence of AF in patients with HF, there has been no evidence of mortality differences by race. The purpose of this study was to assess AF prevalence and inhospital mortality in patients with HF among different racial groups in the United States. Using the National Inpatient Sample registry, the largest publicly available all-payer inpatient care database representing >95% of the US inpatient population, we analyzed subjects hospitalized with a primary diagnosis of HF from 2001 to 2011 (n = 11,485,673) using the International Classification of Diseases, Ninth Edition (ICD 9) codes 428.0-0.1, 428.20-0.23, 428.30-0.33, 428.40-0.43, and 428.9; patients with AF were identified using the ICD 9 code 427.31. We assessed prevalence and mortality among racial groups. Using logistic regression, we examined odds of mortality adjusted for demographics and co-morbidity using Elixhauser co-morbidity index. We also examined utilization of procedures by race. Of the 11,485,673 patients hospitalized with HF in our study, 3,939,129 (34%) had AF. Patients with HF and AF had greater inhospital mortality compared with those without AF (4.6% vs 3.3% respectively, p <0.0001). Additionally, black, Hispanic, Asian, and white patients with HF and AF had a 24%, 17%, 13%, and 6% higher mortality, respectively, than if they did not have AF. Among patients with HF and AF, minority racial groups had underutilization of catheter ablation and cardioversion compared with white patients. In conclusion, minority patients with HF and AF had a disproportionately higher risk of inpatient death compared with white patients with HF. We also found a significant underutilization of cardioversion and catheter ablation in minority racial groups compared with white patients.

Breastfeeding: An Unknown Factor to Reduce Heart Disease Risk Among Breastfeeding Women

BACKGROUND

Breastfeeding confers many health benefits not only to babies but also to their lactating mothers. Breastfeeding is a notable protective factor in the Gail model for breast cancer and is protective for heart disease. Although individuals in the Appalachian region have lower risk of developing breast cancer, their risk of heart disease is elevated compared with the national value for the United States.

SUBJECTS AND METHODS

We surveyed 155 predominantly breastfeeding mothers of toddlers under 3 years old, recruited through parenting groups, daycares, and county extension in Appalachian West Virginia. Participants were asked their perceived comparative risks for breast cancer and heart disease and why they felt their risk was higher, same, or lower than that of the general population.

RESULTS

For breast cancer, 29.7% felt their risk was lower than the general population. For heart disease, 26.5% felt their risk was lower than the general population. Although these risks were highly correlated (p=0.006), there was considerable variability in responses (p<0.03). Qualitative responses for breast cancer risk frequently included breastfeeding (30.3%) and family history (30.3%). Qualitative responses for heart disease noted family history (36.1%) but did not include breastfeeding. A regression analysis found that greater family history, shorter duration of breastfeeding, and fewer pregnancies were associated with greater breast cancer risk perceptions. Family history, lower household income, and current smoking were associated with greater heart disease risk perceptions.

CONCLUSIONS

These well-educated, predominantly lactating women did not know the protective effects of breastfeeding for heart disease. Increased educational efforts about heart disease may be helpful to encourage more women to breastfeed.

Impact of care at comprehensive cancer centers on outcome: Results from a population-based study

BACKGROUND

Rigorous processes ensure quality of research and clinical care at National Cancer Institute-designated comprehensive cancer centers (NCICCCs). Unmeasurable elements of structure and process of cancer care delivery warrant evaluation. To the authors' knowledge, the impact of NCICCC care on survival and access to NCICCCs for vulnerable subpopulations remain unstudied.

METHODS

The current study's population-based cohort of 69,579 patients had newly diagnosed adult-onset (aged 22-65 years) cancers reported to the Los Angeles County cancer registry between 1998 and 2008. Geographic information systems were used for geospatial analysis.

RESULTS

With regard to overall survival across multiple diagnoses, patients not receiving their first planned treatment at NCICCCs experienced poorer outcomes compared with those treated at NCICCCs; differences persisted on multivariable analyses after adjusting for clinical and sociodemographic factors (hepatobiliary: hazard ratio [HR], 1.5; 95% confidence interval [95% CI], 1.4-1.7 [P<.001]; lung: HR, 1.4; 95% CI, 1.3-1.6 [P<.001]; pancreatic: HR, 1.5; 95% CI, 1.3-1.7 [P<.001]; gastric: HR, 1.3; 95% CI, 1.1-1.7 [P = .01]; breast: HR, 1.3; 95% CI, 1.1-1.5 [P<.001]; and colorectal: HR, 1.2; 95% CI, 1.0-1.4 [P = .05]). With regard to barriers to care, multivariable analyses revealed that a lower likelihood of treatment at NCICCCs was associated with race/ethnicity (African-American: OR range across diagnoses: 0.4-0.7 [P<.03]; Hispanic: OR range, 0.5-0.7 [P<.04]); lack of private insurance (public: OR range, 0.6-0.8 [P<.004]; uninsured: OR range, 0.1-0.5 [P<.04]); less than high socioeconomic status (high-middle: OR range, 0.4-0.7 [P<.02]; middle: OR range, 0.3-0.5 [P<.001]; and low: OR range, 0.2-0.6 [P<.01]), and residing >9 miles from the nearest NCICCC (OR range, 0.5-0.7 [P<.02]).

CONCLUSIONS

Among individuals aged 22 to 65 years residing in Los Angeles County with newly diagnosed adult-onset cancer, those who were treated at NCICCCs experienced superior survival compared with those treated at non-NCICCC facilities. Barriers to care at NCICCCs included race/ethnicity, insurance, socioeconomic status, and distance to an NCICCC.

Post-discharge follow-up visits and hospital utilization by Medicare patients, 2007-2010

OBJECTIVE

Document trends in time to post-discharge follow-up visit for Medicare patients with an index admission for heart failure (HF), acute myocardial infarction (AMI), or community-acquired pneumonia (CAP). Determine factors predicting whether the first post-discharge utilization event is a follow-up visit, treat-and-release emergency department (ED) visit, or readmission.

METHODS

Using Medicare claims data from 2007-2010, we plotted annual cumulative incidence functions for the time frame post-discharge to follow-up visit, accounting for competing risks with censoring at 30 days. We used multinomial probit regression to determine factors predicting the probability of first-occurring post-discharge utilization events within 30 days.

RESULTS

For each cohort, the cumulative incidence of follow-up visits increased during the study period. For example, in 2010, 54.6% of HF patients had a follow-up visit within 10 days of discharge compared to 47.9% in 2007. Within each cohort, the largest increase in follow-up visits took place between 2008 and 2009. Follow-up visits were less likely for patients who were Black, Hispanic, and enrolled in Medicaid or Medicare Advantage, and they were more likely for patients with greater comorbidities and prior procedures as well as those with private or supplemental Medicare coverage. There were no changes in 30-day readmission rates.

DISCUSSION

Although increases in follow-up visits may have been influenced by the introduction of publicly reported readmission rates in 2009, these increases did not continue in 2010 and were not associated with a change in readmissions. Patients who were Black, Hispanic, and/or enrolled in Medicaid or Medicare Advantage were less likely to have follow-up visits.

Comparing teaching versus nonteaching hospitals: the association of patient characteristics with teaching intensity for three common medical conditions

PURPOSE

To quantify the role of teaching hospitals in direct patient care, the authors compared characteristics of patients served by hospitals of varying teaching intensity.

METHOD

The authors studied Medicare beneficiaries ≥ 66 years old, hospitalized in 2009-2010 for acute myocardial infarction, heart failure, or pneumonia. They categorized hospitals as nonteaching, teaching, or Council of Teaching Hospitals and Health Systems (COTH) members and performed secondary analyses using intern and resident-to-bed ratios. The authors used descriptive statistics, adjusted odds ratios, and linear propensity scores to compare patient characteristics among teaching intensity levels. They supplemented Medicare mortality model variables with race, transfer status, and distance traveled.

RESULTS

Adjusted for comorbidities, black patients had 2.44 (95% confidence interval [CI] 2.36-2.52), 2.56 (95% CI 2.51-2.60), and 2.58 (95% CI 2.51-2.65) times the odds of COTH hospital admission compared with white patients for acute myocardial infarction, heart failure, and pneumonia, respectively. For patients transferred from another hospital's inpatient setting, the corresponding adjusted odds ratios of COTH hospital admission were 3.99 (95% CI 3.85-4.13), 4.60 (95% CI 4.34-4.88), and 4.62 (95% CI 4.16-5.12). Using national data, distributions of propensity scores (probability of admission to a COTH hospital) varied markedly among teaching intensity levels. Data from Massachusetts and California illustrated between-state heterogeneity in COTH utilization.

CONCLUSIONS

Major teaching hospitals are significantly more likely to provide care for minorities and patients requiring transfer from other institutions for advanced care.Both are essential to an equitable and high-quality regional health care system.

Making equity a value in value-based health care

Equity in health and health care in America continues to be a goal unmet. Certain demographic groups in the United States-including racial and ethnic minorities and individuals with lower socioeconomic status-have poorer health outcomes across a wide array of diseases, and have higher all-cause mortality. Yet despite growing understanding of how social-, structural-, and individual-level factors maintain and create inequities, solutions to reduce or eliminate them have been elusive. In this article, the authors envision how disparities-related provisions in the Affordable Care Act and other recent legislation could be linked with new value-based health care requirements and payment models to create incentives for narrowing health care disparities and move the nation toward equity.Specifically, the authors explore how recent legislative actions regarding payment reform, health information technology, community health needs assessments, and expanding health equity research could be woven together to build an evidence base for solutions to health care inequities. Although policy interventions at the clinical and payer levels alone will not eliminate disparities, given the significant role the social determinants of health play in the etiology and maintenance of inequity, such policies can allow the health care system to better identify and leverage community assets; provide high-quality, more equitable care; and demonstrate that equity is a value in health.

The National Cancer Institute-American Society of Clinical Oncology Cancer Trial Accrual Symposium: summary and recommendations

INTRODUCTION

Many challenges to clinical trial accrual exist, resulting in studies with inadequate enrollment and potentially delaying answers to important scientific and clinical questions.

METHODS

The National Cancer Institute (NCI) and the American Society of Clinical Oncology (ASCO) cosponsored the Cancer Trial Accrual Symposium: Science and Solutions on April 29-30, 2010 to examine the state of accrual science related to patient/community, physician/provider, and site/organizational influences, and identify new interventions to facilitate clinical trial enrollment. The symposium featured breakout sessions, plenary sessions, and a poster session including 100 abstracts. Among the 358 attendees were clinical investigators, researchers of accrual strategies, research administrators, nurses, research coordinators, patient advocates, and educators. A bibliography of the accrual literature in these three major areas was provided to participants in advance of the meeting. After the symposium, the literature in these areas was revisited to determine if the symposium recommendations remained relevant within the context of the current literature.

RESULTS

Few rigorously conducted studies have tested interventions to address challenges to clinical trials accrual. Attendees developed recommendations for improving accrual and identified priority areas for future accrual research at the patient/community, physician/provider, and site/organizational levels. Current literature continues to support the symposium recommendations.

CONCLUSIONS

A combination of approaches addressing both the multifactorial nature of accrual challenges and the characteristics of the target population may be needed to improve accrual to cancer clinical trials. Recommendations for best practices and for future research developed from the symposium are provided.

Heart failure in North America

Heart failure is a major health problem that affects patients and healthcare systems worldwide. Within the continent of North America, differences in economic development, genetic susceptibility, cultural practices, and trends in risk factors and treatment all contribute to both inter-continental and within-continent differences in heart failure. The United States and Canada represent industrialized countries with similar culture, geography, and advanced economies and infrastructure. During the epidemiologic transition from rural to industrial in countries such as the United States and Canada, nutritional deficiencies and infectious diseases made way for degenerative diseases such as cardiovascular diseases, cancer, overweight/obesity, and diabetes. This in turn has resulted in an increase in heart failure incidence in these countries, especially as overall life expectancy increases. Mexico, on the other hand, has a less developed economy and infrastructure, and has a wide distribution in the level of urbanization as it becomes more industrialized. Mexico is under a period of epidemiologic transition and the etiology and incidence of heart failure is rapidly changing. Ethnic differences within the populations of the United States and Canada highlight the changing demographics of each country as well as potential disparities in heart failure care. Heart failure with preserved ejection fraction makes up approximately half of all hospital admissions throughout North America; however, important differences in demographics and etiology exist between countries. Similarly, acute heart failure etiology, severity, and management differ between countries in North America. The overall economic burden of heart failure continues to be large and growing worldwide, with each country managing this burden differently. Understanding the inter-and within-continental differences may help improve understanding of the heart failure epidemic, and may aid healthcare systems in delivering better heart failure prevention and treatment.

The Legacy of the U. S. Public Health Services Study of Untreated Syphilis in African American Men at Tuskegee on the Affordable Care Act and Health Care Reform Fifteen Years After President Clinton's Apology

This special issue addresses the legacy of the United States Public Health Service Syphilis Study on health reform, particularly the Affordable Care Act (ACA). The 12 manuscripts cover the history and current practices of ethical abuses affecting American Indians, Latinos, Asian Americans and African Americans in the United States and in one case, internationally. Commentaries and essays include the voice of a daughter of one of the study participants in which we learn of the stigma and maltreatment some of the families experienced and how the study has impacted generations within the families. Consideration is given in one essay to utilizing narrative storytelling with the families to help promote healing. This article provides the reader a roadmap to the themes that emerged from the collection of articles. These themes include population versus individual consent issues, need for better government oversight in research and health care, the need for overhauling our bioethics training to develop a population level, culturally driven approach to research bioethics. The articles challenge and inform us that some of our assumptions about how the consent process best works to protect racial/ethnic minorities may be merely assumptions and not proven facts. Articles challenge the belief that low participation rates seen in biomedical studies have resulted from the legacy of the USPHS Syphilis Study rather than a confluence of factors rooted in racism, bias and negative treatment. Articles in this special issue challenge the "cultural paranoia" of mistrust and provide insights into how the distrust may serve to lengthen rather than shorten the lives of racial/ethnic minorities who have been used as guinea pigs on more than one occasion. We hope that the guidance offered on the importance of developing a new framework to bioethics can be integrated into the foundation of health care reform.

Racial/ethnic minority access to end-of-life care: a conceptual framework

Minority underutilization of hospice care has been well-documented; however, explanations addressing disparities have failed to examine the scope of factors in operation. Drawing from previous health care access models, a framework is proposed in which access to end-of-life care results from an interaction between patient-level, system-level, and societal-level barriers with provider-level mediators. The proposed framework introduces an innovative mediating factor missing in previous models, provider personal characteristics, to better explain care access disparities. This article offers a synthesis of previous research and proposes a framework that is useful to researchers and clinicians working with minorities at end of life.

Racial/ethnic differences in emergency care for joint dislocation in 53 US EDs

OBJECTIVE

The aim of the study was to investigate racial/ethnic differences in emergency care for patients with joint dislocation.

METHODS

We performed a secondary analysis of the dislocation component of the National Emergency Department Safety Study. Using a principal diagnosis of dislocation, we identified emergency department (ED) visits for joint dislocations in 53 urban EDs across 19 US states between 2003 and 2005. Quality of care was evaluated based on 9 guideline-concordant care measures.

RESULTS

Of the 1945 patients included in this analysis, 1124 (58%) were white; 561 (29%), black, and 260 (13%), Hispanic. One-third of the 53 EDs cared for 51% of minority patients. After multivariable adjustment, black patients were less likely to receive any analgesic treatment (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.51-0.90) or opioid treatment (OR, 0.64; 95% CI, 0.41-0.997), waited longer to receive analgesia (mean difference in time to analgesic treatment, 32 minutes; 95% CI, 16-52 minutes), and were less likely to receive reassessments of pain (OR, 0.49; 95% CI, 0.34-0.70) compared with white patients. There were no ethnic disparities in most of the care measures between Hispanic and white patients. There were no disparities in initial pain assessment, pre- and postprocedural neurovascular assessment, procedural monitoring, or success of joint reduction across the racial/ethnic groups.

CONCLUSIONS

Black patients presenting to the ED with joint dislocations received lower quality of care in some, but not all, areas compared with white patients. Future interventions should target these areas to eliminate racial disparities in dislocation care.

The role of unconscious bias in surgical safety and outcomes

Racial, ethnic, and gender disparities in health outcomes are a major challenge for the US health care system. Although the causes of these disparities are multifactorial, unconscious bias on the part of health care providers plays a role. Unconscious bias occurs when subconscious prejudicial beliefs about stereotypical individual attributes result in an automatic and unconscious reaction and/or behavior based on those beliefs. This article reviews the evidence in support of unconscious bias and resultant disparate health outcomes. Although unconscious bias cannot be entirely eliminated, acknowledging it, encouraging empathy, and understanding patients' sociocultural context promotes just, equitable, and compassionate care to all patients.

Payment source, quality of care, and outcomes in patients hospitalized with heart failure

OBJECTIVES

The aim of this study was to analyze the relationship between payment source and quality of care and outcomes in heart failure (HF).

BACKGROUND

HF is a major cause of morbidity and mortality. There is a lack of studies assessing the association of payment source with HF quality of care and outcomes.

METHODS

A total of 99,508 HF admissions from 244 sites between January 2005 and September 2009 were analyzed. Patients were grouped on the basis of payer status (private/health maintenance organization, no insurance, Medicare, or Medicaid) with private/health maintenance organization as the reference group.

RESULTS

The no-insurance group was less likely to receive evidence-based beta-blockers (adjusted odds ratio [OR]: 0.73; 95% confidence interval [CI]: 0.62 to 0.86), implantable cardioverter-defibrillator (OR: 0.59; 95% CI: 0.50 to 0.70), or anticoagulation for atrial fibrillation (OR: 0.73; 95% CI: 0.61 to 0.87). Similarly, the Medicaid group was less likely to receive evidence-based beta-blockers (OR: 0.86; 95% CI: 0.78 to 0.95) or implantable cardioverter-defibrillators (OR: 0.86; 95% CI: 0.78 to 0.96). Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and beta-blockers were prescribed less frequently in the Medicare group (OR: 0.89; 95% CI: 0.81 to 0.98). The Medicare, Medicaid, and no-insurance groups had longer hospital stays. Higher adjusted rates of in-hospital mortality were seen in patients with Medicaid (OR: 1.22; 95% CI: 1.06 to 1.41) and in patients with reduced systolic function with no insurance.

CONCLUSIONS

Decreased quality of care and outcomes for patients with HF were observed in the no-insurance, Medicaid, and Medicare groups compared with the private/health maintenance organization group.

Predictors of nonadherence to national hospital quality measures for heart failure and pneumonia

BACKGROUND

Understanding factors associated with process measure nonadherence may improve both patient care and future measure design.

METHODS

We analyzed 3401 patients with heart failure and 2186 patients with pneumonia who were eligible for at least 1 National Hospital Quality Measure at an urban tertiary medical center from July 1, 2004, to June 30, 2008. We investigated the association of socioeconomic, demographic, clinical, and care delivery factors with process measure nonadherence, using multivariable analysis.

RESULTS

Demographic and socioeconomic variables were unrelated to heart failure measure adherence. Nonadherence with angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker use was more common in patients with renal failure (odds ratio [OR] 2.56; 95% confidence interval [CI], 1.46-4.49), and patients admitted to noncardiac units more often failed the heart failure all-or-none measure (OR 2.22; 95% CI, 1.79-2.75). Patients with pneumonia who were admitted via the emergency department were less likely to fail antibiotic timing (OR 0.41; 95% CI, 0.27-0.63), whereas those with a history of methicillin-resistant Staphylococcus aureus (OR 2.63; 95% CI, 1.31-5.28) or requiring intensive care unit admission (OR 11.4; 95% CI, 6.3-20.8) were more likely to fail the antibiotic selection measure.

CONCLUSION

Demographic and socioeconomic factors were generally unrelated to process measure nonadherence, demonstrating that excellent inpatient care can be delivered even to vulnerable populations. Clinical predictors suggest opportunities for improving both medical record documentation of appropriate exclusions and future measure specifications, especially for complex patients. Care delivery factors substantially affect process adherence.

Hospital-reported data on the pneumonia quality measure "Time to First Antibiotic Dose" are not associated with inpatient mortality: results of a nationwide cross-sectional analysis

OBJECTIVES

Significant controversy exists regarding the Centers for Medicare & Medicaid Services (CMS) "time to first antibiotics dose" (TFAD) quality measure. The objective of this study was to determine whether hospital performance on the TFAD measure for patients admitted from the emergency department (ED) for pneumonia is associated with decreased mortality.

METHODS

This was a cross-sectional analysis of 95,704 adult ED admissions with a principal diagnosis of pneumonia from 530 hospitals in the 2007 Nationwide Inpatient Sample. The sample was merged with 2007 CMS Hospital Compare data, and hospitals were categorized into TFAD performance quartiles. Univariate association of TFAD performance with inpatient mortality was evaluated by chi-square test. A population-averaged logistic regression model was created with an exchangeable working correlation matrix of inpatient mortality adjusted for age, sex, comorbid conditions, weekend admission, payer status, income level, hospital size, hospital location, teaching status, and TFAD performance.

RESULTS

Patients had a mean age of 69.3 years. In the adjusted analysis, increasing age was associated with increased mortality with odds ratios (ORs) of >2.3. Unadjusted inpatient mortality was 4.1% (95% confidence interval [CI] = 3.9% to 4.2%). Median time to death was 5 days (25th-75th interquartile range = 2-11). Mean TFAD quality performance was 77.7% across all hospitals (95% CI = 77.6% to 77.8%). The risk-adjusted OR of mortality was 0.89 (95% CI = 0.77 to 1.02) in the highest performing TFAD quartile, compared to the lowest performing TFAD quartile. The second highest performing quartile OR was 0.94 (95% CI = 0.82 to 1.08), and third highest performing quartile was 0.91 (95% CI = 0.79 to 1.05).

CONCLUSIONS

In this nationwide heterogeneous 2007 sample, there was no association between the publicly reported TFAD quality measure performance and pneumonia inpatient mortality.

Association of race/ethnicity with clinical risk factors, quality of care, and acute outcomes in patients hospitalized with heart failure

BACKGROUND

Black and Hispanic populations are at increased risk for developing heart failure (HF) at a younger age and experience differential morbidity and possibly differential mortality compared with whites. Yet, there have been insufficient data characterizing the clinical presentation, quality of care, and outcomes of patients hospitalized with HF as a function of race/ethnicity.

METHODS

We analyzed 78,801 patients from 257 hospitals voluntarily participating in the American Heart Association's Get With The Guidelines-HF Program from January 2005 thru December 2008. There were 56,266 (71.4%) white, 17,775 (22.6%) black, and 4,760 (6.0%) Hispanic patients. In patients hospitalized with HF, we sought to assess clinical characteristics, adherence to core and other guideline-based HF care measures, and in-hospital mortality as a function of race and ethnicity.

RESULTS

Relative to white patients, Hispanic and black patients were significantly younger (median age 78.0, 63.0, 64.0 years, respectively), had lower left ventricular ejection fractions, and had more diabetes mellitus and hypertension. With few exceptions, the provision of guideline-based care was comparable for black, Hispanic, and white patients. Black and Hispanic patients had lower in-hospital mortality than white patients: black/white odds ratio 0.69, 95% CI 0.62-0.78, P < .001 and Hispanic/white odds ratio 0.81, 95% CI 0.67-0.98, P = .03.

CONCLUSIONS

Hispanic and black patients hospitalized with HF have more cardiovascular risk factors than white patients; however; they have similar or better in-hospital mortality rates. Within the context of a national HF quality improvement program, HF care was equitable and improved in all racial/ethnic groups over time.

Sex is not enough: the need for gender-based analysis in health research

To gain a more detailed understanding of health care utilization patterns, researchers have begun to disaggregate administrative data by a number of important variables, including sex. Our purpose in this article is to confirm the need for sex-disaggregated data in health research, but also to argue that the further step of gender-based analysis is necessary. We focus on a number of conceptual and methodological issues surrounding sex-disaggregated administrative data, and we conclude that sex disaggregation alone is insufficient. Gender-sensitive indicators must be developed and used in order to understand the context of health differences and develop appropriate policies and programs.

Thirty-day readmission rates for Medicare beneficiaries by race and site of care

CONTEXT

Understanding whether and why there are racial disparities in readmissions has implications for efforts to reduce readmissions.

OBJECTIVE

To determine whether black patients have higher odds of readmission than white patients and whether these disparities are related to where black patients receive care.

DESIGN

Using national Medicare data, we examined 30-day readmissions after hospitalization for acute myocardial infarction (MI), congestive heart failure (CHF), and pneumonia. We categorized hospitals in the top decile of proportion of black patients as minority-serving. We determined the odds of readmission for black patients compared with white patients at minority-serving vs non-minority-serving hospitals.

SETTING AND PARTICIPANTS

Medicare Provider Analysis Review files of more than 3.1 million Medicare fee-for-service recipients who were discharged from US hospitals in 2006-2008.

MAIN OUTCOME MEASURE

Risk-adjusted odds of 30-day readmission.

RESULTS

Overall, black patients had higher readmission rates than white patients (24.8% vs 22.6%, odds ratio [OR], 1.13; 95% confidence interval [CI], 1.11-1.14; P < .001); patients from minority-serving hospitals had higher readmission rates than those from non-minority-serving hospitals (25.5% vs 22.0%, OR, 1.23; 95% CI, 1.20-1.27; P < .001). Among patients with acute MI and using white patients from non-minority-serving hospitals as the reference group (readmission rate 20.9%), black patients from minority-serving hospitals had the highest readmission rate (26.4%; OR, 1.35; 95% CI, 1.28-1.42), while white patients from minority-serving hospitals had a 24.6% readmission rate (OR, 1.23; 95% CI, 1.18-1.29) and black patients from non-minority-serving hospitals had a 23.3% readmission rate (OR, 1.20; 95% CI, 1.16-1.23; P < .001 for each); patterns were similar for CHF and pneumonia. The results were unchanged after adjusting for hospital characteristics including markers of caring for poor patients.

CONCLUSION

Among elderly Medicare recipients, black patients were more likely to be readmitted after hospitalization for 3 common conditions, a gap that was related to both race and to the site where care was received.

Disparity of care in the acute care of patients with heart failure

OBJECTIVES

It has been well documented that screening, prevention, and treatment disparities in cardiovascular care exist. Most studies have focused on the outpatient setting. The purpose of the present analysis was to assess if a disparity of care exists in the care of emergency department (ED) patients with acute heart failure in a secondary analysis of the Heart Failure and Audicor Technology for Rapid Diagnosis and Initial Treatment (HEARD-IT) multinational study.

METHODS

Only patients with an adjudicated diagnosis of acute heart failure were included in this analysis. Racial groups included in this analysis were limited to white and African American or black patients, due to their predominance in the cohort. Logistic regression including clinically relevant demographics, past medical history, exam, diagnostic tests, and adjudicated diagnosis of acute heart failure as covariates was performed to assess the association of race with treatment with a diuretic or nitroglycerin and 30-day death or readmission.

RESULTS

Of the cohort, 418 of 1,076 (38.8%) were included in the analysis. Median age was 69 years (interquartile range [IQR]=55-79 years), 49% were white, and 51% were African American or black. There was no difference in the correct admitting diagnosis in the two groups (p=0.83). Multivariate adjustment revealed that African American or black race was not associated with treatment with diuretics (adjusted odds ratio [OR]=1.00, 95% confidence interval [CI]=0.55 to 1.82) or nitrates (adjusted OR=1.27, 95% CI=0.76 to 2.13) in the ED. In a separate regression analysis there was no association with African American or black race with 30-day adverse events (adjusted OR=1.22, 95% CI=0.68 to 2.16).

CONCLUSIONS

This secondary analysis of HEARD-IT data did not identify racial disparities in the treatment of adults with acute heart failure in the ED.

Disparities in the use of radiation therapy in patients with local-regionally advanced breast cancer

BACKGROUND

Radiation therapy (RT) is indicated for the treatment of local-regionally advanced breast cancer (BCa).

HYPOTHESIS

We hypothesized that black and Hispanic patients with local-regionally advanced BCa would receive lower rates of RT than their white counterparts.

METHODS

The Surveillance Epidemiology and End Results database was used to identify white, black, Hispanic, and Asian patients with invasive BCa and ≥10 metastatic lymph nodes diagnosed between 1988 and 2005. Univariate and multivariate logistic regression evaluated the relationship of race/ethnicity with use of RT. Multivariate models stratified for those undergoing mastectomy or lumpectomy.

RESULTS

Entry criteria were met by 12,653 patients. Approximately half of the patients did not receive RT. Most patients were white (72%); the remainder were Hispanic (10.4%), black (10.3%), and Asian (7.3%). On univariate analysis, Hispanics (odd ratio [OR] 0.89; 95% confidence interval [CI], 0.79-1.00) and blacks (OR 0.79; 95% CI, 0.70-0.89) were less likely to receive RT than whites. On multivariate analysis, blacks (OR 0.76; 95% CI, 0.67-0.86) and Hispanics (OR 0.80; 95% CI, 0.70-0.90) were less likely than whites to receive RT. Disparities persisted for blacks (OR 0.74; 95% CI, 0.64-0.85) and Hispanics (OR 0.77; 95% CI, 0.67-0.89) who received mastectomy, but not for those who received lumpectomy.

CONCLUSIONS

Many patients with local-regionally advanced BCa do not receive RT. Blacks and Hispanics were less likely than whites to receive RT. This disparity was noted predominately in patients who received mastectomy. Future efforts at improving rates of RT are warranted. Efforts at eliminating racial/ethnic disparities should focus on black and Hispanic candidates for postmastectomy RT.

Health disparities: a primer for public health social workers

In 2001, the U.S. Department of Health and Human Services published Healthy People 2010, which identified objectives to guide health promotion and to eliminate health disparities. Since 2001, much research has been published documenting racial and ethnic disparities in healthcare. Although progress has been made in eliminating the disparities, ongoing work by public health social workers, researchers, and policy analysts is needed. This paper focuses on racial and ethnic health disparities, why they exist, where they can be found, and some of the key health/medical conditions identified by the U.S. Department of Health and Human Services to receive attention. Finally, there is a discussion of what policy, professional and community education, and research can to do to eliminate racial and ethnic disparities in healthcare.

Do hospitals provide lower quality of care to black patients for pneumonia?

OBJECTIVES

Recent studies reported lower quality of care for black vs. white patients with community-acquired pneumonia and suggested that disparities persist at the individual hospital level. We examined racial differences in emergency department and intensive care unit care processes to determine whether differences persist after adjusting for case-mix and variation in care across hospitals.

DESIGN

Prospective, observational cohort study.

SETTING

Twenty-eight U.S. hospitals.

PATIENTS

Patients with community-acquired pneumonia: 1738 white and 352 black patients.

INTERVENTIONS

None.

MEASUREMENTS

We compared care quality based on antibiotic receipt within 4 hrs and adherence to American Thoracic Society antibiotic guidelines, and intensity based on intensive care unit admission and mechanical ventilation use. Using random effects and generalized estimating equations models, we adjusted for case-mix and clustering of racial groups within hospitals and estimated odds ratios for differences in care within and across hospitals.

MAIN RESULTS

Black patients were less likely to receive antibiotics within 4 hrs (odds ratio, 0.55; 95% confidence interval, 0.43-0.70; p < .001) and less likely to receive guideline-adherent antibiotics (odds ratio, 0.72; 95% confidence interval, 0.57-0.91; p = .006). These differences were attenuated after adjusting for casemix (odds ratio, 0.59; 95% confidence interval; 0.46-0.76 and 0.84; 95% confidence interval, 0.66 -1.09). Within hospitals, black and white patients received similar care quality (odds ratio, 1; 95% confidence interval, 0.97-1.04 and 1; 95% confidence interval, 0.97-1.03). However, hospitals that served a greater proportion of black patients were less likely to provide timely antibiotics (odds ratio, 0.84; 95% confidence interval, 0.78-0.90). Black patients were more likely to receive mechanical ventilation (odds ratio, 1.57; 95% confidence interval, 1.02-2.42; p = .042). Again, within hospitals, black and white subjects were equally likely to receive mechanical ventilation (odds ratio, 1; 95% confidence interval, .94-1.06) and hospitals that served a greater proportion of black patients were more likely to institute mechanical ventilation (odds ratio, 1.13; 95% confidence interval, 1.02-1.25).

CONCLUSIONS

Black patients appear to receive lower quality and higher intensity of care in crude analyses. However, these differences were explained by different case-mix and variation in care across hospitals. Within the same hospital, no racial differences in care were observed.

Mortality after hospitalization for heart failure in blacks compared to whites

Heart failure (HF) disproportionately affects black compared to white Americans, and overall mortality from HF is greater among blacks. Paradoxically, mortality rates after a hospitalization for HF are lower in black than in white patients. These racial differences might reflect hospital, physician, and patient factors and could have implications for comparative hospital profiles. We identified published studies reporting the posthospitalization mortality for black and white patients with a discharge diagnosis of HF and conducted random-effects meta-analyses with the outcome of all-cause mortality. We included 29 cohorts of hospitalized black and white patients with HF. The unadjusted mean mortality rate after HF hospitalization for black and white patients, respectively, was 6% and 9% for in-hospital, 6% and 10% for 30-day, 10% and 15% for 60- to 180-day, 28% and 34% for 1-year, and 41% and 47% for >1-year follow-up, respectively. The unadjusted combined odds ratios for mortality in black versus white patients ranged from 0.48 for in-hospital (95% confidence interval [CI] 0.45 to 0.51) to 0.77 after >1 year follow-up (95% CI 0.75 to 0.79). In meta-analyses using adjusted data, the combined odds ratio was 0.68 for short-term mortality (95% CI 0.63 to 0.74), and the combined hazard ratio was 0.84 for long-term mortality (95% CI 0.77 to 0.91). In conclusion, mortality after hospitalization for HF was 32% lower during short-term follow-up and 16% lower during long-term follow-up for black than for white patients. The mortality differences imply unmeasured differences by race in clinical severity of illness at hospital admission and might lead to biased hospital mortality profiles.