White Coat Underground

ResearchBlogging.orgAn interesting article was recently published in the Annals of Internal Medicine, the journal of the American College of Physicians (my professional organization). It has been noted in previous studies that there are differences in outcomes between African Americans and whites who are diagnosed with a heart attack. What hasn’t been clear is the reason for these differences.

There are known disparities in access to health care, and there is sometimes a stated distrust in the medical system by minorities (not just due to such atrocities as the Tuskegee Syphilis Study). Many of us who practice clinical medicine have had to work hard to earn the trust of our minority patients. There are also significant differences in health risks in self-indentified blacks and whites. Do these explain the extent of health disparities? In documenting disparities we only identify the problem; if we don’t know why blacks and whites have different outcomes, we cannot move forward to improve care.

This study is a prospective cohort study. White and black patients who had myocardial infarctions and survived were enrolled and followed over the course of about two years. The study focused on how people felt, and on clinical factors such as re-hospitalization.

Mortality rates at two years were significantly higher for blacks (19.9% for black patients versus 9.3% for white patients; crude hazard ratio (HR) 2.31 (CI, 1.77 to 3.00)). Blacks were not more likely to be re-hospitalized (a surrogate measure of outcome and health), but were significantly more likely to experience chest pain and reported a decreased quality of life compared to white patients.

But here comes the interesting part:

In general, the outcome differences between black and white patients were most attenuated by adjusting for patient characteristics present before admission (such as socioeconomic status and comorbid conditions) and were only marginally affected by adjusting for differences in treatment. Our findings suggest that racial disparities in outcome are associated with a myriad of racial differences in risk factors for adverse outcomes and that focusing on the processes of care for myocardial infarction may not be the most effective strategy for achieving equity in outcomes.

In other words, most of the differences in black and white patients were not due to disparities in their hospital care but in their overall health and socioeconomic status.

This has profound implications regarding health care inequality in the U.S. If these data are accurate, independent of how we treat people in the hospital during a heart attack, a patient’s position in society, and to some extent their other ethnically-linked health problems, predict outcomes. This implies that health care inequalities have a significant societal component independent of how patients are treated in the hospital. Disparities in class may be more significant than disparities in treatment.

This certainly makes sense. Those who are poor have less access to insurance, medication, and frequent medical follow up care.

I may be beating a dead horse here, but universal coverage may be one big step toward eliminating racial disparities in our health care system.

John A. Spertus, MD, MPH; Philip G. Jones, MS; Frederick A. Masoudi, MD, MSPH; John S. Rumsfeld, MD, PhD; and Harlan M. Krumholz, MD, SM (2009). Factors Associated With Racial Differences in Myocardial Infarction Outcomes Annals of Internal Medicine, 150 (5), 314-324 PMID: 19258559

Comments

  1. #1 paulie
    March 12, 2009

    First, let me say that I’m a fan of the blog, and another practicing internist who favors universal health coverage, preferably via a single payor system.

    But I beg to differ with one point you made about the article, when you said “we treat people pretty much the same in the hospital during a heart attack”. What this fascinating study actually showed is that 1) black patients were significantly less likely to get percutaneous intervention, any left heart cath at all, bypass surgery, or certain standard medications like statins and 2)that the relative lack of these procedures and medications, when eliminated by statistical legerdemain, didn’t adversely affect their outcomes nearly as much as did the social and economic factors that they entered the hospital with. We (well, at least I) would LIKE to believe that people with similar acute, life threatening conditions would get similar in-hospital treatment, but it was simply not the case. Of course, I don’t know what the optimal rate of, for example, PCI after acute MI would be – but I’m pretty sure it isn’t 100%, and I don’t know if white people got it too often, or black people not often enough…

  2. #2 PalMD
    March 12, 2009

    ive re-read the piece and made corrections based on your comments…….much appreciated.

  3. #3 Dianne
    March 13, 2009

    Blacks were not more likely to be re-hospitalized (a surrogate measure of outcome and health), but were significantly more likely to experience chest pain and reported a decreased quality of life compared to white patients.

    The above statement suggests that the main problem with treatment may not be the treatment administered when the patient gets to the hospital but the outpatient treatment. Blacks are more likely to have chest pain but no more likely to be hospitalized. Therefore, a white person will more likely be hospitalized for a given level of symptomatology than a black person.

    This could be occurring for a number of reasons from a higher percentage of black patients being uninsured (and therefore more reluctant to seek treatment) to blatant prejudice (doctors being less willing to believe a black patient when s/he complains of chest pain or less willing to take the pain seriously).

    Unfortunately, my first idea on how to test how much prejudice influences treatment would almost certainly get refused by an IRB…

  4. #4 Dianne
    March 13, 2009

    I’m currently doing some epidemiologic data dredging out of the SEER database. This post reminded me to stick race in as a variable…I won’t go into the details until we publish, but it looks like not only do blacks do worse with a particular type of cancer, survival is not improving for blacks while it is improving for whites. So we can’t even blame residual prejudice or past problems: it’s still getting worse. Sigh. Not what I was hoping to find…

  5. #5 Donna B.
    March 13, 2009

    Just curious… was this a nationwide study, or regional?

  6. #6 Club 166
    March 21, 2009

    Hi, Pal,

    Found your blog via “Perky Sceptic”. Some nice stuff here.

    While I share your concern that we need to fix access to medical care in the US, don’t get sucked into thinking that doing so will necessarily lead to elimination of disparities in outcomes.

    One need only look to the Whitehall II study in the UK (where, of course, they have single payer universal health care) to see that social status is still inversely related to health status.

    http://www.ncbi.nlm.nih.gov/pubmed/1674771

    Joe