Association of Race With Mortality and Cardiovascular Events in US Veterans

Study Questions:

Do African-Americans experience higher mortality than their white peers when they have similar access to health care?

Methods:

The study evaluated all-cause mortality, incident coronary heart disease (CHD), and incident ischemic stroke using multivariable adjusted Cox models in a nationwide cohort of 547,441 African-American and 2,525,525 white patients with baseline estimated glomerular filtration rate (eGFR) ≥60 ml/min/1.73 m2 receiving care from the US Veterans Health Administration. Outcomes in African-American versus white individuals were compared using the National Health and Nutrition Examination Survey 1999-2004 (NHANES).

Results:

The baseline age was 59.9 ± 14.0 years, and 93.6% were men. African-Americans were more likely to be younger, female, service connected, hypertensive, diabetic, and to have human immunodeficiency virus/acquired immunodeficiency syndrome, and less likely to be married, and to have prevalent CHD and chronic lung disease. African-Americans also had more frequent health care encounters, higher systolic blood pressure and diastolic blood pressure, a lower per capita income, and were more likely to live in areas with high housing stress, lower education level, and persistent poverty. After multivariable adjustments in veterans, African-American race was associated with a 24% lower all-cause mortality and 37% lower incidence of CHD (p < 0.001 for each), but similar incidence of ischemic stroke (adjusted hazard ratio [aHR], 0.99; 95% confidence interval [CI], 0.97-1.01; p = 0.3). However, using the NHANES data, African-American race was associated with a 42% higher adjusted mortality among individuals with eGFR ≥60 ml/min/1.73 m2 (aHR, 1.42; 95% CI, 1.09-1.87).

Conclusions:

African-American veterans with normal eGFR have lower all-cause mortality and incidence of CHD, and similar incidence of ischemic stroke. These associations are in contrast with the higher mortality experienced by African-American individuals in the general US population.

Perspective:

The findings suggest it would be cost-effective to provide for an open access health care system in the United States, in which it would be less likely that institutional barriers or cost would disproportionately prevent African-Americans from obtaining health care. However, the pattern of health care provided during government service may have had a major influence on utilization and compliance with lifestyle and medical therapies in the retired veterans.


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