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.

Clinical Topics: Prevention

Keywords: Acquired Immunodeficiency Syndrome, African Americans, Blood Pressure, Coronary Disease, Diabetes Mellitus, Glomerular Filtration Rate, Health Services Accessibility, Life Style, Lung Diseases, Mortality, Poverty, Primary Prevention, Stroke, United States Department of Veterans Affairs


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