Sex and Race/Ethnicity Differences in CAD Outcomes
Do coronary artery disease (CAD) health disparities exist for sex, race, and ethnic distributions among US hospitals?
Data from the Get With The Guidelines–Coronary Artery Disease registry were linked with Medicare inpatient data for the present analysis. Patients ages ≥65 years admitted to one of 366 US hospitals for CAD were included. The primary outcome was mortality disparities of sex, race/ethnicity, and geographic region with 3-year mortality. Quality care metrics were examined as mediators of the outcome. These included: 1) aspirin within 24 hours; 2) aspirin on hospital discharge; 3) beta-blocker on hospital discharge; 4) angiotensin-converting enzyme inhibitor/angiotensin-receptor blocker for patients with low ejection fraction on hospital discharge; 5) smoking cessation counseling; and 6) lipid-lowering medications.
A total of 49,358 patients, ages ≥65 years admitted to 366 US hospitals between 2003 and 2009 were included. During 3 years of follow-up, 16,130 (32.7%) deaths were identified; 8,323 (35.6%) were women and 7,807 (30.8%) were men. African American and Asian patients displayed the highest unadjusted mortality rates (38.5% and 38.3%, respectively), followed by white (32.3%) and Hispanic (29.8%) patients. Women were less likely to receive optimal care as compared to men (odds ratio [OR], 0.92; 95% confidence interval [CI], 0.88-0.95; p < 0.0001). Furthermore, women who did not receive optimal care experienced a higher mortality (OR, 1.25; 95% CI, 1.00-1.55; p = 0.05, p for interaction = 0.04). Approximately 69% of the sex disparity may potentially be reduced by providing optimal quality of care to women. Quality of care did not differ across racial/ethnic groups or geographic regions. African Americans were more likely to die than whites (OR, 1.33; 95% CI, 1.21-1.46; p < 0.0001). This disparity persisted regardless of the quality of care received.
The investigators concluded that women were less likely to receive optimal care at time of discharge compared to men. Differences in mortality between the sexes may be reduced by providing equitable and optimal care to all patients. In contrast, the higher mortality observed in African American patients appears not to be explained by disparities in quality of care.
These data suggest that differences in mortality between sexes may be reduced by interventions to improve quality of care. However, additional factors may be contributing to racial disparities in mortality. Further research is warranted.
Keywords: Adrenergic beta-Antagonists, Angiotensin-Converting Enzyme Inhibitors, Aspirin, Coronary Artery Disease, Ethnic Groups, Geriatrics, Lipids, Medicare, Mortality, Outcome Assessment (Health Care), Quality Improvement, Quality of Health Care, Sex, Smoking Cessation, Women
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