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Outcomes in Black and White VA Patients After PCI
Study Questions:
What is the impact of race on outcomes at 1 year in patients undergoing percutaneous coronary intervention (PCI) at US Veterans Affairs (VA) hospitals?
Methods:
This study compared black and white patients who underwent PCI between October 1, 2007, and September 30, 2013, at 63 VA hospitals using data recorded in the VA Clinical Assessment, Reporting, and Tracking System for Cardiac Catheterization Laboratories (CART-CL) program. A generalized linear mixed model with a random intercept for site assessed the relative difference in odds of outcomes between black and white patients. The setting was integrated institutionalized hospital care. All patients of other races or those with multiple listed races and those with missing data regarding race or the diagnostic cardiac catheterization were excluded. The dates of analysis were January 7, 2016, to April 17, 2017. The primary outcome was 1-year mortality. Secondary outcomes were 30-day all-cause readmission rates, 30-day acute kidney injury, 30-day blood transfusion, and 1-year readmission rates for myocardial infarction (MI). In addition, variations in procedural and postprocedural care were examined, including the use of intravascular ultrasound, optical coherence tomography, fractional flow reserve measurements, bare-metal stents, postprocedural medications, and radial access.
Results:
A total of 42,391 patients (13.3% black and 98.4% male; mean [standard deviation] age, 65.2 [9.1] years) satisfied the inclusion and exclusion criteria. In unadjusted analyses, black patients had higher rates of 1-year mortality (7.1% vs. 5.9%, p < 0.001) as well as secondary outcomes of 30-day acute kidney injury (20.8% vs. 13.8%, p < 0.001), 30-day blood transfusion (3.4% vs. 2.7%, p < 0.01), and 1-year readmission rates for MI (3.3% vs. 2.7%, p = 0.01) compared with white patients. After adjustment for demographics, comorbidities, and procedural characteristics, odds for 1-year mortality (odds ratio [OR], 1.04; 95% confidence interval [CI], 0.90-1.19) were not different between black and white patients. There were also no differences in secondary outcomes with the exception of a higher rate of adjusted 30-day acute kidney injury (OR, 1.22; 95% CI, 1.10-1.36).
Conclusions:
The authors concluded that race was not independently associated with 1-year mortality among patients undergoing PCI in VA hospitals.
Perspective:
This study reports no significant association between black race and adjusted 1-year mortality for patients receiving PCI at VA hospitals. Furthermore, there were no significant associations with adjusted 30-day all-cause readmission rates, 30-day blood transfusion, or 1-year readmission rates for MI. However, two important differences were noted in treatment patterns between black and white patients. First, black patients were less likely to receive a drug-eluting stent regardless of whether they were initially seen with stable coronary artery disease or acute coronary syndrome. Second, black patients were less likely to be treated with beta-blockers after PCI regardless of presentation status. These important differences suggest the need for additional studies looking at racial differences in cardiac care among VA and non-VA populations.
Keywords: Acute Coronary Syndrome, Acute Kidney Injury, African Americans, Blood Transfusion, Cardiac Catheterization, Coronary Artery Disease, Diagnostic Imaging, Fractional Flow Reserve, Myocardial, Myocardial Infarction, Myocardial Ischemia, Outcome Assessment, Health Care, Percutaneous Coronary Intervention, Stents, Tomography, Optical Coherence, Ultrasonography, Veterans
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