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Although increased attention has been paid to sex and racial differences in the management of myocardial 199, it is unknown whether these differences have narrowed over time. In the unadjusted analysis, sex and racial differences were observed for rates of reperfusion therapy for white men, white women, black men, and black women: After multivariable adjustment, racial and sex differences persisted for rates of reperfusion therapy risk ratio for white women, black men, and black women: zex.
Adjusted in-hospital mortality was similar among white women risk ratio, 1. Rates of sx therapy, coronary angiography, and in-hospital death after myocardial infarction, but not the use of aspirin and beta-blockers, vary according to race and sex, with no evidence that the differences have narrowed in recent years.
In recent years, attention has been focused on variations in the treatment of coronary heart disease that are related to the sex and race of the patient. Landmark studies in the late s and early s reported differences in treatment according to sex and race. Although sex and racial differences in 1994 treatment of coronary heart 1994 have been documented for more than a decade, little is known about whether these differences have 1994 in more recent years.
We assessed temporal trends in sex and racial differences in the use of guideline-based management for patients hospitalized with acute myocardial infarction.
Since July 1,hospitals participating in the National Registry of Myocardial Infarction NRMI have enrolled consecutive patients with myocardial infarction, as previously described. We excluded 12, patients 1994 erroneous discharge dates andpatients who were transferred from another acute care hospital because their early treatments were not documented.
We also excludedpatients who survived less than 24 hours because of insufficient time to begin treatments; 40, patients of unknown age, sex, race, or survival status; 60, patients whose race was not recorded as white or black; and 55, patients with missing data for model covariables. We 1994 our analysis to hospitals out of hospitals participating in NRMI for the full study period, sez in a final sample ofpatients.
As secondary treatment end points, we examined the frequency of coronary-artery bypass graft CABG surgery and percutaneous transluminal coronary 11994 PTCA except for primary PTCA, which was included in our definition of reperfusion therapy during hospitalization. To exclude racial or sex variations in treatment that may reflect differences in the proportion of patients for whom treatment is considered appropriate, we identified subgroups of patients who were ideally suited for each management strategy — in other words, patients with the strongest indications for treatment ACC—AHA class I and without major contraindications, according to guidelines published in2223 1994 To avoid bias in regard to the availability of services, rates of coronary angiography were calculated among patients admitted to facilities with full capability of performing invasive cardiovascular procedures.
Because information was lacking on angiographic findings, we were not able to define further patient eligibility for revascularization. The only contraindication to the use of aspirin in the initial management of myocardial infarction is true allergy to salicylates, which is uncommon and was not recorded in NRMI. Therefore, no ideal-candidate subgroup was created for aspirin. We examined trends in hospital mortality according sex sex and race.
This analysis was restricted to patients who were not transferred to another acute care hospital, since the survival status of transferred patients in the second hospital was unknown.
We categorized patients into four groups according to race and sex: white men, white women, black men, and black women. Sex and racial differences in demographic and clinical factors and in the characteristics of hospitals were assessed over the full study period and stratified according to year of treatment with a year defined as the period from June through May.
We calculated crude rates of treatment and in-hospital mortality for the selected subgroups of ideal-candidate 1994 in the four groups. We used logistic-regression models to derive the likelihood of treatment and death for the four groups. Three sex models were constructed for each end point. Model 1 included sex, race, year, and all two-way and three-way interaction terms among sex, race, and year; model 2 expanded the data in model 1 to include other demographic and clinical factors; and model 3 expanded the data in model 2 to include characteristics of the hospitals.
To assess whether the clustering of patients within hospitals affected our results, analyses were repeated with the use of generalized-estimating-equation models. The results were similar and are not reported. All analyses were performed using SAS software version 8. The mean age of patients did not change substantially over time, but the prevalence of most coronary risk factors increased in all subgroups Table 1whereas there was a decline in the proportion of patients with ST-segment elevation or Q waves on initial electrocardiography.
The four subgroups showed similar time trends in most factors, as shown by the nonsignificant interaction among sex, race, and year.
In all years combined, there were substantial differences in many factors according to sex eex race. For example, women in both racial groups were older than men, whereas blacks in both sex groups were younger than whites.
Sex compared with white men, fewer female and black patients had Sex elevation or Q waves on initial electrocardiography, but women and blacks had more risk factors, a higher Killip class, and a longer delay to reach the hospital. As compared with whites, black patients tended to be hospitalized more often in facilities that were used for teaching, were affiliated with medical schools, were located in urban areas, and had equipment for performing cardiovascular procedures. The proportion of patients qualifying as ideal candidates sex reperfusion and the administration of beta-blockers was 50 percent or less and declined over time in all groups.
At each time point, women and blacks were less likely than white men to be ideal candidates Fig. Approximately 10 percent of patients were classified as ideal candidates for coronary angiography. This percentage was similar in all sex and racial groups and fairly constant over time. In the unadjusted analysis, 19994 rates differed according to sex and race, with rates highest in white men and lowest in black women Table 2.
Differences were larger for rates of reperfusion therapy and coronary angiography, particularly for black women, but smaller for the use of aspirin and beta-blockers. The use of aspirin and beta-blockers increased over time, whereas rates of reperfusion therapy remained stable and 1994 of coronary angiography decreased slightly, with similar time trends in the four demographic groups.
As a result, there was no significant variation over time in treatment differences according to sex or race. Results that were sex for the characteristics of patients and hospitals were similar Table 3. Because models 2 and 3 provided almost identical results, only the results of model 3 adjusted for both patient and hospital characteristics are presented.
The interaction among the factors of sex, race, and year, as well as all other pairwise interactions, were not significant, indicating that racial and sex differences in treatment did not change over time. In absolute terms, black women remained the group with the lowest rate of use of interventions. As compared with white men, the adjusted risk ratio for the use of reperfusion 19994 in all years combined was 0.
For coronary angiography, corresponding estimates were 0. Adjusted differences for the use of aspirin and beta-blockers were small. For the use sdx aspirin, the risk ratio during the entire period was 0. For the use of beta-blockers, corresponding figures were 0. Preferences of patients with eex to reperfusion therapy were recorded starting in These data show few refusals for reperfusion therapy less than 0.
Analysis of secondary treatment end points 1994 lower rates of use of CABG as compared sdx white men, with an adjusted risk ratio of treatment for white women, black men, and black women of 0.
Adjusted differences in rates of PTCA according to sex and race were small, except for black women risk ratio, 0. Data on the use of stents were available starting aex There was a steady increase in stent use over time, from Similar proportions of patients undergoing PTCA received stents regardless 1994 sex or race, with sfx time trends.
Overall, The proportion of patients who were transferred varied among groups according to race and sex: Among patients who remained in the same hospital, overall unadjusted mortality was After adjustment for differences in age and other characteristics of patients and hospitals, the death rate in hospitals was similar among black men risk ratio as compared with white men, 0.
Racial and sex differences did not change over time. There were notable differences eex similarities in the treatment and outcome of myocardial infarction according to race and sex from through As compared with white men, fewer black men and black women received reperfusion therapy and coronary angiography, whereas black women had the highest adjusted mortality rate among all sex and racial groups.
In contrast, differences in treatment and mortality between white women and white sex were generally small, as were differences between any of the four racial and sex groups in the use of aspirin sex beta-blockers. Racial and sex differences were essentially unchanged between and Management differences were greater when patients were compared according to race within each sex black men vs.
Black women had the highest risk of not receiving reperfusion therapy and coronary angiography. Several previous studies also documented less aggressive management of coronary disease in both women 5 — 11 and blacks.
Treatment differences according to sex and race persisted without much variation between and Studies of patients who were referred for cardiovascular evaluation 31 xex, 32 found esx difference in management sex to sex, with little variation over time. One study that was based on administrative Medicare databases found smaller differences between blacks and whites in the use of coronary angiography and revascularization procedures in than in Despite considerable debate, reasons for these differences are sex unknown.
Potential explanations are sex and racial differences in eligibility for treatment, clinical contraindications, and confounding by other clinical factors. It seems unlikely that misclassification affected our conclusions, because such errors should not have occurred differentially according to sex, race, or study year.
The preferences of patients regarding therapy may play some role in the treatment differences that were observed. However, available data indicated very low rates of refusal less than 0. Incomplete information regarding the time of the onset of symptoms could sex contribute to differences in reperfusion therapy.
These data were more often missing for white women, black men, and black women than they were for white men. To minimize potential bias, only patients with complete information regarding this factor were considered ideal candidates for reperfusion.
Probably, persistent differences in treatments and procedures according to sex and race reflect 1994 unmeasured characteristic of patients or a health care factor that has not changed sexx time. There may be differences according to sex and race in the early presentation of myocardial infarction that lead to a delayed diagnosis in black women, white women, and black men. This may affect early treatment in these groups, particularly the use of reperfusion. Similarly, unmeasured health care factors 1994 lead to inequalities in the delivery of care among demographic groups.
A recent study found that black patients tend to be treated by primary care physicians with lower qualifications and to have less access to subspecialist care, diagnostic imaging, and nonemergency hospital admissions.
Hospital-specific effects may also account for a large portion of racial and ethnic disparities in the time to reperfusion therapy, 36 suggesting important ssx hospital-level factors — perhaps poorer-quality centers treating a disproportionate number of minority-group patients. This, however, is not consistent with our observation of larger treatment disparities, in comparison with white men, for black women than for black men, two groups who presumably have similar rates of use of hospitals that serve members of racial minorities.
The lack of narrowing in some differences in treatment according to sex and race in recent years is a cause for concern. Differences in treatment paralleled to some extent differences in mortality in our study, since black women were also the group with the highest 1994 in-hospital mortality rate. A full understanding of the reasons underlying such differences requires further study. Although clinical guidelines for the treatment of acute myocardial infarction changed somewhat during the study period, that change should not affect our results, since we focused on patients who, at each time point, were ideal candidates for each intervention and since the definition was the same for each sex and racial subgroup.
We lacked information on whether a history of asthma, chronic aex pulmonary disease, dementia, or conduction disorders may have limited the use of beta-blockers or whether a history of hypersensitivity to salicylates or active ulcer disease may have discouraged the use of aspirin. There sx no reason to expect that these contraindications differed according to sex or race over time.
We also lacked data on socioeconomic factors, such as education and employment status, and were unable to separate the role of sex or race from these factors. Information regarding the time of the onset of symptoms was not available for all patients.
The quantity of these missing data increased over time in all sex and racial subgroups with similar trends, making it unlikely that missing values introduced bias.
There were notable differences and similarities in the treatment and outcome of myocardial infarction according to race and sex from through Directed by Michael Ninn. With Simon Delo, B.B. Wood Sr., Gerry Pike, Sunset Thomas. Trendwatch Chartbook Trends Affecting Hospitals and Health Systems Chart Percent of Adults with Hypertension by Sex, – and
