Alexander M, Grumbach K, Selby J, Brown AF, Washington E.
Hospitalization for congestive heart failure. Explaining racial differences.
JAMA 1995;274(13):1037-42.

While some hypothesize that racial differences in rates of congestive heart failure (CHF) are due to differences in the underlying prevalence of clinical risk factors, others hypothesize that differences in access to medical care are responsible, as access to care may alter the development or clinical course of CHF. Racial discrimination has also been proposed as a factor that could explain treatment differences and lead to a more severe clinical picture for blacks than whites with coronary artery disease. The purpose of this study was to examine factors leading to hospitalization for CHF in a well-insured (HMO) population. The authors hypothesized that persistent racial differences in elements of the process of care would cause African Americans to remain at higher risk for being hospitalized for CHF after controlling for underlying risk factors. The study included patients who were first hospitalized for CHF during the period from 1978 to 1984.

This study found that the racial difference in rates of first hospitalization for CHF was largely explained by the greater prevalence among African Americans of certain clinical factors, particularly hypertension and diabetes. In men and women aged 60 years and older, the RR for hospitalization for blacks versus whites was 0.95 (95% confidence interval =0.77 to 1.18) after adjusting for risk factors. In men under 60 years, after adjusting for risk factors, the RR for hospitalization for blacks versus whites to 1.19 (95% confidence interval =0.84 to 1.65). However, for women under 60 years, adjustment for risk factors did not fully explain the racial difference in rate of hospitalization (RR=1.49; 95% confidence interval=1.0 to 2.21).

The authors offer several suggestions that might explain the increased adjusted relative rate of hospitalization for young African American women. First, the finding might be a chance subgroup finding or the underlying risk factors for disease or treatment processes might not be adequately characterized by the data available for this study. Second, racial discrimination may have been operating. The authors state, "There may be differences in the type of care received by younger African American women in this HMO." However, they also add that while "racial discrimination could influence both treatment decisions and patient behaviors, we failed to detect a racial differences in outcome for [the other groups, including] men and older women." Finally, the authors suggest that young African American women might be less likely to adhere to medical treatment because of their burdens of childcare responsibility or the effects of poverty that might impair their ability to attend to their medical needs.

The authors conclude that it will be necessary to further evaluate whether differences in the type of care received by African Americans compared with whites is responsible for the racial difference in hospitalization rates found in this study and others.