Rathore SS, Berger AK, Weinfurt KP, Feinleib M, Oetgen WJ, Gersh BJ, Schulman KA.
Race, sex, poverty and the medical treatment of acute myocardial infarction in the elderly.
Circulation 2000;102(6):642-8. (Comment in: Circulation. 2000;102(9):943-4.)

The purpose of this study was to determine the association of patient race, sex, and poverty (a geographic measure) with use of medical therapy during treatment of acute myocardial infarction (AMI). Data for this study were drawn from the Cooperative Cardiovascular Project, which included Medicare beneficiaries (over the age of 64 years) who were discharged from non-governmental acute-care hospitals in the United States with a primary discharge diagnosis of AMI during the period from 1994 to 1996.

Ideal candidates for use of aspirin on admission, reperfusion, prescription of aspirin on discharge, and prescription of beta-blockers on discharge were identified based on the American College of Cardiology/American Heart Association recommendations. A total of 115,699 ideal patients were identified. Black, female, and poor patients were less likely to be classified as ideal for reperfusion and beta-blockers but were comparable to white, male, and non-poor patients for aspirin classification. Among the ideal cohort, black, female and poor patients had significantly lower rates of therapy use than white, male, and non-poor patients respectively. Patients receiving therapy were younger and had less severe illness than those who did not receive treatment.

In analyses that adjusted for age, severity of illness, physician specialty, geographic location, and treating hospital characteristics, black patients were less likely to undergo reperfusion (RR=0.84, 95% CI=0.78,0.91), receive aspirin on admission (RR=0.97, 95% CI=0.96, 0.99), or receive beta-blockers on discharge (RR=0.94, 95% CI=0.96, 1.00). Female and poor patients were less likely to receive aspirin on admission or discharge. Poor patients were also less likely to receive beta-blockers or reperfusion therapy. The race, gender and poverty influences on treatment use were similar in the ideal cohort and the total cohort for all treatments except reperfusion therapy. For this treatment, women were less likely to receive treatment in the total cohort despite being equally likely to receive treatment in the ideal category.

With regard to the reported racial differences, the authors note that "although disease prevalence and severity may differ by race, there is no literature to suggest racial variability in efficacy of ACA/AHA-recommended medical treatments, particularly among the ideal group of patients evaluated. Although patient presentation has been postulated to vary by race, this potential confounder does not account for the disparate use of medications at discharge when the diagnosis of MI has been confirmed. Patients who were documented as having refused treatment were excluded from analysis, thus variations in care do not reflect racial differences in perceived treatment compliance or patient care preferences." The authors indicate that racial differences in physician recommendation may be involved.

This study was based on a retrospective chart review; therefore, the identification of "ideal" candidates for specific procedures may have been biased to the extent that recording medical data on patient charts are biased.