Blacks less likely to receive evidence-based medicine

Even as newer registries show greater use of evidence-based therapies, the disparity continues.

ATLANTA – Reperfusion therapy tends to be less frequently used in black patients, and these patients are less frequently treated with implantable cardioverter defibrillators.

“The efforts to overcome these disparities will be found in efforts to promote the use of evidence-based quality of care for all patients,” Eric Peterson, MD, Duke University, said at the American College of Cardiology Scientific Session 2006.

Peterson spoke during a joint symposium of the ACC and the Association of Black Cardiologists. He said efforts like Pay for Performance could help motivate doctors to “leave no patient behind.”

“Based on the guidelines, we know what works in the treatment of acute coronary syndromes and myocardial infarction. The list is not long, and we in medicine have an obligation to be consistently delivering this to every patient every time, regardless of their race, gender or ability to pay,” he said.

Disparity is widespread

Peterson said the disparity in treatment between blacks and whites is “ubiquitous,” no matter which database is sampled.

For example, a study of the Veterans Affairs medical system, where insurance is not an issue, still found racial differences: Blacks received less thrombolytic therapy than whites. The use of ACE inhibitors, beta-blockers and aspirin were similar between racial groups.

Using data from the National Registry of Myocardial Infarction, researchers compared white men with white women and then with black men and black women. “African-American women tended to have the lowest rates of therapy, although ... the absolute difference was modest,” Peterson said.

Analyzing the data by region of the country showed that the racial disparities tended to be most pronounced in the Southeast. Doctors who were more likely to see blacks in their practice were also more likely to treat them with evidence-based therapies. Black patients also received reperfusion therapy much more slowly than white patients.

“Even as newer registries show a greater use of evidence-based therapies overall, the disparity between blacks and whites continues to exist,” Peterson said.

For the newer and more expensive therapies like use of GPIIb/IIIa inhibitors, the difference in use can be as high as 20%. Peterson said that blacks after hospital discharge were 70% more likely than white patients to stop taking aspirin, beta-blockers or statins within one year.

Affect on health

“The big question is, if there are so many differences in the use of proven therapies, does it matter? Is it producing an impact in outcomes? Showing this difference in outcomes is far more difficult,” Peterson said.

A survival study among a VA population found that acute outcomes following MI were actually better in black patients, but the difference disappeared over the course of two years.

However, a five-year post-catheterization mortality study at Duke University found a 40% higher rate of mortality among black patients compared with whites. “If we controlled for clinical factors, the differences did go away somewhat but remained significant. When we controlled for clinical as well as treatment factors, we found that the differences disappeared,” Peterson said.

Treatment differences also appeared to affect quality of life in a study of physical functioning and angina symptoms. “Racial differences in quality-of-life outcomes became nonsignificant after controlling for the treatments we were giving patients,” he said. – by Jeremy Moore

For more information:

• Peterson ED. Underuse of proven therapies. Presented at the American College of Cardiology Scientific Session 2006. March 11-14, 2006. Atlanta.