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Race not a factor for post-PCI mortality at VA hospitals
A new study highlights no independent association between race and 1-year mortality among patients undergoing PCI at VA hospitals.
The large study focused on 42,391 black and white patients who underwent PCI at 63 VA hospitals from October 2007 through September 2013.
In adjusted analyses, the rate of 1-year mortality was 7.1% among black patients compared with 5.9% among white patients (P < .001). However, after adjustment for demographics, comorbidities and procedural characteristics, there was no difference in the odds of mortality at 1 year among black vs. white patients (OR = 1.04; 95% CI, 0.9-1.19).
The researchers also examined racial differences in secondary outcomes including 30-day all-cause readmission, 30-day acute kidney injury, 30-day blood transfusion and 1-year readmission for MI.
Outcomes by race
Unadjusted analyses revealed higher rates of 30-day acute kidney injury (20.8% vs. 13.8%; P < .001), 30-day blood transfusion (3.4% vs. 2.7%; P < .001) and 1-year readmission for MI (3.3% vs. 2.7%; P = .01) among black patients. In adjusted analyses, black patients had an increased risk for 30-day acute kidney injury, which was defined as at least one creatinine level of at least 0.3 mg/dL above baseline (adjusted OR = 1.22; 95% CI, 1.1-1.36). The researchers reported no differences in other secondary outcomes after adjustment.
Patients in this study had a mean age of 65 years. More than 98% of the population was male and 87% were white.
The researchers did, however, find differences in procedural and postprocedural care of this population. After adjustment, compared with white patients, black patients were more likely to receive a bare-metal stent (OR = 1.26; 95% CI, 1.16-1.37), had similar odds of receiving an ACE inhibitor or angiotensin receptor blocker (OR = 1.08; 95% CI, 1.01-1.16) and were less likely to receive a beta-blocker prescription (OR = 0.88; 95% CI, 0.82-0.95). In unadjusted models, black patients were more likely to have PCI performed via radial access and white patients were more likely to undergo advanced intracoronary imaging or physiologic testing.
“In post hoc analyses, we found that differences in the unadjusted primary outcome were primarily attenuated by adjustment for comorbidities, presentation and anatomic factors. Black patients had a greater burden of medical comorbidities and manifested higher-acuity presentations than their white counterparts,” the researchers wrote in JAMA Cardiology.
Detailed records
This study focused on data from the VA Clinical Assessment, Reporting and Tracking System for Cardiac Catheterization Laboratories (CART-CL) program. Jay Giri, MD, MPH, from the Corporal Michael J. Crescenz Veterans Affairs Medical Center and the University of Pennsylvania, told Cardiology Today’s Intervention that “the beauty of the VA’s electronic medical records is that they are so incredibly detailed, so we had access to a lot of data that we don’t have in other non-VA studies.”
The VA CART-CL program amasses data from a patient’s clinical history via the VA electronic health record and also compiles standard patient and procedural data from all procedures performed at VA catheterization laboratories. This process also allows for derivation of longitudinal patient data, including inpatient and outpatient visits, laboratory data and pharmacy refills.
The finding of no mortality difference between black and white patients after adjustment in this study contrasts with prior analyses in non-VA populations. Giri referenced a study that utilized data from the National Cardiovascular Data Registry CathPCI Registry and CMS that yielded a higher adjusted mortality over 30 months of follow-up in black patients compared with white patients. However, he also noted differences between the VA population vs. the Medicare population. One difference, he said, is that the VA is an integrated health system that provides both primary and specialty care as well as inpatient services and outpatient pharmaceuticals. Another key difference, he said, is that VA employees are generally salaried workers and thus do not have financial incentives based on medical decision making.
“I view health equity as important to assess in the context of outcomes in all systems and, at least in this area of PCI, it looks like equitable health care is being provided at VA hospitals,” said Giri, a Cardiology Today Next Gen Innovator.
This particular study utilized a mediation analysis, by which the researchers analyzed whether certain characteristics that are directly under a physician’s control would explain or mediate any of the differences found in the study.
Based on what was observed in this study, “when it comes to CV care, at least for PCI, which is the most common CV procedure performed in the VA [system], there aren’t great health disparities relating to procedural outcomes of PCI once they get on the table. What we should be doing is taking a step back and looking at how we can address primary and secondary prevention issues ... and focus on things factors that will truly improve health care,” he said. – by Katie Kalvaitis
For more information:
Jay Giri, MD, MPH, can be reached at Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave., Eighth Floor, Philadelphia, PA 19104.
Disclosure: Giri reports no relevant financial disclosures.