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Abstract & Commentary
Source: Bradley EH, et al. Racial and ethnic differences in time to acute reperfusion therapy for patients hospitalized with myocardial infarction. JAMA 2004;292:1563-1572.
A number of recent studies have begun to reveal racial disparity in the way certain patient populations are treated. In a recent New England Journal of Medicine study, researchers1 reported that physicians treating African-American patients were less likely to be board certified (77% vs 86%) and reported being less able to access high-quality diagnostic imaging, specialists, nonemergency hospital days, adequate number of inpatient days, or high-quality ancillary services.
In the reviewed article, Bradley and colleagues identified racial and ethnic differences in the treatment of patients identified with acute coronary syndrome (ACS) in U.S. hospitals. This retrospective study, utilizing the National Registry of Myocardial Infarction (NRMI) database, encompassed 73,032 patients who received fibrinolytic therapy and 37,143 patients who received primary percutaneous intervention between Jan. 1, 1999 and Dec. 31, 2002. The primary outcome measure— minutes between hospital arrival and reperfusion therapy—was compared across racial and ethnic lines. The results are presented in Table 1.
Time to Reperfusion Across Racial/Ethnic Groups
These results confirmed those from previously reported smaller studies that had demonstrated disparities in care. However, the authors of this study went farther in determining if these differences could be explained by examining the mean times to treatment within each treating hospital, rather than across hospitals. For example, they sought to determine whether African-Americans were being treated predominantly at hospitals with longer door-to-therapy times, in contrast to differential treatment within a particular hospital-based on race/ethnicity. When examined this way, a substantial portion of the racial/ethnic disparity in time-to-treatment was accounted for, although not eliminated. The results are presented in Table 2.
Time to Reperfusion vs. Racial/Ethnic Groups
Controlling for Hospital Differences
Commentary by Andrew Perron, MD, FACSM
The concept of disparate treatment based on racial/ethnic factors has become an increasingly important field of study within all fields of medicine. Without the benefit of studies like this, I am willing to wager that most clinicians would be unaware of such a divide in care. Most individual practitioners would say they carry absolutely no treatment bias, but clearly, as demonstrated here, this is not the case.
This study serves two purposes. First it confirms that this disparity that has been demonstrated in smaller studies does indeed exist when viewed across a very large database (more than 100,000 patients in the United States). Second, the study begins to look for answers as to where this disparity lies. Although the racial/ethnic disparities still were significant after accounting for differences in mean times to treatment for the hospitals in which patients were treated, they were reduced substantially. This is an important first step in devising strategies to counteract this system bias. Of course, the larger question is: Why are the times to treatment longer at institutions where these minorities are seen primarily? Again, when looked at in the context of Bach’s study, one can postulate that it is related to the difficulty with specialty consultation, reduced percentage of board-certified physicians, inadequate ancillary services, as well as the other factors identified in that study.
Where do we go from here? In an accompanying editorial, Margaret Winkler, MD, sums up best what we can learn from this and where we can direct future efforts: "Determining race can be an important initial step in assessing quality of care delivery and outcomes, as the study by Bradley and colleagues illustrates. However, it is just a first step. By reporting race and ethnicity transparently and beginning to explore other important and related characteristics, biomedical research can move beyond race as a social construct in itself and explore other tangible components that can be affected to improve the public’s health."2
Dr. Perron, Residency Program Director, Department of Emergency Medicine, Maine Medical Center, Portland, ME, is on the Editorial Board of Emergency Medicine Alert.
1. Bach PB, et al. Primary care physicians who treat blacks and whites. N Engl J Med 2004;351:575-584.
2. Winkler MA. Measuring race and ethnicity: Why and how? JAMA 2004;292:1612-1614.