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In VA System, Black Heart Failure Patients Get Similar Care and Better Outcomes
"In the VA health care system, a system designed to provide financially ‘equal access’ to care for all enrolled patients, the racial gap in patterns of health care utilization following a hospitalization for heart failure is small. The observation of better survival in black patients after a hospitalization for heart failure is not readily explained by differences in health care utilization and needs further evaluation," said Anita Deswal, MD, MPH with the Veterans Affairs Medical Center and Baylor College of Medicine in Houston.
Previous studies of racial differences in heart failure and its treatment have indicated African-Americans tend to have higher rates of disease and hospitalization, yet better short-term survival after hospitalization, than white patients. One reason suggested, but not really studied, has been differential access to medical care by race. According to this scenario, if blacks (who are more likely to be uninsured and unable to pay for care) have less access to outpatient care, they may be more likely to be hospitalized than a white patient with similar disease severity. In order to investigate whether differences in access to care might explain some of the earlier findings, the researchers studied veterans using VA facilities. Not only is access to care at VA hospitals not restricted by insurance status or inability to pay, the VA maintains databases on health care utilization that can be linked to outcomes, including survival.
The researchers reviewed data on 4,901 black and 17,093 white veterans who were hospitalized with congestive heart failure in 153 VA hospitals during a two-year period. They looked at short-term and long-term death rates (30 days and two years after admission), as well as information on outpatient and emergency room visits and re-hospitalization rates.
Black veterans had lower risk-adjusted death rates both short-term (30-day mortality odds ratio of 0.70; 95% confidence interval [CI] 0.60 to 0.82) and long-term (two-year mortality odds ratio of 0.84; 95% CI 0.78 to 0.91) compared to white veterans. In the year following discharge, blacks had the same rate of readmissions as whites. Blacks had a lower rate of medical outpatient clinic visits and a higher rate of urgent care/emergency room visits than whites, although these differences were small.
Dr. Deswal pointed out that other studies indicating worse outcomes for African-American heart failure patients usually looked at the general population, while this study included only those patients who were hospitalized during the study period.
"It should be emphasized that the results of our study are consistent with some other prior studies of patients hospitalized for heart failure that have also demonstrated better survival in black patients. In our study, racial differences in health care utilization did not provide an explanation for this finding as had been postulated from prior studies," Dr. Deswal said.
Dr. Deswal said this retrospective study could not rule out potential effects of disease or societal differences or other factors that weren't measured. She noted that the VA databases did not include information on clinical severity, and that they did not have data on non-VA treatment for these patients, although reviews of other information do not indicate higher rates of non-VA, Medicare-reimbursed inpatient treatment for white heart failure patients. Also, 99 percent of the patients were men, so the results cannot be generalized to women.
Dr. Deswal said the VA experience may offer some lessons for addressing racial differences in health care.
"In the VA setting, we found that both black and white patients with heart failure received relatively high-intensity outpatient care," Dr. Deswal said. "The overall outpatient care received by black patients appeared to be successful in keeping the pattern of readmissions similar to the white patients. This is in contrast to the non-VA setting where most studies have shown a higher number of rehospitalizations in black patients with heart failure. The overall increased access to care in the outpatient setting of the VA may have reduced the racial differences in in-hospital use of services observed in non-VA studies. These findings highlight the potential importance of reducing disparities in access to outpatient health care," Dr. Deswal said.
In an editorial in the journal, Jonathan D. Sackner-Bernstein, MD, FACC and Hal A. Skopicki, MD, PhD, FACC with the North Shore University Hospital in Manhasset, New York, wrote that significant social, educational, religious, or economic differences between races must not be confused with the small genetic variations. They also note that even when genetic variations have biologic consequences, the differences between subgroups of whites, for example, are often more significant than the variations between whites and blacks.
“The key message of our editorial is that we believe that the attention to the role of race in medicine has missed the target. Based on the literature that we review in brief in the editorial, race is not a biologic characteristic. This means that it is not a factor that mechanistically relates to the way a disease progresses or a patient responds to a treatment. Gender is a biologic issue. The functional level of an enzyme is a biologic issue. Race is not,” Dr. Sackner-Bernstein said.
“We don't argue that race is unimportant. However, the data that appears to support its importance in medicine is primarily derived from retrospective analyses of existing databases. The data indicates that the impact of race is more likely to be due to biases within our society and/or the fact that race is often a surrogate for socioeconomic status. This is why we believe that we as investigators and health care providers must work hard to assure our patients and ourselves that we will remain colorblind even while our society does not,” Dr. Sackner-Bernstein added.
Source: The American College of Cardiology