Gender Disparities Exist in Cardiovascular Care

ORLANDO, Fla. — Women and black patients with heart disease appear to have higher mortality rates after hospital discharge, according to new data.

The research, which was presented at the American Heart Association Scientific Sessions, indicates that women with coronary artery disease (CAD) are less likely than men to receive optimal care at discharge from U.S. hospitals, which is likely driving the difference in mortality rates, Deepak L. Bhatt, MD, MPH, and colleagues reported.

However, the disparity in mortality rates for black patients could not be explained by the differences in hospitals’ quality of care, they noted.

Dr Bhatt and colleagues analyzed data from the American Heart Association Get with the Guidelines-Coronary Artery Disease (GWTG-CAD) registry linked with Medicare inpatient data. The study included 49 358 Medicare patients hospitalized at 366 U.S. hospitals from 2003 to 2009.

The researchers evaluated quality of care based on how many performance measures hospitals followed for eligible patients. They also looked at the 3-year death rates from any cause after being discharged.

Among the more than 16 000 deaths identified at the follow-up, the researchers found that women were less likely to receive optimal care at discharge (adjusted odds ratio [OR]=0.92; 95% CI, 0.88-0.95). When they received suboptimal care, they were 23% more likely to die than men (adjusted OR=1.23; 95% CI, 0.99-1.54). The disparity disappeared when women received optimal care (adjusted OR=0.97; 95% CI, 0.92-1.01).

While researchers observed no difference in care quality across racial and ethnic groups, as well as across geographic regions, they did uncover a 36% higher likelihood that black patients would die compared with white patients (adjusted OR=1.36; 95% CI, 1.24-1.50). The disparity remained regardless of the quality of care.

“We wanted to see if we could explain why there are disparities in care in patients with heart disease. We used a sophisticated, labor-intense statistical method called mediation analysis. Other studies have examined disparities in cardiovascular care, but none to my knowledge have previously used mediation analysis. Mediation analysis allowed us to determine what proportion of a difference in outcomes was due to differences in care vs other factors,” said Dr Bhatt, who is the executive director of Interventional Cardiovascular Programs at Brigham and Women’s Hospital Heart and Vascular Center and a professor of medicine at Harvard Medical School.

Of the 16 130 (32.7%) deaths that occurred over the 3 years of follow-up, numbers were higher among women (n=8323; 35.6%) vs men (n=7807; 30.8%), according to the study data.

Compared with white (32.3%) and Hispanic patients (29.8%), black (38.5%) and Asian patients (38.3%) had higher unadjusted mortality rates.

“What we found was that more than two-thirds of the excess mortality in women vs men with heart disease was due to suboptimal care. The implication is that by eliminating suboptimal care, the majority of the disparity in cardiovascular mortality between the sexes could be reduced. So, any worse outcomes are not predominantly due to biological factors, for example,” Dr. Bhatt told Endocrinology Advisor. 

“In African American patients with heart disease, on the other hand, the excess mortality compared with whites was not mediated by suboptimal hospital care. Therefore, other factors will need to be identified to eliminate that disparity.”

Dr Bhatt said approximately 69% of the association between sex and all-cause mortality could potentially be reduced by providing optimal quality of care to women patients hospitalized for cardiac conditions. 

In this study, black patients had a higher prevalence of diabetes, hypertension, and dialysis compared with white patients.  However, both groups were similar regarding quality-of-care measures received. Dr Bhatt explained that there is an urgent need to look into these issues and how best to address them.

In comparison with the other 3 geographical regions, the South exhibited the lowest measure in patients discharged on ACE inhibitors or angiotensin II receptor blockers (ARBs; 77%) and the administration of lipid-lowering medications for patients with LDL cholesterol greater than 100 mg/dL (79%).  

In addition, the researchers found that the West region had the lowest prevalence of patients discharged on aspirin (94%) and discharged on beta-blockers (89%).  

Overall, the researchers found no statistically significant differences in terms of quality of care across geographic regions.

Reference

1. Bhatt D. 269 – Sex and Race Related Disparities in Care and Outcomes After Hospitalization for Coronary Artery Disease Among Older Adults. Presented at the American Heart Association Scientific Sessions; November 7-11, 2015; Orlando, FL.