DALLAS, Aug. 8 -- Blacks, women and poor people who have a heart attack are less likely to receive proven, inexpensive treatments such as aspirin or beta-blocker therapy, according to an article in today's Circulation: Journal of the American Heart Association.
"Aspirin and beta-blockers are very, very cheap," says Kevin A. Schulman, M.D., an associate professor of Medicine at Duke University Medical Center in Durham, N.C., and co-author of the study conducted at Georgetown University Medical Center. "Both have been shown to reduce death from heart attacks and are considered some of the best medications doctors have available."
Schulman says treatment discrepancies were strongest among blacks and the poor.
"We found that race influences treatment recommendations for individual patients, and we saw that poorer individuals seem to experience differences in care, even when the treatment is covered by Medicare," he says.
"The differences in treatment that we found are not huge, but they are significant," says co-author Bernard J. Gersh, M.B., D. Phil., professor of medicine at the Mayo Foundation and a consultant in the division of cardiovascular diseases at the Mayo Clinic.
"Clearly, physicians don't willingly treat patients differently just because they're poor, black, or women," says Gersh. "There are many factors at work. The important thing is to find out what they are and how to correct them."
Researchers evaluated four medical therapies recommended for the treatment of heart attack two given on admission, and two prescribed on discharge among 169,079 Medicare beneficiaries who were hospitalized for a heart attack between 1994 and 1996. The research team evaluated whether the patients were given aspirin or clot-busting drugs upon admission to the hospital, then whether they were prescribed aspirin and/or beta-blockers when they were released from the hospital.
In the first few hours after a heart attack, aspirin and clot-busting drugs have been proven to improve a person's chance of survival and minimize heart damage. Once a heart attack survivor is released from the hospital, aspirin and beta-blockers help prevent recurrent heart attacks.
Researchers found that blacks were 16 percent less likely than whites to get clot-busting drugs and 3 percent less likely to get aspirin upon admission to the hospital. Blacks also were 6 percent less likely to leave the hospital with prescriptions for beta-blockers. Women were 2 percent less likely than men to get aspirin on arrival or departure, but received the other drugs at the same rate as men. Individuals from low-income areas were 2 to 3 percent less likely to get every treatment than people who were not poor. Among all categories of patients, those in the study who did receive the therapies tended to be younger and to have less severe disease.
"Although 2 or 3 percent doesn't sound very high, heart disease is one of the most prevalent conditions in the country," Schulman says. "Even a small percentage difference in treatment methods can mean large numbers of patients missing out on these therapies."
Schulman says there have been some explanations for racial differences in the treatment of heart attacks, but they don't seem to add up. "Although the prevalence and severity of heart disease may differ by race, there is no research to suggest that recommended treatments will be more or less effective in different races."
Schulman speculates that part of the issue with women may be that they haven't been included in many of the major clinical trials in cardiology. As a result, he says, the amount of information to base medical decisions on is lacking for women.
As for the lower income individuals, Schulman says decreased use of these therapies is hard to explain. "While deductibles or copayments might account for variation in the use of high-cost therapies, it is unlikely that they would influence the use of aspirin or beta-blockers, which are relatively inexpensive," he says. Independent of a patient's race and gender, the researchers found that poorer patients were less likely to receive any of the four treatments discussed in the study.
"On the physicians' side," Schulman says, "we need to understand how we train physicians to deal with patients who differ from themselves either by race, gender or socioeconomic status, as well as how to communicate more effectively."
Co-authors of the study include Saif S. Rathore, A.B.; Alan K. Berger, M.D.; Kevin P. Weinfurt, Ph.D.; Manning Feinleib, M.D., Dr.P.H.; and William J. Oetgen, M.D., M.B.A.
NR00-1162 (Circ/Schulman)
Media advisory: Dr. Schulman can be reached by phone at 919-668-8101; by fax at 919-668-7124; or by Email at schulman012@mc.duke.edu.
Dr. Gersh can be reached by phone at 507-284-4139; by fax at 507-266-0228; or by email at gersh.bernard@mayo.edu (Please do not publish telephone numbers or email addresses).
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