"This is the first study to examine racial difference in health status outcomes, including symptoms, function and quality of life, between whites and blacks; and it has found a significant difference, with blacks having more angina, physical limitations and poorer quality of life one year after an acute coronary syndrome than whites," said John Spertus, M.D., M.P.H., F.A.C.C., at the Mid America Heart Institute of Saint Luke's Hospital, the University of Missouri-Kansas City, and the Truman Medical Center in Kansas City, Mo.
Disparities remained even after the researchers took into account differences in hospital treatments and severity of illness.
The researchers tracked 1,159 consecutive patients (196 black and 963 white) who were treated between Feb. 1, 2000 and Oct. 31, 2001 at two Kansas City hospitals, the Mid America Heart Institute and Truman Medical Center. One-year health status was quantified with the Seattle Angina questionnaire (SAQ) and Short Form-12 Physical Component score (SF-12). After one year, 81 patients had died and 199 could not be interviewed.
Although mortality rates were almost identical (7.1 percent for blacks vs. 7.0 for whites), blacks had a higher prevalence of angina (43.4 percent vs. 27.1 percent), worse quality of life according to the Seattle Angina questionnaire, and poorer physical function according to the Short Form-12 Physical Component score. After adjusting for hospital treatments and other factors, the differences in quality of life and physical function remained statistically significant, and there was a trend toward more angina among black patients.
Dr. Spertus said this study found racial differences that were not seen in previous studies because it looked beyond just the overall survival rates.
"There have been dozens of studies looking at survival outcomes of whites and blacks and essentially all have shown no differences; despite a well-documented difference in the use of angiography, angioplasty, stents and bypass surgery. Yet, these procedures are primarily done to improve symptoms, function and quality of life," he said.
So he said physicians should pay closer attention to follow-up care among their African-American patients.
"Be sensitive to residual symptoms of angina, physical limitations and poorer quality of life in blacks after an acute coronary syndrome, so that additional therapies may be offered to eradicate residual symptoms and optimize patients' quality of life," Dr. Spertus said.
He said it is important to distinguish the differences in the type and amount of health care provided to whites and African-Americans from disparities in their health outcomes.
"'Differences' refers to differences in care. The previously known different rates of angiography, angioplasty and bypass surgery are just that, differences. 'Disparities' implies that there are adverse consequences to one group because of the differences. While it has widely been touted that there are disparities between whites and blacks in heart attack care and outcomes, this is really the first study to demonstrate it," Dr. Spertus said.
Dr. Spertus noted that this study was based on patients seen at only two centers in Kansas City, Mo. He said similar studies should be done in additional settings.
Rita F. Redberg, M.D., M.S.C., F.A.C.C., from the University of California in San Francisco wrote an editorial in the journal about differences in cardiac care associated with race that were reported by Spertus et al., as well as gender differences reported in a separate article by Anand et al.
"The importance of the two articles is that they look at use of procedures and therapies by sex and by race in cardiology. We value the important contribution of clinical trials and registries in cardiology but often fail to recognize that there are sex and race differences in cardiovascular care. In order to optimize treatment for all Americans, we need more sex- and race-specific data, as these two articles offer," Dr. Redberg said. "Both studies should be applauded for helping to fill in the gaps in our knowledge of sex and race differences in cardiac care."
John S. Rumsfeld, M.D., Ph.D., F.A.C.C., from the Denver VA Medical Center and the University of Colorado in Denver, who was not connected with the study, said it is a major contribution to the literature. He noted that most patients, both black and white, survive acute coronary syndromes, but until now no study has documented racial differences in the quality of life of those patients.
"This study suggests that current post-acute coronary syndrome health care is failing blacks," Dr. Rumsfeld said. "This study is the first to highlight this racial disparity, but the reasons for these results remain unclear. Are blacks not getting the same level or quality of follow-up care? Are they not getting appropriate cardiac rehabilitation? Are they less likely to remain on guideline-indicated medical therapies? Are they getting the support necessary, medically and socioeconomically, to fully benefit from available therapies and not be left with poor health-related quality of life? This study should directly stimulate further research to get these answers, and more important, lead to interventions to improve post-acute coronary syndrome care for blacks and improve their health status outcomes."
Dr. Spertus owns the copyright to the Seattle Angina Questionnaire, which was one of the tools used to assess the health status outcomes of patients in this study. The study was funded by the Agency for Healthcare Research and Quality.
Dr. Redberg is supported in part by the Robert Wood Johnson Foundation Health Policy Fellowship and by the Flight Attendant Medical Research Institute.