Many studies have documented disparities in cardiovascular care for minorities, specifically African Americans compared to white patients. Coronary artery bypass grafting (CABG) is a common procedure in the United States, and the outcomes and post-surgical care for African Americans tend to be worse. Investigators from Brigham and Women's Hospital examined whether patients insured through TRICARE -- a universal insurance and equal-access system that covers more than 9 million active-duty members, veterans and their families -- experienced these disparities. The team found no racial disparities in quality-of-care outcomes, providing insights about the potential impacts of universal insurance and an equal-access health care system. The findings are published in Health Affairs.
"In our study, we found a complete absence of racial disparities," said first author Muhammad Ali Chaudhary, MD, a research fellow at the Center for Surgery and Public Health in the Department of Surgery at the Brigham. "In the military, the color of your uniform matters more than the color of your skin. Here, we have an opportunity to look beyond just the impact of universal insurance. This is a system that may be eliminating other factors that contribute to racial disparities in care such as implicit provider bias, health care segregation, differential access to care, and mistrust in the system."
The study included 8,183 TRICARE patients, aged 18-64, who had undergone CABG. The study took its data from TRICARE health care claims from the Military Health System Data Repository for the years of 2006 to 2014.
The primary outcomes for the study were prescription of beta blockers, prescription of statins, and readmission rates within a 30-day period following surgery. All three outcomes are quality-of-care metrics endorsed by the National Quality Forum (NQF) for CABG. African Americans were found to have 10 percent greater odds of beta-blocker prescription than whites and 10 percent lower odds of 30-day readmission, but neither of these findings reached statistical significance. The team found no difference in statin prescription by race. Overall, the study showed no significant difference in quality-of-care metrics for African American and white patients following CABG.
Since the data from the study were taken from a database, researchers could not account for a doctor's reasoning in choosing to prescribe, or not to prescribe, medication. Since TRICARE is a military insurance, its patients might not accurately model the United States population. However, the TRICARE population is socially, geographically and ethnically diverse, and only 20 percent of those covered by TRICARE are actively serving. The rest are veterans and family members of veterans or active-duty members. Unlike Medicare, which provides data for a limited age range, TRICARE covers people of all ages, which may serve as a better model of the American working population.
"It's one of the hypotheses that we've been building for years: Universal health care access and equal access can eradicate racial disparities," said Chaudhary. "With TRICARE, we have a model that provides a window into the potential impacts of universal insurance and an equal-access health care system."
Other authors of this paper include Elzerie de Jager, Nizar Bhulani, Nicollette K. Kown, Adil H. Haider, Eric Goralnick, Tracey P. Koehlmoos and Andrew J. Schoenfeld.
This study was funded through a grant from the Henry M. Jackson Foundation for the Advancement of Military Medicine.
Paper Cited: Chaudhary MA et al. "No Racial Disparities In Surgical Care Quality Observed After Coronary Artery Bypass Grafting In TRICARE Patients" Health Affairs DOI: 10.1377/hlthaff.2019.00265