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Blacks, Hispanics Less Apt to Get Best Heart Failure Care
Date:3/6/2009

Disparity exists even though more minorities than whites meet criteria for cutting-edge treatment

FRIDAY, March 6 (HealthDay News) -- When black and Hispanic Medicare recipients suffer severe heart failure, they are less likely than their white counterparts to be treated with the most cutting-edge treatment available, a new analysis suggests.

"We found that there were real but modest differences between racial and ethnic groups in the use of the most advanced devices for the treatment of severe heart failure, even after considering all the medical and diagnostic factors when providing those treatments," explained the study's author, Dr. Steven A. Farmer, a fellow of cardiovascular medicine in the cardiovascular division of the Hospital of the University of Pennsylvania in Philadelphia.

In this case, the treatment in question is actually a combination of two interventions: the insertion of a small, battery-powered, implantable defibrillator (ICD) to regulate heart rhythms; and "cardiac resynchronization therapy" (CRT), a newer approach that relies on a special pacemaker that realigns heartbeats whenever the normally simultaneous pulsing of the right and left ventricle falls out of sync.

Farmer's team, which reports the finding in the March issue of Heart Rhythm Journal, noted that the combined treatment, known as CRT-D, is appropriate for 15 percent to 20 percent of heart failure patients.

The authors further noted that congestive heart failure strikes more than 5 million Americans each year. Racial and ethnic minorities are particularly vulnerable, with 2005 figures from the U.S. Department of Health & Human Services indicating that more than a quarter of all deaths in those groups are attributable to heart disease, making cardiovascular illness the number one killer of blacks and Hispanics.

In particular, the department noted that black men have a 30 percent greater risk of dying from heart disease than non-Hispanic whites -- even though a smaller proportion of blacks than white actually have heart disease (10 vs. 12 percent).

The current findings are based on a national comparison of more than 108,000 white, black and Hispanic cardiac patients who received care for severe heart failure between 2005 and 2007 at one of more than 1,000 hospitals across the United States.

All the patients were enrolled in the National Cardiovascular Data Registry, which by definition meant that all were Medicare patients and all had received either ICD alone or the combined CRT-D treatment.

Despite the fact that minority patients were actually more likely to qualify for the combined approach than white patients, the authors found that blacks and Hispanics were nonetheless more likely to receive just the defibrillator device. By contrast, white patients were more likely to get the double therapy -- whether or not they met the treatment guidelines.

Farmer and his colleagues specifically found that among white patients considered "eligible" for CRT-D, 79 percent got the treatment. However, among blacks, that figure fell to 77 percent, and among Hispanics it fell further, to 75 percent.

"Now certainly these are not whopping differences," Farmer noted. "They're modest, and other studies have shown this kind of difference in the past. But what's new here is that all the many factors that typically might account for the differences we did see -- being uninsured, the lack of availability of a particular device, patient preferences, the specific medical condition being handled -- cannot explain it."

"This is because," he continued, "all the patients in our study were from a group where everyone had gone to a doctor and gotten diagnostic testing, and everyone was already set to get treatment for their heart failure with a device of some kind. And an expensive device at that. It's just that you were more likely to get the most sophisticated and most expensive device if you were white."

"So this initial study," Farmer said, "shows that there are differences in treatment by race that are not accounted for by medical factors. And we are now doing additional studies to look at all the economic and socioeconomic factors at the hospital level that might account for this, at least in part."

Dr. Paul Underwood, former president of the Association of Black Cardiologists and medical director at Boston Scientific Corp., said the findings are not unexpected.

"I can't say one would be really surprised, if we looked at disparities in terms of cardiovascular disease and morbidity across race in this country," he noted.

"So, yes, here we may not yet know what the exact answer is, which factors working together are contributing to the problem," Underwood said. "But what is clear is that there is a lot of work that needs to be done in terms of leveling the playing field in terms of providing options for treating cardiovascular disease."

More information

For more on heart disease and minorities in the United States, visit the U.S. Department of Health & Human Services.



SOURCES: Steven A. Farmer, M.D., Ph.D., fellow, cardiovascular medicine, cardiovascular division, Hospital of the University of Pennsylvania, Philadelphia; Paul Underwood, M.D., interventional cardiologist, Boston, former president, Association of Black Cardiologists, Atlanta, and medical director, Boston Scientific Corp.; March 2009 Heart Rhythm Journal


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