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Saif S. Rathore, MPH; JoAnne M. Foody, MD; Yongfei Wang, MS; Grace L. Smith, MPH; Jeph Herrin, PhD; Frederick A. Masoudi, MD, MSPH; Pamela Wolfe, MS; Edward P. Havranek, MD; Diana L. Ordin, MD, MPH; Harlan M. Krumholz, MD, SM

JAMA. 2003;289:2517-2524.

Context  Black patients hospitalized with heart failure reportedly receive poorer quality of care and have worse outcomes than white patients. Because previous studies have been based on selected patient populations treated more than a decade ago, it is unclear if racial differences in quality of care and outcomes currently exist in the United States.

Objective  To evaluate differences in quality of care and patient outcomes between black and white Medicare beneficiaries hospitalized with heart failure.

Design  Retrospective analysis of medical record data systematically collected for the National Heart Failure Project.

Setting and Patients  Nationwide US sample of 29 732 fee-for-service Medicare beneficiaries hospitalized with heart failure in 1998 and 1999.

Main Outcome Measures  Prescription of angiotensin-converting enzyme (ACE) inhibitors, measurement of left ventricular ejection fraction (LVEF), readmission within 1 year of discharge, and mortality within 30 days and 1 year of admission.

Results  Black patients and white patients had similar crude rates of LVEF assessment (67.8% black vs 66.6% white; P = .29). Among patients classified as ideal for ACE inhibitor use, black patients had higher crude rates of ACE inhibitor use than white patients (81.0% vs 73.8% white; P<.001) but had similar rates of ACE inhibitor or angiotensin receptor blocker (ARB) use (85.7% black vs 82.5% white; P = .08). After multivariable adjustment, black patients had comparable rates of LVEF assessment (risk ratio [RR], 0.99; 95% confidence interval [CI], 0.95-1.03). Black patients remained more likely to be prescribed ACE inhibitors (RR, 1.22; 95% CI, 1.14-1.28) than were white patients in an adjusted analysis, but there were no significant racial differences in the prescription of ACE inhibitors or ARBs (black vs white, RR, 1.03; 95% CI, 0.97-1.07). Black patients had higher rates of readmission within 1 year of discharge (68.2% vs 63.0%; P<.001) but had lower crude 30-day (6.3% vs 10.7%; P<.001) and 1-year (31.5% vs 40.1%; P<.001) mortality rates than white patients. After multivariable adjustment, black patients had a slightly higher rate of readmission than white patients (RR, 1.09; 95% CI, 1.06-1.13) but remained at lower risk of 30-day mortality (RR, 0.78; 95% CI, 0.68-0.91) and 1-year mortality (RR, 0.93; 95% CI, 0.88-0.98).

Conclusions  Black Medicare patients hospitalized with heart failure received comparable quality of care and had slightly higher rates of readmission but had lower mortality rates up to 1 year after hospitalization than did white patients.

Author Affiliations: Section of Cardiovascular Medicine, Department of Internal Medicine (Messrs Rathore and Wang, Drs Foody and Krumholz, and Ms Smith) and Section of Health Policy and Administration, Department of Epidemiology and Public Health (Dr Krumholz), Yale University School of Medicine, New Haven, Conn; Flying Buttress Associates, Charlottesville, Va (Dr Herrin); Division of Cardiology, Department of Medicine, Denver Health Medical Center (Drs Masoudi and Havranek), and Divisions of Geriatric Medicine (Dr Masoudi) and Cardiology (Drs Masoudi and Havranek), Department of Medicine, University of Colorado Health Sciences Center, Denver; Colorado Foundation for Medical Care, Aurora (Drs Masoudi and Havranek and Ms Wolfe); and the Centers for Medicare & Medicaid Services, Boston, Mass (Dr Ordin).

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