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Racial and Ethnic Differences in Time to Acute Reperfusion Therapy for Patients Hospitalized With Myocardial Infarction
Elizabeth H. Bradley, PhD;
Jeph Herrin, PhD;
Yongfei Wang, MS;
Robert L. McNamara, MD, MHS;
Tashonna R. Webster, MPH;
David J. Magid, MD, MPH;
Martha Blaney, PharmD;
Eric D. Peterson, MD;
John G. Canto, MD, MSPH;
Charles V. Pollack,, Jr, MD, MA;
Harlan M. Krumholz, MD, SM
JAMA. 2004;292:1563-1572.
Context Nonwhite patients experience significantly longer times to fibrinolytic therapy (door-to-drug times) and percutaneous coronary intervention (door-to-balloon times) than white patients, raising concerns of health care disparities, but the reasons for these patterns are poorly understood.
Objectives To estimate race/ethnicity differences in door-to-drug and door-to-balloon times for patients receiving primary reperfusion for ST-segment elevation myocardial infarction; to examine how sociodemographic factors, insurance status, clinical characteristics, and hospital features mediate racial/ethnic differences.
Design, Setting, and Patients Retrospective, observational study using admission and treatment data from the National Registry of Myocardial Infarction (NRMI) for a US cohort of patients with ST-segment elevation myocardial infarction or left bundle-branch block and receiving reperfusion therapy. Patients (73 032 receiving fibrinolytic therapy; 37 143 receiving primary percutaneous coronary intervention) were admitted from January 1, 1999, through December 31, 2002, to hospitals participating in NRMI 3 and 4.
Main Outcome Measure Minutes between hospital arrival and acute reperfusion therapy.
Results Door-to-drug times were significantly longer for patients identified as African American/black (41.1 minutes), Hispanic (36.1 minutes), and Asian/Pacific Islander (37.4 minutes), compared with patients identified as white (33.8 minutes) (P<.01 for all). Door-to-balloon times for patients identified as African American/black (122.3 minutes) or Hispanic (114.8 minutes) were significantly longer than for patients identified as white (103.4 minutes) (P<.001 for both). Racial/ethnic differences were still significant but were substantially reduced after accounting for differences in mean times to treatment for the hospitals in which patients were treated; significant racial/ethnic differences persisted after further adjustment for sociodemographic characteristics, insurance status, and clinical and hospital characteristics (P<.01 for all).
Conclusion A substantial portion of the racial/ethnic disparity in time to treatment was accounted for by the specific hospital to which patients were admitted, in contrast to differential treatment by race/ethnicity inside the hospital.
Author Affiliations: Section of Health Policy and Administration, Department of Epidemiology and Public Health (Drs Bradley and Krumholz and Ms Webster), Section of Cardiovascular Medicine (Drs McNamara and Krumholz and Mr Wang), and Robert Wood Johnson Clinical Scholars Program (Dr Krumholz), Department of Medicine at the Yale University School of Medicine, New Haven, Conn; Yale-New Haven Hospital Center for Outcomes Research and Evaluation, New Haven (Dr Krumholz); Flying Buttress Associates, Charlottesville, Va (Dr Herrin); Kaiser Permanente Clinical Research Unit, Denver, Colo (Dr Magid); Department of Preventive Medicine and Biometrics and the Division of Emergency Medicine at the University of Colorado Health Sciences Center, Denver (Dr Magid); Genentech Inc, South San Francisco, Calif (Dr Blaney); Division of Cardiology, Department of Medicine, Duke University, Durham, NC (Dr Peterson); Center for Cardiovascular Prevention, Research, and Education, Watson Clinic, Lakeland, Fla (Dr Canto); and Department of Emergency Medicine, Pennsylvania Hospital, Philadelphia (Dr Pollack).
Corresponding Author: Harlan M. Krumholz, MD, SM, Yale University School of Medicine, 333 Cedar St, PO Box 208088, New Haven, CT 06520-8088 (harlan.krumholz{at}yale.edu).
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