OBJECTIVE--To assess whether rates of coronary revascularization procedures differ between blacks and whites after coronary angiography is performed and to assess the relationship of these rates to hospital characteristics. DESIGN--A retrospective cohort study using 1987 and 1988 data on hospital claims and characteristics from the Health Care Financing Administration. SETTING--One thousand four hundred twenty-nine acute care hospitals that provide coronary angiography in the United States. PATIENTS--A national sample of 27,485 Medicare Part A enrollees, aged 65 to 74 years, who underwent inpatient angiography for coronary heart disease in 1987. MAIN OUTCOME MEASURE--The adjusted odds of revascularization with either coronary angioplasty or bypass graft surgery within 90 days of angiography for whites relative to blacks, controlling for age, sex, region, Medicaid eligibility, principal diagnosis, comorbid diagnoses, and hospital characteristics of ownership, teaching status, urban/suburban or rural location, and availability of revascularization procedures. RESULTS--White men and women were significantly more likely than black men and women, respectively, to receive a revascularization procedure after coronary angiography (57% and 50% vs 40% and 34%, both P <.001). The adjusted odds of receiving a revascularization procedure after coronary angiography were 78% higher for whites than blacks (95% confidence interval for odds ratio, 1.56 to 2.03). Statistically significant racial differences in the adjusted odds of receiving a revascularization procedure were present in all types of hospitals except rural hospitals, and these differences did not vary significantly by any of the four hospital characteristics (all P >.20 for interaction terms). CONCLUSIONS--Among Medicare enrollees, whites are more likely than blacks to receive revascularization procedures after coronary angiography. Racial differences of similar magnitude occur in all types of hospitals. These differences may reflect overuse in whites or underuse in blacks, but they are unlikely to reflect access to cardiologists or hospitals that perform revascularization procedures. Potential explanations include unmeasured clinical or socioeconomic factors, differing patient preferences, and racial bias at the hospitals performing angiography.

BACKGROUND--The objective of this study was to compare treatment and outcome of acute myocardial infarction in women and men. METHODS--In this survey, patient hospital records were reviewed, and information about patient characteristics, treatments, and hospital events was entered in the Myocardial Infarction Triage and Intervention Registry. Between January 1988 and June 1990, a total of 4891 consecutive patients, including 1659 women, were hospitalized for acute myocardial infarction in 19 hospitals in the Seattle (Wash) metropolitan area. In-hospital thrombolytic therapy, coronary angiography, angioplasty, and bypass surgery were examined, as were in-hospital complications and death. RESULTS--Women were older and more often had histories previous hypertension and previous congestive heart failure. Thrombolytic therapy was used less often in women, although information about eligibility for treatment was not available to determine if this difference was due to treatment bias or differences in eligibility. Both coronary angiography and coronary angioplasty were used less frequently in women. However, of patients who had coronary angiography, equal proportions of women and men received angioplasty and/or coronary bypass surgery. Hospital mortality was 16% for women and 11% for men, although this difference was diminished by age adjustment. Mortality was higher in women undergoing bypass surgery, but this difference, too, was less apparent after age adjustment. CONCLUSIONS--Despite high levels of risk factors and mortality, coronary angiography and angioplasty were used less often in women, although among those who underwent coronary angiography, there were no gender differences in the use of angioplasty or bypass surgery. Clearly, more needs to be known about decision making for coronary angiography, as this process seems to differ for women and men with acute myocardial infarction.

OBJECTIVE: To compare racial differences in clinical presentation, natural history, and access to medical care and procedures among emergency-department patients with acute chest pain. DESIGN: Prospective follow-up study of consecutive patients coming to the emergency department because of acute chest pain. SETTING: Two university medical centers. PATIENTS: A total of 3031 patients who were 30 years or older and who came to the emergency department with acute chest pain from 1984 to 1986. MAIN RESULTS: African-Americans tended to have slightly, but not always significantly, lower rates of acute myocardial infarction, acute ischemic heart disease, and major complications, after adjusting for presenting symptoms and signs; the adjusted odds ratios for African-Americans were as follows: 0.77 (95% CI, 0.54 to 1.1) for acute myocardial infarction, 0.75 (CI, 0.59 to 0.95) for ischemic heart disease, and 0.79 (CI, 0.45 to 1.4) for death or major complications. Clinical factors classically associated with acute myocardial infarction were equally predictive in African-Americans and whites. After adjustments were made for multiple clinical factors, a lower proportion of African-Americans were admitted to the hospital (odds ratio, 0.69; CI, 0.56 to 0.84), and, once admitted, were somewhat less likely to be triaged to the coronary care unit (odds ratio, 0.81; CI, 0.65 to 1.0). In adjusted analyses, African-Americans were as likely to undergo cardiac catheterization as whites (odds ratio, 0.86; CI, 0.64 to 1.2) but were less likely to undergo coronary artery bypass procedures once severity of coronary disease was included in the analysis (odds ratio, 0.24; CI, 0.08 to 0.71). CONCLUSION: African-Americans and whites had a similar presentation and natural history of acute myocardial infarction and, after adjusting for probability of clinical events, similar access to most medical care and cardiac procedures. However, the rate of coronary artery bypass procedures was much lower among African-Americans than among whites. Reasons for this difference should be studied.

BACKGROUND. During the past decade the use of coronary angiography after acute myocardial infarction has substantially increased. Among the possible contributing factors, the increasing availability of cardiac catheterization facilities was the focus of our investigation. METHODS. We investigated whether the availability of cardiac catheterization facilities at an admitting hospital was associated with the likelihood that a patient would undergo coronary angiography. After adjusting for age, sex, cardiac history, and cardiac complications during hospitalization, we evaluated this association in 5867 consecutive patients with acute myocardial infarction admitted to 19 Seattle-area hospitals. We also assessed the association between the presence of on-site cardiac catheterization facilities and in-hospital mortality. RESULTS. Patients admitted to hospitals with on-site cardiac catheterization facilities were far more likely to undergo coronary angiography (odds ratio, 3.21; 95 percent confidence interval, 2.81 to 3.67) than patients admitted to hospitals where transfer to another institution would be required to perform cardiac catheterization. Admission to a hospital with on-site facilities was more strongly associated with the use of coronary angiography than any characteristic of the patient. Although our study had limited power to detect differences in mortality, the availability of coronary angiography had no discernible association with in-hospital mortality rates (odds ratio for mortality among patients admitted to hospitals with on-site facilities vs. patients admitted to hospitals without such facilities, 0.88; 95 percent confidence interval, 0.71 to 1.09). CONCLUSIONS. In this community-wide study, the availability of on-site cardiac catheterization facilities was associated with a higher likelihood that a patient would undergo coronary angiography. However, admission to hospitals with these facilities did not appear to be associated with lower short-term mortality.

OBJECTIVES: The goal of this study was to assess racial differences in process of care and outcome for acute myocardial infarction in the VA health care system. DESIGN: Retrospective cohort study using clinical data. SETTING: Eighty-one acute care VA hospitals. PATIENTS: Four thousand seven hundred sixty veterans discharged with a confirmed diagnosis of acute myocardial infarction. The analysis was restricted to 606 black and 4005 white patients. MAIN OUTCOME MEASURES: Comparison of use of guideline-based medications, invasive cardiac procedures, and all-cause mortality at 30 days, 1 year, and 3 years. RESULTS: Black patients were equally likely to receive beta-blockers, more likely than white patients to receive aspirin (86.8% vs. 82.0%; P <0.05), and marginally more likely to receive angiotensin converting enzyme inhibitors (55.7% vs. 49.6%; P = 0.07) at the time of discharge. In contrast, black patients were less likely than white patients to receive thrombolytic therapy at the time of arrival (32.4% vs. 48.2%; P <0.01). There was no significant difference in refusal of angiography or percutaneous transluminal coronary angioplasty between black patients and white patients, or in crude rates of either of these procedures. There was also no difference overall in the percentage of patients who refused coronary artery bypass graft surgery. However, black patients were less likely than white patients to undergo bypass surgery (6.9% vs. 12.5% by 90 days; P <0.001). Black patients remained less likely to undergo bypass surgery even when high-risk specific coronary anatomy subgroups were examined. There was no difference in mortality in the two groups. CONCLUSIONS: In this integrated health care system, no significant racial disparities in use of noninterventional therapies, diagnostic coronary angiography, or short- or long-term mortality was found. Disparities in use of thrombolytic therapy and coronary artery bypass surgery existed, however, even after accounting for differences in clinical indications for treatment and patient refusals. Further work should assess the role of the medical interaction and physician behavior in racial disparities in use of health care.

We determined whether adherence to recommendations for coronary angiography more than 12 h after symptom onset but prior to hospital discharge after acute myocardial infarction (AMI) resulted in better survival. Using propensity scores, we created a matched retrospective sample of 19,568 Medicare patients hospitalized with AMI during 1994-1995 in the United States. Twenty-nine percent, 36%, and 34% of patients were judged necessary, appropriate, or uncertain, respectively, for angiography while 60% of those judged necessary received the procedure during the hospitalization. The 3-year survival benefit was largest for patients rated necessary [mean survival difference (95% CI): 17.6%(15.1, 20.1)] and smallest for those rated uncertain [8.8%(6.8, 10.7)]. Angiography recommendations appear to select patients who are likely to benefit from the procedure and the consequent interventions. Because of the magnitude of the benefit and of the number of patients involved, steps should be taken to replicate these findings.

BACKGROUND: Scottish MONICA used medical and medico-legal records and World Health Organization MONICA Project criteria to register coronary events in 25- to 64-year-old residents of the high-incidence area of north Glasgow from 1985 to 1991. METHODS AND RESULTS: Age-standardized data from 3991 episodes of nonfatal definite myocardial infarction and coronary deaths in men (mean age, 55.5 years) were compared with 1551 in women (57.0 years). Many results, such as the overall 28-day fatality rates of 49.8% in men and 48.5% in women, showed insignificant differences. However, 74.3% of deaths in men occurred out of hospital versus 67.8% in women (P =.0004). After admission to hospital, fatality rates in women were 14% higher (P =.07) and after admission to coronary care, 22% higher (P =.04). Women were more often widowed. Fewer had a history of previous myocardial infarction, but the prevalence of angina pectoris, of smoking, and of chest pain in the attack was the same as in men; more had shock, syncope, and breathlessness. More consulted a doctor before admission to hospital, which delayed their coming under care. More men had ECG Q-wave progression, and more women had smaller ECG changes. This, and marginally reduced chances of direct admission to coronary care, of thrombolysis, of aspirin, and of beta-blockers, did not explain women's excess hospital fatality. CONCLUSIONS: Acute coronary events appear to be recognized and treated fairly equally in men and women 25 to 64 years old in Glasgow, so differences are small but subtle. More men die suddenly out of hospital; the reason why more women die after arrival may be because the equivalent number of men have already died outside.

BACKGROUND: The outcome after myocardial infarction may be influenced by the type of physician providing ambulatory care. METHODS: We studied 35,520 patients 65 years of age or older who were hospitalized for myocardial infarction in seven states during 1994 and 1995 and who survived for at least three months after discharge. From Medicare claims, we identified ambulatory visits to cardiologists, internists, and family practitioners. Using propensity scores to adjust for demographic, clinical, and hospital characteristics, we analyzed treatment and mortality at two years among patients matched according to their estimated propensity to receive care from a cardiologist within three months after discharge. RESULTS: As compared with patients who saw only an internist or a family practitioner in the three months after discharge, patients who saw a cardiologist were younger, were more likely to be white, were more likely to be male, had fewer coexisting conditions, and were more likely to have undergone invasive cardiac procedures while hospitalized (P<0.01 for all comparisons). Patients who saw a cardiologist were more likely to undergo cardiac procedures and rehabilitation after discharge. Patients who saw a cardiologist had a lower two-year mortality rate than matched patients who saw only an internist or a family practitioner (14.6 percent vs. 18.3 percent, P<0.001). Patients who saw both a cardiologist and an internist or a family practitioner had a lower mortality rate than matched patients who saw only a cardiologist (11.1 percent vs. 12.1 percent, P=0.02). CONCLUSIONS: Ambulatory visits to cardiologists were associated with greater use of cardiac procedures and decreased mortality after myocardial infarction. Concurrent care by an internist or a family practitioner was associated with a further reduction in mortality.

OBJECTIVE--To investigate changes between 1987 and 1990 in the care and outcomes associated with acute myocardial infarction (AMI) in elderly patients. DESIGN--Retrospective cohort study using a longitudinal database created from Medicare administrative files. PATIENTS--Cohorts comprising a total of 856,847 AMI patients insured by Medicare between 1987 and 1990. MAIN OUTCOME MEASURES--Annual rates of mortality at 30 days and 1 year following AMI, and the use of coronary angiography, coronary artery bypass graft surgery, and percutaneous transluminal coronary angioplasty during the first 90 days after a new AMI. RESULTS--Between 1987 and 1990, mortality rates decreased 10% overall from 26% to 23% at 30 days (P <.001) and from 40% to 36% at 1 year following AMI (P <.001). Declines in mortality and adjusted risks of 1-year mortality were similar in men and women and in blacks and whites, but mortality declines were more evident in those younger than 85 years. Meanwhile, the proportion of elderly AMI patients having angiography within the first 90 days after their index admission increased from 24% to 33%(P <.001); proportions increased for both genders and all races. The proportion of patients undergoing revascularization procedures increased from 13% to 21%; while rates of bypass surgery increased from 8% to 11%, rates of angioplasty doubled from 5% to 10%(all P <.001). CONCLUSIONS--Between 1987 and 1990, survival of elderly patients following AMI improved significantly. While changes in patient treatment may be responsible, the increased use of thrombolytic therapy appears to be only a partial explanation. Also, while the use of coronary angiography and revascularization procedures increased dramatically, the degree to which it caused the improvement in survival could not be determined.

BACKGROUND: Policies to concentrate or regionalize invasive procedures at high-volume medical centers are under active consideration. Such policies could improve outcomes among those who undergo procedures while increasing their underuse among those who never reach such centers. We compared the underuse of needed angiography after acute myocardial infarction in a traditional Medicare fee-for-service system with underuse in the regionalized Department of Veterans Affairs (VA) health care system. METHODS: We studied 1665 veterans from 81 VA hospitals and 19,305 Medicare patients from 1530 non-VA hospitals, all of whom were elderly men. We compared adjusted angiography use and one-year mortality among patients for whom angiography was rated as clinically needed. We compared underuse in models before and after controlling for the on-site availability of cardiac procedures. RESULTS: After adjustment for the need for angiography, underuse was present in both groups, but VA patients remained significantly less likely than Medicare patients to undergo angiography (43.9 percent vs. 51.0 percent; odds ratio, 0.75; 95 percent confidence interval, 0.57 to 0.96). After also controlling for on-site availability of cardiac procedures at the admitting hospital, we found no significant difference in the underuse of angiography among VA patients as compared with Medicare patients (odds ratio, 1.02; 95 percent confidence interval, 0.82 to 1.26) or in one-year mortality (odds ratio, 1.08; 95 percent confidence interval, 0.89 to 1.28). CONCLUSIONS: There is underuse of needed angiography after acute myocardial infarction in both the VA and Medicare systems, but the rate of underuse is significantly higher in the VA. These differences appear to be associated with limited on-site availability of cardiac procedures in the regionalized VA health care system. Further work should focus on how regionalization policies could be improved with effective referral and triage processes.