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1. Re: Unequal Treatment

   • John A. Spertus, MD, MPH
   • Philip G. Jones, MS, and Harlan M. Krumholz, MD, SM

   Mid America Heart Institute and the University of Missouri-Kansas City

   Dr. Webster is correct that we found disparities in quality of care by race. The differences were, for the most part, modest in absolute terms and each measure is relevant to only a subset of the patients. For that reason we are not surprised that differences in the quality measures did not have a dominant effect in explaining differences in outcomes among the entire cohort. That observation does not suggest that the indicators are not important to the subset of patients to which they apply or that addressing that disparity is unimportant, but what we do find is that when considering the entire group and the differences in outcomes, that differences in the clinical characteristics of the patients on admission explain much of the difference in outcomes. Nevertheless, we emphatically do support the use of evidence-based therapies in all patients, regardless of race.

   Dr. Rhan raised a concern about the representativeness of the enrolled patients and the inferred assumptions of causality between race, or its associated risk factors, and outcomes. With regard to recruitment bias, we previously reported the representativeness of the PREMIER patients by comparing their characteristics with those of the entire population of eligible myocardial infarction patients at our enrolling centers. While not previously described by race, 55.1% of black patients enrolled in our study were male, as compared with 54.1% of the entire black population. We thus feel that it is unlikely that enrollment bias contributed to the larger proportion of blacks who were female as compared with whites.

   Conflict of Interest:

   None declared

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   Published June 10, 2009
2. The causality of racial differences and myocardial infarction outcomes

   • Yu Han, PhD
   • Liu Hong, Cuiping Zhong and Jianhua Qiu

   Xijing Hospital, Fourth Military Medical University

   To the editor:

   We read with great interest the excellent paper by Dr Spertus JA and colleagues (1), in which the authors drew a conclusion that black patients with myocardial infarction have worse outcomes than white patients.

   Although the study was potentially clinically directive, we would like to express 2 concerns. First, since the white patients were predominantly men, extrapolation of the findings to women must be done with caution. Furthermore, there might be enrollment bias for 2 groups due to different proportation of males. Second, the fundamental question of causality between racial differences and myocardial infarction outcomes could not be answered in this observational study. Thus, before one speculated about the putative mechanisms underlying the observed survival advantage of white race over black, perhaps one should firstly investigate the reason behind the unsignificant differences between 2 groups after adjustment for patient factors and site of care.

   References:

   1 Spertus JA, Jones PG, Masoudi FA, et al. Factors associated with racial differences in myocardial infarction outcomes. Ann Intern Med. 2009;150(5):314-24.

   Conflict of Interest:

   None declared

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   Published March 16, 2009
3. Unequal Treatment

   • James R Webster, MD, MS, MACP
   • None

   Feinberg School of Medicine of Northwestern University

   To the Editor: Data in the paper by Spertus et. al. (1) confirms the findings of many other studies demonstrating that Black patients with heart disease receive lower quality care than Whites. The authors document major care disparities with Black patients getting significantly fewer diagnostic catheterizations and revascularizations and less discharge counseling regarding smoking cessation and exercise, all at P values of < 0.0001! Contrary to current dogma do the authors honestly believe that these interventions have no value and that the differences in health outcomes in the Black and White study populations were simply due to “cardiac risk factors”? If so we must seriously reconsider our approach to all our patients with myocardial infarction. In any case one of the conclusions of their research should be that there is still a great deal of unequal treatment (2) going on in the U.S. today.

   References

   1. Spertus JA, Jones PG, Masoudi FA et. al. Factors associated with racial differences in myocardial infarction outcomes. Ann Intern Med 2009;150:314-324.

   2. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington DC: National Academies Pr. 2003

   Conflict of Interest:

   None declared

   Submit response
   Published March 11, 2009