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Bradley EH, Herrin J, Wang Y, et al. Racial and Ethnic Differences in Time to Acute Reperfusion Therapy for Patients Hospitalized With Myocardial Infarction. JAMA. 2004;292(13):1563–1572. doi:10.1001/jama.292.13.1563
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).
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
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.
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