Correspondence

Heart Disease and Race

N Engl J Med 1994; 330:216-218January 20, 1994

Article

To the Editor:

The article by Becker et al. (Aug. 26 issue)1 on racial differences in rates of cardiac arrest and subsequent survival calls attention to a problem that has been ignored for years. There are indeed several lines of evidence for a genetic or racial influence on cardiovascular diseases. Nevertheless, race is inextricably connected with socioeconomic, cultural, behavioral, and medical conditions, any of which could largely explain the differences in the incidence of cardiac arrest and associated deaths.

Although the authors did mention that race may be a marker of other factors, the analysis presented in the article failed to control for socioeconomic status. Poverty, which is often prevalent in African American communities in the United States, has an influence on many factors related to heart disease, from diet to stress. The authors' own data showed that some factors possibly linked with survival -- specifically, cardiopulmonary resuscitation administered at the site of the arrest and the presence of witnesses -- may also be related to living conditions in neighborhoods.

Because the authors were blessed with a large data set, it would be worth the effort to develop a surrogate marker for socioeconomic status by using the census-tract income figures for the tracts in which the cardiac arrests and deaths occurred. This would strengthen the argument that race is related to the incidence of cardiac arrest and subsequent death.

Shenghan Lai, M.B., Ph.D., M.P.H.
Comprehensive AIDS Program

J. Bryan Page, Ph.D.
University of Miami School of Medicine, Miami, FL 33101

1 References

1. 1

   Becker LB, Han BH, Meyer PM, et al. Racial differences in the incidence of cardiac arrest and subsequent survival. N Engl J Med 1993;329:600-606
   Full Text | Web of Science | Medline

To the Editor:

Becker and his colleagues conclude that the incidence of cardiac arrest and the associated fatality rate were higher among black patients than among white patients. However, certain variables that may have contributed to the differences observed between the two groups were not included in their analysis. One such variable is the location of the cardiac arrests. Those occurring outside the home are more likely to be witnessed and are associated with a higher incidence of cardiopulmonary resuscitation initiated by a bystander1. Witnessed arrests and resuscitative efforts by bystanders occurred more frequently in the group of white patients; these two factors can increase survival2. There is evidence to suggest that patients who have a cardiac arrest outside the home tend to be younger and have fewer previous symptoms than patients who have an arrest at home.

Becker et al. also do not mention the patients' state of health before the cardiac arrests. Preexisting illness or risk factors may account for the higher incidence of mortality from cardiovascular disease and from all causes in the black population3. The location of the arrest and previous health status are essential variables that should not be overlooked in the analysis of survival differences between the two groups.

Evens Rodney, M.D.
Balendu C. Vasavada, M.D.
Terrence J. Sacchi, M.D.
Long Island College Hospital, Brooklyn, NY 11201

3 References

1. 1

   Litwin PE, Eisenberg MS, Hallstrom AP, Cummings RO. The location of collapse and its effect on survival from cardiac arrest. Ann Emerg Med 1987;16:787-791
   CrossRef | Web of Science | Medline

2. 2

   Guzy PM, Pearce ML, Greenfield S. The survival benefit of bystander cardiopulmonary resuscitation in a paramedic served metropolitan area. Am J Public Health 1983;73:766-769
   CrossRef | Web of Science | Medline

3. 3

   Otten MW Jr, Teutsch SM, Williamson DF, Marks JS. The effect of known risk factors on the excess mortality of black adults in the United States. JAMA 1990;263:845-850
   CrossRef | Web of Science | Medline

To the Editor:

The articles by Becker and Whittle et al. and Ayanian's editorial (Aug. 26 issue) are provocative1,2.

I wonder whether a closer scrutiny by Whittle et al. of a few cases from the Department of Veterans Affairs files might clarify the decision-making process that resulted in the use of fewer cardiovascular procedures in blacks than in whites. I would like to know the thinking that led to the treatment decision and the ensuing dialogue between doctor and patient. I suspect that the clearest understanding of racial differences in treatment would come from an analysis of those conversations. Trust between patient and physician, clarity of explanation, use of language that the patient understands, and enlistment of the patient in his or her own treatment plan are all important factors. I suspect that the process of communication between a white physician and a black patient differs from that between a physician and a patient of the same race.

I also wonder about Dr. Ayanian's discussion of measures that may lead to improvement in the health of black Americans. Yes, access to effective medical care, education of patients, and a commitment on the part of physicians to avoid racial bias may help. But I would rank as more important improved general education for all races, more and better jobs, and support for families. As Dr. Ayanian notes, we are not sure that more cardiovascular procedures lead to longer or better lives. We can be pretty sure, however, about the positive effects of education, employment, and family support.

Frederic W. Platt, M.D.
1901 E. 20th Ave., Denver, CO 80205

2 References

1. 1

   Whittle J, Conigliaro J, Good CB, Lofgren RP. Racial differences in the use of invasive cardiovascular procedures in the Department of Veterans Affairs medical system. N Engl J Med 1993;329:621-627
   Full Text | Web of Science | Medline

2. 2

   Ayanian JZ. Heart disease in black and white. N Engl J Med 1993;329:656-658
   Full Text | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: The letters in response to our article reflect the diverse concerns about racial differences in health care and also suggest how complicated and challenging a task it can be to present the truth.

Drs. Lai and Page remind us of the importance of socioeconomic status, that race may be a marker for other factors, and that the analysis of the 6451 patients who had cardiac arrests did not control for socioeconomic status. We considered including a surrogate marker for socioeconomic status. However, there is concern about the validity of using census-tract data to reflect socioeconomic status for patients with cardiac arrests1. Our patients were much older than the general population; therefore, assumptions based on pooled data might be seriously flawed. Even if accurate data on socioeconomic status were available, exactly when during a patient's life would a value reflect that patient's cumulative lifetime experience with the health care system, diet, income, smoking, stress, and the factors thought to be mediators of socioeconomic status? We believe that determining the influence of socioeconomic status on the incidence of cardiac arrests and subsequent survival is a worthy and complex analytic task. We are currently conducting an analysis that may overcome some of these shortcomings and appreciate the encouragement to do so.

Rodney et al. point out that location and previous health status may partly explain the racial difference in cardiac arrests and survival. We agree and note that no large-scale study of cardiac arrests before hospitalization has included these important data. However, Rodney et al. also suggest that the racial difference in survival may be related in part to blacks' being witnessed and receiving cardiopulmonary resuscitation less frequently because of their location at the time of the arrest. In the logistic-regression model we used, the terms for “cardiopulmonary resuscitation by bystander” and “witnessed” would have taken these factors into account2. They do not explain the racial effect we observed.

The authors hope that future studies will identify the underlying factors that resulted in a lower survival rate for blacks than for whites. It is important that the basic message of our study not be blunted: none of the patient groups fared very well, and the black patients fared the worst. What worries us is a growing suspicion that most communities have low survival rates, despite the higher rates reported in a few communities3. We should all be alarmed that despite our knowledge about lifesaving care, we do not yet provide effective emergency cardiac care for the majority of Americans. It is vital that health care providers focus on improving the chain of survival for all citizens, with particular attention to high-risk groups.

Lance B. Becker, M.D.
University of Chicago, Chicago, IL 60637

Peter M. Meyer, Ph.D.
Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL 60612

3 References

1. 1

   Hallstrom A, Boutin P, Cobb L, Johnson E. Socioeconomic status and prediction of ventricular fibrillation survival. Am J Public Health 1993;83:245-248
   CrossRef | Web of Science | Medline

2. 2

   McCullagh P, Nelder JA. Generalized linear models. 3rd ed. New York: Chapman and Hall, 1989:37.
   

3. 3

   Becker LB, Ostrander MP, Barrett J, Kondos GT. Outcome of CPR in a large metropolitan area -- where are the survivors? Ann Emerg Med 1991;20:355-361
   CrossRef | Web of Science | Medline

Author/Editor Response

We appreciate Dr. Platt's suggestions regarding potential causes of the differences in the use of cardiovascular procedures that we found between black and white veterans admitted to Veterans Affairs hospitals. It is certainly possible that some of the variation in the use of procedures reflects barriers to doctor-patient communication when the doctor and the patient are not of the same race. An investigation of this communication process would be a fascinating project that could provide a great deal of useful information. We have found that a retrospective review of medical records does not allow adequate insight into the process that occurs during that interchange. Such a study will probably require prospective data collection.

Jeff Whittle, M.D., M.P.H.
Joseph Conigliaro, M.D., M.P.H.
C.B. Good, M.D., M.P.H.
Veterans Affairs Medical Center, Pittsburgh, PA 15240

Citing Articles (2)

Citing Articles

1. 1

   (1997) Recommended Guidelines for Reviewing, Reporting, and Conducting Research on In-hospital Resuscitation: The In-hospital “Utstein Style”*. Academic Emergency Medicine 4:6, 603-627
   CrossRef

2. 2

   Richard O. Cummins, Douglas Chamberlain, Mary Fran Hazinski, Vinay Nadkarni, Walter Kloeck, Efraim Kramer, Lance Becker, Colin Robertson, Rudi Koster, Arno Zaritsky, Leo Bossaert, Joseph P. Ornato, Victor Callanan, Mervyn Allen, Petter Steen, Brian Connolly, Arthur Sanders, Ahamed Idris, Stuart Cobbe. (1997) Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation: the in-hospital ‘Utstein style’. Resuscitation 34:2, 151-183
   CrossRef