Special Article
Relation of Race and Sex to the Use of Reperfusion Therapy in Medicare Beneficiaries with Acute Myocardial Infarction
N Engl J Med 2000; 342:1094-1100April 13, 2000
- Abstract
Background
There are few reports describing the combined influence of the race and sex of a patient on the use of reperfusion therapy for acute myocardial infarction.
Methods
To determine the relation of race and sex to the receipt of reperfusion therapy for myocardial infarction in the United States, we reviewed the medical records of 234,769 Medicare patients with myocardial infarction. From these records we identified 26,575 white or black patients who met strict eligibility criteria for reperfusion therapy. We then performed bivariate and multivariate analyses of prevalence ratios to determine predictors of the use of reperfusion therapy in four subgroups of patients categorized according to race and sex: white men, white women, black men, and black women.
Results
Among eligible patients, white men received reperfusion therapy with the highest frequency (59 percent), followed by white women (56 percent), black men (50 percent), and black women (44 percent). After adjustment for differences in demographic and clinical characteristics, white women were as likely as white men to receive reperfusion therapy (prevalence ratio, 1.00; 95 percent confidence interval, 0.98 to 1.03). Likewise, black women were as likely as black men to receive reperfusion therapy (prevalence ratio, 1.00; 95 percent confidence interval, 0.89 to 1.13). However, black women were significantly less likely to receive reperfusion therapy than white men (prevalence ratio, 0.90; 95 percent confidence interval, 0.82 to 0.98), as were black men (prevalence ratio, 0.85; 95 percent confidence interval, 0.78 to 0.93).
Conclusions
After adjustment for differences in clinical and demographic characteristics and clinical presentation, differences according to sex in the use of reperfusion therapy are minimal. However, blacks, regardless of sex, are significantly less likely than whites to receive this potentially lifesaving therapy.
Media in This Article
Table 1
Demographic and Clinical Characteristics of the Patients.Table 2
Presenting Characteristics of the Patients and Characteristics of the Hospitals.Article Activity
- Article
Every year, more than 1 million patients in the United States have acute myocardial infarction, and almost half these patients have myocardial infarction with ST-segment elevation. Guidelines on myocardial infarction issued by the American College of Cardiology and the American Heart Association1 recommend prompt restoration of anterograde coronary blood flow as the main goal of treatment in such patients. Thrombolytic therapy is the most common method used to restore flow,2 and primary angioplasty has been accepted as an alternative method of reperfusion.3-5 However, there is increasing evidence that reperfusion may be underused among blacks,6-8 women,9-14 and the elderly.15-17
The effect of race on the risk and incidence of ischemic heart disease and its associated mortality differs between men and women.18,19 For example, among men, the prevalence of the risk factor of cigarette smoking is higher in blacks than in whites, but among women, the opposite is true.19 Similarly, the effect of sex on the risk and incidence of ischemic heart disease and its associated mortality differs between blacks and whites.19 For instance, among blacks, the prevalence of the risk factor of obesity is markedly higher in women than in men, whereas among whites, the prevalence of obesity is slightly higher in men.19 These observations have prompted other investigators to pay careful attention to the interactions of race and sex in epidemiologic studies of ischemic heart disease and its risk factors, frequently analyzing subgroups of patients categorized according to race and sex when sufficient numbers of subjects are available.18,19
The Cooperative Cardiovascular Project is an ongoing national project, sponsored by the Health Care Financing Administration, that is designed to improve the treatment and outcomes of Medicare beneficiaries who have had acute myocardial infarction. The project has a large clinical data base that includes information on patients of all races, both sexes, and all ages who have had myocardial infarction. Our primary objective was to examine the potential interaction of race and sex with respect to the rate of use of reperfusion therapy in a sample of patients who are primarily older than 65 years of age.
Methods
Study Sample
We retrospectively identified patients with a principal diagnosis of myocardial infarction (code 410) according to the International Classification of Diseases, 9th Revision, Clinical Modification, 20 from codes designating discharge diagnoses, excluding the codes with a fifth digit of 2, which designates a subsequent episode of care. Copies of the complete medical records of these patients were sent to a study center for the abstraction of clinical data by trained chart abstractors. A random sample of the entire Medicare cohort with myocardial infarction from February 1994 to July 1995 was selected, and the charts from 234,769 patients hospitalized at 6684 hospitals in the United States were reviewed. A complete description of the methods used has been published elsewhere.21 Because all study data were fully encrypted and we had no way of identifying individual patients and providers, approval by the institutional review board and informed consent were not required.
Our analysis involved only patients who were eligible for reperfusion therapy. To be eligible, patients had to present to the hospital after at least 30 minutes but less than 12 hours of chest pain and had to have ST-segment elevation of at least 1 mm on two contiguous leads on the initial electrocardiogram. Patients were excluded from the analysis if they were older than 80 years of age, if they had been transferred from another hospital, if there was documentation that thrombolysis had been considered by the physician but was declined by the patient or otherwise decided against, if the patients were not white or black or their race was not known, or if they had any known absolute or relative contraindication to the administration of thrombolytic therapy.21
Statistical Analysis
We categorized patients in four subgroups according to race and sex — white men, white women, black men, and black women — and compared their demographic and clinical characteristics, including their presenting characteristics at the hospital. An analysis of prevalence ratios was performed to ascertain the association of race and sex with the receipt of acute reperfusion therapy (the dependent variable). We computed the adjusted probability of undergoing reperfusion for blacks and whites separately, using multiple logistic-regression models to adjust for potential confounders. We then used these adjusted probabilities of reperfusion to compute the adjusted prevalence ratios among the subgroups of patients.22 To determine the 95 percent confidence intervals, statistical differentials were used to approximate the variance for the prevalence ratios.23 In addition, potential confounders were entered into a regression model in which the main independent variables were the subgroups of patients, represented by three dummy variables, with white men as the reference group.
For all multivariate models, predictive variables that may have influenced the receipt of reperfusion therapy were entered into a series of models to provide us with better understanding of the additive effects of the following confounding factors: age (as a continuous variable), medical history, clinical presentation, and characteristics of the hospital. Variables were entered sequentially, but all variables were kept in the final models; almost all coefficients were significant (P values of less than 0.05 were considered to indicate statistical significance).
To ascertain more precisely the differences in the use of acute reperfusion therapy according to race and sex, we developed additional multivariate models, as follows: women only, in which the main independent predictor was race; men only, in which the main independent predictor was race; blacks only, in which the main independent predictor was sex; and whites only, in which the main independent predictor was sex. Age, medical history, clinical presentation, and characteristics of the hospital were also included as independent variables in each of these models. An additional multivariate model with two dichotomous independent variables (race and sex) and a term for their interaction (rather than the dummy variables for each subgroup) was also studied, but it yielded no additional insight. Finally, we performed separate analyses that included an adjustment for the clustering of patients in hospitals by correcting for overdispersion.24 The results remained consistent with our previous findings and therefore are not reported here. All initial statistical analyses were performed with the use of Stata statistical software (version 4.0, Stata Corporation, College Station, Tex.) and were independently verified with SAS software (version 6.12, SAS Institute, Cary, N.C.).
Results
Demographic and Clinical Characteristics
Of the 234,769 Medicare patients with acute myocardial infarction whom we identified, 26,575 (11 percent) met the criteria for inclusion in the study and had been eligible for reperfusion therapy (Table 1Table 1
Demographic and Clinical Characteristics of the Patients.). On average, white women were older (mean age, 72.1 years) and black men were younger (mean age, 66.0 years) than the patients in the other subgroups. The prevalence of diabetes, hypertension, prior myocardial infarction, and prior renal failure was higher in black men and women than in white men and women. The highest rate of current smoking was among black men, and the greatest frequency of limited mobility was among black women. A history of percutaneous transluminal coronary angioplasty or coronary-artery bypass surgery was most frequent among white men and least frequent among black women.Characteristics at Presentation and Characteristics of the Hospitals
Black women had the highest mean systolic blood pressure (151.0 mm Hg) and the highest mean heart rate (86.6 beats per minute) (Table 2Table 2
Presenting Characteristics of the Patients and Characteristics of the Hospitals.). White men were the most likely to present in Killip class I (63.6 percent), and black women the least likely (51.4 percent). Black patients were more likely than white patients to present at large hospitals (with more than 400 beds), those with an urban location and teaching affiliations, and those with cardiac catheterization facilities.Use of Reperfusion Therapy
Overall, only 57 percent of the study patients who were eligible to receive reperfusion therapy received such therapy. White men were most likely to receive reperfusion therapy (59 percent of them did), followed by white women (56 percent), black men (50 percent), and black women (44 percent) (Table 3Table 3
Probability of Receiving Reperfusion Therapy.). In each group, the predominant method of restoring anterograde flow in an infarct-related coronary artery was thrombolytic therapy (range, 87.6 to 92.3 percent of those who received reperfusion therapy). After stratification according to geographic region, black men and women were less likely to receive reperfusion therapy than white men and women, regardless of geographic region (data not shown).After stepwise adjustment for differences in age, medical history, clinical presentation, and hospital characteristics, the differences according to both race and sex in the probability of receiving reperfusion therapy were attenuated, but the racial differences remained significant (Table 4Table 4
Prevalence Ratios for Receipt of Reperfusion Therapy According to Subgroup.). After adjustment, white women were as likely as white men to receive reperfusion therapy (prevalence ratio, 1.00; 95 percent confidence interval, 0.98 to 1.03). However, black women were significantly less likely than white men to receive reperfusion therapy (prevalence ratio, 0.90; 95 percent confidence interval, 0.82 to 0.98), as were black men (prevalence ratio, 0.85; 95 percent confidence interval, 0.78 to 0.93). When the analysis was repeated with only the patients who presented within six hours after the onset of symptoms included in the models, the results did not change substantially (data not shown).To determine more precisely the magnitude of the differences according to race and sex in the likelihood of receiving reperfusion therapy, we analyzed four separate multivariate models (Table 5Table 5
Adjusted Prevalence Ratios for Receipt of Reperfusion Therapy in Four Logistic-Regression Models Stratified According to Race and Sex.). When patients were stratified according to sex, race remained an important predictor of the receipt of acute reperfusion therapy. However, when patients were stratified according to race, sex was not significantly associated with the probability of receiving therapy. These models confirm that among Medicare beneficiaries with myocardial infarction who were eligible for reperfusion therapy, race, but not sex, was important in predicting the receipt of such therapy.Discussion
In this national sample of 26,575 Medicare beneficiaries with acute myocardial infarction who were eligible for reperfusion therapy, white women were as likely as white men to receive reperfusion therapy after adjustment for differences in age and clinical and presenting characteristics. However, blacks, regardless of sex, were significantly less likely than whites to receive this potentially life-saving therapy.
The reasons for the lower rate of use of reperfusion therapy in blacks in this study are not readily apparent, but they may include the following: the preferences of the patient, the expertise and preferences of the physician, hospital-related factors, and residual racial differences in clinical presentation that were not captured in our data. Given the extensive clinical information collected in the Cooperative Cardiovascular Project and used in these analyses, the latter is perhaps the least plausible explanation. Our analysis was confined to patients with myocardial infarction who met strict eligibility criteria for reperfusion therapy. Patients were excluded if there was sufficient documentation that they had declined reperfusion therapy. Therefore, the preferences of the patient are not likely to provide a full explanation of the observed differences. Furthermore, in our analysis we adjusted for differences in the characteristics of the hospital — such as number of beds, urban as compared with rural location, teaching affiliations, and the availability of cardiac catheterization facilities. Thus, many measurable hospital-related factors were accounted for. Also, the analysis involved only Medicare patients; thus the ability of a patient to pay for medical care should not have been a factor.
A more likely explanation for our findings is that the decisions of physicians, as a result of clinical ambiguity, lack of adequate training, insufficient knowledge, or physicians' own preferences or biases, contributed to the racial differences we observed in this study. A recent study by Borzak et al.8 has suggested that blacks may have clinical characteristics that differ from those of whites, thus making diagnosis and a decision to treat with thrombolytic therapy more difficult. The authors reported that physicians were more likely to admit white patients than black patients to the coronary care unit with a confirmed diagnosis of myocardial infarction, and that physicians were more likely to admit black patients than white patients with a diagnosis of suspected myocardial infarction. However, their study was limited to findings from a single institution and did not include a cohort of patients who were eligible for reperfusion therapy.
In another study, Taylor et al.7 reported that black patients with a confirmed myocardial infarction were significantly less likely to present with chest pain than white patients with such a diagnosis. This difference in clinical presentation may be important, because the absence of chest pain was shown in the data of the National Registry of Myocardial Infarction 2 to be one of the most important determinants of withholding reperfusion therapy.9 Although only patients who presented with chest pain were included in our analysis, it is possible that other clinically related factors may have decreased suspicion on the part of the physician that a black patient was having a myocardial infarction.
Taylor et al.7 found that blacks were more likely than whites to have nondiagnostic electrocardiograms, despite retrospective confirmation of myocardial infarction. For example, blacks may have more electrocardiographic confounders, such as changes in the electrocardiogram due to early repolarization (which can mimic the appearance of acute ST-segment elevation) or patterns of left ventricular strain (which may make the interpretation of ST segments more difficult), thus affecting the differential diagnosis. Regional discrimination based on race may be possible, although this is not a likely explanation, especially because racial differences in the receipt of reperfusion therapy were found in all regions of the United States.
Lastly, cultural barriers may have contributed to racial disparities in the administration of reperfusion therapy. For example, in a recent paper, Schulman et al.25 attempted to ascertain the influence that race and sex may have on patterns of referral for cardiac catheterization. Physicians were found to refer blacks (especially black women) less frequently than whites for coronary angiography in the evaluation of chest pain, even after adjustment for differences in symptoms, clinical characteristics, and the physicians' estimates of the probability of coronary disease. Clearly, additional studies are warranted to address the factors that lead to racial disparities in the administration of acute reperfusion therapy.
In our study, race was an important determinant of the receipt of reperfusion therapy, although sex was not. Our results are in marked contrast to those of some studies, which have shown that women are less likely than men to receive thrombolytic therapy after acute myocardial infarction,9-14 but other studies have found no difference according to sex.17,26,27 However, many of the previous studies that examined differences according to sex in the receipt of thrombolytic therapy did not adjust for the presence of generally recognized eligibility criteria for the use of reperfusion therapy in patients with myocardial infarction (such as duration of symptoms, electrocardiographic criteria, and the absence of contraindications to thrombolytic therapy) or a patient's decision not to undergo therapy. Also, most studies had sample sizes that were inadequate for determining the interactions of race and sex. Therefore, it is unclear whether previously reported differences in terms of sex were due to confounding by other factors known to influence the rate of use of reperfusion therapy or were the result of true sex differences. Furthermore, in contrast to many of the previous studies, our study involved primarily older patients.
Only the studies by Maynard et al. (the western Washington trial of tissue plasminogen activator),10 Krumholz et al. (the Connecticut cohort of the Cooperative Cardiovascular Project pilot study),17 McLaughlin et al. (a study of 37 hospitals in Minnesota),11 and Barron et al. (National Registry of Myocardial Infarction)9 used generally accepted criteria for eligibility for acute reperfusion therapy to select the study population. However, the study by Maynard et al.,10 which found that women were less likely than men to receive reperfusion therapy, did not adjust for differences in clinical and presenting characteristics. In the Connecticut Medicare cohort of the Cooperative Cardiovascular Project pilot study, a preliminary study conducted before the national Cooperative Cardiovascular Project that was the source of our data, Krumholz et al.17 demonstrated that every increase of one year in age independently predicted an 8 percent reduction in the rate of use of thrombolytic therapy. However, sex and race were not reported to be statistically important predictors of the use of such therapy, although the power of the study was insufficient to detect differences according to sex and race, given the small number of blacks and women in the study.
McLaughlin et al.11 and Barron et al.9 both found that, after adjustment for important clinical differences, women were significantly less likely than men to receive acute reperfusion therapy. However, the study by McLaughlin et al. pertained only to Minnesota residents and did not account for patients who were referred for primary angioplasty, and the study by Barron et al. was not restricted to Medicare beneficiaries. Finally, neither of the studies examined the interaction of race and sex. In our analysis, we used an extensive clinical data base to adjust more completely for potential confounders, we included strict criteria for eligibility for acute reperfusion therapy, and equally important, we rigorously analyzed the interaction of race and sex.
Our analysis was limited to Medicare patients who were primarily elderly, and we excluded patients who were not black or white, therefore limiting the generalizability of our results with respect to race. Also, we were not able to adjust directly for socioeconomic status, which could be an important confounder of the associations we observed. As in any observational study, unknown factors may have influenced the use of reperfusion strategies. Race was determined from a review of medical charts but was not directly confirmed. However, prior studies have demonstrated the validity of the racial designation in Medicare codes.21,28-30 Furthermore, we performed our own validation study of the concordance of race as listed in the Medicare charts of the Cooperative Cardiovascular Project with race as ascertained from Medicare claims from Alabama; we found that the agreement was 99.74 percent and that the kappa was extremely high, at 0.9795. Random misclassification of patients according to race would have biased our results toward confirming the null hypothesis, and there is no reason to believe that any misclassification was not random. The data in the Cooperative Cardiovascular Project did not contain information on the specialty of the attending physician, but this limitation alone is unlikely to have changed our main findings significantly.
Only widely accepted clinical criteria were used to determine eligibility for reperfusion therapy in this cohort of patients who had acute myocardial infarction with ST-segment elevation. These strict eligibility requirements were developed to increase the specificity of the analysis and thus minimize the possibility that controversial indications for reperfusion would decrease the importance of our findings. For example, age alone, the absence of chest pain, or the presence of left bundle-branch block is not necessarily accepted as an indication for withholding reperfusion therapy. In addition, many patients with contraindications to thrombolytic therapy (an exclusion criterion for our analyses) may have been referred for primary angioplasty.
In summary, we have shown that racial differences in the use of reperfusion therapy for myocardial infarction persisted after adjustment for sex and multiple clinical variables, as well as for characteristics of the hospitals. On the other hand, within each racial group, unadjusted sex differences in the use of such therapy were markedly reduced, if not eliminated, after adjustment. Thus, we found that in Medicare beneficiaries with myocardial infarction who were eligible for reperfusion therapy, race, but not sex, was important in predicting the receipt of such therapy. Our findings emphasize the need to continue searching for explanations of racial differences in the risk factors for, incidence of, mortality associated with, and treatment of ischemic heart disease. Understanding these differences will provide the key to reducing racial disparities.
Supported in part by grants from the National Institutes of Health, National Center for Research Resources (RR00032), and the Agency for Healthcare Research and Quality (HS08843 and HS09446). The content of this article does not necessarily reflect the views or policies of the Department of Health and Human Services.
Source Information
From the Center for Outcomes and Effectiveness Research and Education, University of Alabama at Birmingham, Birmingham.
Address reprint requests to Dr. Canto at the University of Alabama at Birmingham, 363 BDB, 1808 7th Ave. S., Birmingham, AL 35294-0012.
- References
References
1
Ryan TJ ,Anderson JL ,Antman EM , et al. ACC/AHA guidelines for management of patients with acute myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). J Am Coll Cardiol 1996;28:1328-1428
CrossRef | Web of Science | Medline2
Rogers WJ ,Bowlby LJ ,Chandra NC , et al. Treatment of myocardial infarction in the United States (1990 to 1993): observations from the National Registry of Myocardial Infarction. Circulation 1994;90:2103-2114
Web of Science | Medline3
Grines CL ,Browne KF ,Marco J , et al. A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. N Engl J Med 1993;328:673-679
Full Text | Web of Science | Medline4
Gibbons RJ ,Holmes DR ,Reeder GS ,Bailey KR ,Hopfenspirger MR ,Gersh BJ . Immediate angioplasty compared with the administration of a thrombolytic agent followed by conservative treatment for myocardial infarction. N Engl J Med 1993;328:685-691
Full Text | Web of Science | Medline5
Zijlstra F ,de Boer MJ ,Hoorntje JCA ,Reiffers S ,Reiber JHC ,Suryapranata H . A comparison of immediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction. N Engl J Med 1993;328:680-684
Full Text | Web of Science | Medline6
Allison JJ ,Kiefe CI ,Centor RM ,Box JB ,Farmer RM . Racial differences in the medical treatment of elderly Medicare patients with acute myocardial infarction. J Gen Intern Med 1996;11:736-743
CrossRef | Web of Science | Medline7
Taylor HA ,Canto JG ,Sanderson B ,Rogers WJ ,Hilbe J . Management and outcomes for black patients with acute myocardial infarction in the reperfusion era. Am J Cardiol 1998;82:1019-1023
CrossRef | Web of Science | Medline8
Borzak S ,Joseph C ,Harvard S , et al. Lower thrombolytic use for African Americans with myocardial infarction: an influence of clinical presentation? Am Heart J 1999;137:338-345
CrossRef | Web of Science | Medline9
Barron HV ,Bowlby LJ ,Breen T , et al. Use of reperfusion therapy for acute myocardial infarction in the United States: data from the National Registry of Myocardial Infarction 2. Circulation 1998;97:1150-1156
Web of Science | Medline10
Maynard C ,Althouse R ,Cerqueira M ,Olsufka M ,Kennedy JW . Underutilization of thrombolytic therapy in eligible women with acute myocardial infarction. Am J Cardiol 1991;68:529-530
CrossRef | Web of Science | Medline11
McLaughlin TJ ,Soumerai SB ,Willison DJ , et al. Adherence to national guidelines for drug treatment of suspected acute myocardial infarction: evidence for undertreatment in women and the elderly. Arch Intern Med 1996;156:799-805[Erratum, Ann Intern Med 1996;156:1920.]
CrossRef | Web of Science | Medline12
Yarzebski J ,Col N ,Pagley P ,Savageau J ,Gore J ,Goldberg R . Gender differences and factors associated with the receipt of thrombolytic therapy in patients with acute myocardial infarction: a community-wide perspective. Am Heart J 1996;131:43-50
CrossRef | Web of Science | Medline13
Dellborg M ,Swedberg K . Acute myocardial infarction: difference in the treatment between men and women. Qual Assur Health Care 1993;3:261-26514
Chandra NC ,Ziegelstein RC ,Rogers WJ , et al. Observations of the treatment of women in the United States with myocardial infarction: a report from the National Registry of Myocardial Infarction-I. Arch Intern Med 1998;158:981-988
CrossRef | Web of Science | Medline15
Weaver WD ,Litwin PE ,Martin JS , et al. Effect of age on use of thrombolytic therapy and mortality in acute myocardial infarction. J Am Coll Cardiol 1991;18:657-662
CrossRef | Web of Science | Medline16
Gurwitz JH ,Gore JM ,Goldberg RJ ,Rubison M ,Chandra N ,Rogers WJ . Recent age-related trends in the use of thrombolytic therapy in patients who have had acute myocardial infarction: National Registry of Myocardial Infarction. Ann Intern Med 1996;124:283-291
Web of Science | Medline17
Krumholz HM ,Murillo JE ,Chen J , et al. Thrombolytic therapy for eligible elderly patients with acute myocardial infarction. JAMA 1997;277:1683-1688
CrossRef | Web of Science | Medline18
Division of Chronic Disease Control and Community Intervention. Cardiovascular disease surveillance, ischemic heart disease, 1980-1989. Atlanta: Centers for Disease Control and Prevention, 1993.
19
Health United States, 1998 with socioeconomic status and health chartbook. Hyattsville, Md.: National Center for Health Statistics, 1998.
20
The international classification of diseases, 9th rev., clinical modifi-cation: ICD-9-CM. Washington, D.C.: Government Printing Office, 1980.
21
Chen J ,Radford MJ ,Wang Y ,Marciniak TA ,Krumholz HM . Do “America's Best Hospitals“ perform better for acute myocardial infarction? N Engl J Med 1999;340:286-292
Full Text | Web of Science | Medline22
Zocchetti C ,Consonni D ,Bertazzi PA . Relationship between prevalence rate ratios and odds ratios in cross-sectional studies. Int J Epidemiol 1997;26:220-223
CrossRef | Web of Science | Medline23
Johnson N, Kotz S. Encyclopedia of statistics. New York: John Wiley, 1988:646-7.
24
Agresti A. Categorical data analysis. New York: John Wiley, 1990.
25
Schulman KA ,Berlin JA ,Harless W , et al. The effect of race and sex on physicians' recommendations for cardiac catheterization. N Engl J Med 1999;340:618-626[Erratum, N Engl J Med 1999;340:1130.]
Full Text | Web of Science | Medline26
Pagley PR ,Yarzebski J ,Goldberg R , et al. Gender differences in the treatment of patients with acute myocardial infarction: a multihospital, community-based perspective. Arch Intern Med 1993;153:625-629
CrossRef | Web of Science | Medline27
Behar S ,Gottlieb S ,Hod H , et al. Influence of gender in the therapeutic management of patients with acute myocardial infarction in Israel. Am J Cardiol 1994;73:438-443
CrossRef | Web of Science | Medline28
Gornick ME ,Eggers PW ,Reilly TW , et al. Effects of race and income on mortality and use of services among Medicare beneficiaries. N Engl J Med 1996;335:791-799
Full Text | Web of Science | Medline29
Lauderdale DS ,Goldberg J . The expanded racial and ethnic codes in the Medicare data files: their completeness of coverage and accuracy. Am J Public Health 1996;86:712-716
CrossRef | Web of Science | Medline30
Pan CX ,Glynn RJ ,Mogun H ,Choodnovskiy I ,Avorn J . Definition of race and ethnicity in older people in Medicare and Medicaid. J Am Geriatr Soc 1999;47:730-733
Web of Science | Medline
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Jan P. Vandenbroucke, Erik von Elm, Douglas G. Altman, Peter C. Gøtzsche, Cynthia D. Mulrow, Stuart J. Pocock, Charles Poole, James J. Schlesselman, Matthias Egger. (2007) Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). Epidemiology 18:6, 805-835
CrossRef23
Cheryl L. Robbins, Irene Padavic. (2007) Structural Influences on Racial and Ethnic Disparities in Women's Health Care. Sociology Compass 1:2, 682-700
CrossRef24
Edward L. Hannan, Michael Racz, Gary Walford, Luther T. Clark, David R. Holmes, Spencer B. King, Samin Sharma. (2007) Differences in Utilization of Drug-Eluting Stents by Race and Payer. The American Journal of Cardiology 100:8, 1192-1198
CrossRef25
Soko Setoguchi, Robert J. Glynn, Jerry Avorn, Raisa Levin, Wolfgang C. Winkelmayer. (2007) Ten-Year Trends of Cardiovascular Drug Use After Myocardial Infarction Among Community-Dwelling Persons ≥65 Years of Age. The American Journal of Cardiology 100:7, 1061-1067
CrossRef26
M. Filipovic, V. Seagroatt, M. J. Goldacre. (2007) Differences between women and men in surgical treatment and case fatality rates for ruptured aortic abdominal aneurysm in England. British Journal of Surgery 94:9, 1096-1099
CrossRef27
Alexander R. Green, Dana R. Carney, Daniel J. Pallin, Long H. Ngo, Kristal L. Raymond, Lisa I. Iezzoni, Mahzarin R. Banaji. (2007) Implicit Bias among Physicians and its Prediction of Thrombolysis Decisions for Black and White Patients. Journal of General Internal Medicine 22:9, 1231-1238
CrossRef28
Brahmajee K. Nallamothu, Martha E. Blaney, Susan M. Morris, Lori Parsons, Dave P. Miller, John G. Canto, Hal V. Barron, Harlan M. Krumholz. (2007) Acute Reperfusion Therapy in ST-Elevation Myocardial Infarction from 1994-2003. The American Journal of Medicine 120:8, 693.e1-693.e8
CrossRef29
JOSHUA A. JACOBI, SHAILJA V. PARIKH, DARREN K. McGUIRE, JAMES A. DELEMOS, SABINA A. MURPHY, ELLEN C. KEELEY. (2007) Racial Disparity in Clinical Outcomes Following Primary Percutaneous Coronary Intervention for ST Elevation Myocardial Infarction: Influence of Process of Care. Journal of Interventional Cardiology 20:3, 182-187
CrossRef30
Bonnie K. Sanderson, Saema Mirza, Rachel Fry, Jeroan J. Allison, Vera Bittner. (2007) Secondary prevention outcomes among black and white cardiac rehabilitation patients. American Heart Journal 153:6, 980-986
CrossRef31
Arnold R. Eiser, Glenn Ellis. (2007) Viewpoint: Cultural Competence and the African American Experience with Health Care: The Case for Specific Content in Cross-Cultural Education. Academic Medicine 82:2, 176-183
CrossRef32
Daniel P. Schauer, Joseph A. Johnston, Charles J. Moomaw, Mark Wess, Mark H. Eckman. (2007) Racial Disparities in the Filling of Warfarin Prescriptions for Nonvalvular Atrial Fibrillation. The American Journal of the Medical Sciences 333:2, 67-73
CrossRef33
Laurent G. Glance, Richard . Wissler, Christopher Glantz, Turner M. Osler, Dana B. Mukamel, Andrew W. Dick. (2007) Racial Differences in the Use of Epidural Analgesia for Labor. Anesthesiology 106:1, 19-25
CrossRef34
Cielito C. Reyes-Gibby, Lu Ann Aday, Knox H. Todd, Charles S. Cleeland, Karen O. Anderson. (2007) Pain in Aging Community-Dwelling Adults in the United States: Non-Hispanic Whites, Non-Hispanic Blacks, and Hispanics. The Journal of Pain 8:1, 75-84
CrossRef35
Carole Decker. (2006) Quality Indicators. Cardiology in Review 14:6, 308-311
CrossRef36
William H. Shrank, Steven M. Asch, John Adams, Claude Setodji, Eve A. Kerr, Joan Keesey, Shaista Malik, Elizabeth A. McGlynn. (2006) The Quality of Pharmacologic Care for Adults in the United States. Medical Care 44:10, 936-945
CrossRef37
Sunil Kripalani, Jada Bussey-Jones, Marra G. Katz, Inginia Genao. (2006) A Prescription for Cultural Competence in Medical Education. Journal of General Internal Medicine 21:10, 1116-1120
CrossRef38
Steven A. Farmer, Debra L. Roter, Irene J. Higginson. (2006) Chest pain: Communication of symptoms and history in a London emergency department. Patient Education and Counseling 63:1-2, 138-144
CrossRef39
Pamela Echeverria, Jyotsna Sahni. 2006. Women's Health. .
CrossRef40
Dana B. Mukamel, David L. Weimer, Alvin I. Mushlin. (2006) Referrals to High-Quality Cardiac Surgeons: Patients' Race and Characteristics of Their Physicians. Health Services Research 0:0, 060720074824047-???
CrossRef41
Thea L. James, James Feldman, Supriya D. Mehta. (2006) Physician Variability in History Taking When Evaluating Patients Presenting with Chest Pain in the Emergency Department. Academic Emergency Medicine 13:2, 147-152
CrossRef42
Christopher S. Hollenbeak, Carol S. Weisman, Michael Rossi, Steven M. Ettinger. (2006) Gender Disparities in Percutaneous Coronary Interventions for Acute Myocardial Infarction in Pennsylvania. Medical Care 44:1, 24-30
CrossRef43
Erik J Groessl, Theodore G Ganiats, Andrew J Sarkin. (2006) Sociodemographic Differences in Quality of Life in Rheumatoid Arthritis. PharmacoEconomics 24:2, 109-121
CrossRef44
Carmen R. Green, S. Khady Ndao-Brumblay, Brady West, Tamika Washington. (2005) Differences in Prescription Opioid Analgesic Availability: Comparing Minority and White Pharmacies Across Michigan. The Journal of Pain 6:10, 689-699
CrossRef45
Jha, Ashish K., Fisher, Elliott S., Li, Zhonghe, Orav, E. John, Epstein, Arnold M., . (2005) Racial Trends in the Use of Major Procedures among the Elderly. New England Journal of Medicine 353:7, 683-691
Full Text46
Vaccarino, Viola, Rathore, Saif S., Wenger, Nanette K., Frederick, Paul D., Abramson, Jerome L., Barron, Hal V., Manhapra, Ajay, Mallik, Susmita, Krumholz, Harlan M., . (2005) Sex and Racial Differences in the Management of Acute Myocardial Infarction, 1994 through 2002. New England Journal of Medicine 353:7, 671-682
Full Text47
Ashish K. Jha, Jonathan B. Perlin, Michael A. Steinman, John W. Peabody, John Z. Ayanian. (2005) Quality of Ambulatory Care for Women and Men in the Veterans Affairs Health Care System. Journal of General Internal Medicine 20:8, 762-765
CrossRef48
T. K. Houston, I. C. Scarinci, S. D. Person, P. G. Greene. (2005) Patient Smoking Cessation Advice by Health Care Providers: The Role of Ethnicity, Socioeconomic Status, and Health. American Journal of Public Health 95:6, 1056-1061
CrossRef49
Joe Feinglass, Cheryl Rucker-Whitaker, Lee Lindquist, Walter J. McCarthy, William H. Pearce. (2005) Racial differences in primary and repeat lower extremity amputation: Results from a multihospital study. Journal of Vascular Surgery 41:5, 823-829
CrossRef50
Jerry Cromwell, Nancy T. McCall, Joseph Burton, Carol Urato. (2005) Race/Ethnic Disparities in Utilization of Lifesaving Technologies by Medicare Ischemic Heart Disease Beneficiaries. Medical Care 43:4, 330-337
CrossRef51
Amber E. Barnato, F Lee Lucas, Douglas Staiger, David E. Wennberg, Amitabh Chandra. (2005) Hospital-Level Racial Disparities in Acute Myocardial Infarction Treatment and Outcomes. Medical Care 43:4, 308-319
CrossRef52
Kaytura Felix-Aaron, Ernest Moy, Minsun Kang, Mona Patel, Francis D. Chesley, Carolyn Clancy. (2005) Variation in Quality of Men??s Health Care by Race/Ethnicity and Social Class. Medical Care 43:Supplement, I-72-I-81
CrossRef53
Rosanna M. Coffey, Roxanne M. Andrews, Ernest Moy. (2005) Racial, Ethnic, and Socioeconomic Disparities in Estimates of AHRQ Patient Safety Indicators. Medical Care 43:Supplement, I-48-I-57
CrossRef54
Audrey Smedley, Brian D. Smedley. (2005) Race as Biology Is Fiction, Racism as a Social Problem Is Real: Anthropological and Historical Perspectives on the Social Construction of Race.. American Psychologist 60:1, 16-26
CrossRef55
Alan R. Fleischman, Jeremiah A. Barondess. (2004) Urban Health: A Look Out Our Windows. Academic Medicine 79:12, 1130-1132
CrossRef56
Omofolasade Kosoko-Lasaki, Mildred M.G. Olivier. (2004) African American Health Disparities: Glaucoma as a Case Study. International Ophthalmology Clinics 43:4, 123-131
CrossRef57
Sofia B. Ahmed, Sherry L. Grace, Henry Thomas Stelfox, George Tomlinson, Angela M. Cheung. (2004) Gender bias in cardiovascular advertisements. Journal of Evaluation in Clinical Practice 10:4, 531-538
CrossRef58
Bach, Peter B., Pham, Hoangmai H., Schrag, Deborah, Tate, Ramsey C., Hargraves, J. Lee, . (2004) Primary Care Physicians Who Treat Blacks and Whites. New England Journal of Medicine 351:6, 575-584
Full Text59
David E. Lanfear, Sharon Marsh, Sharon Cresci, William D. Shannon, John A. Spertus, Howard L. McLeod. (2004) Genotypes associated with myocardial infarction risk are more common in African Americans than in European Americans. Journal of the American College of Cardiology 44:1, 165-167
CrossRef60
Brian C. Hiestand, Dawn M. Prall, Christopher J. Lindsell, James W. Hoekstra, Charles V. Pollack, Judd E. Hollander, Brian R. Tiffany, W. Frank Peacock, Deborah B. Diercks, W. Brian Gibler. (2004) Insurance Status and the Treatment of Myocardial Infarction at Academic Centers. Academic Emergency Medicine 11:4, 343-348
CrossRef61
Tiina Hetemaa, Ilmo Keskimäki, Veikko Salomaa, Markku Mähönen, Kristiina Manderbacka, Seppo Koskinen. (2004) Socioeconomic inequities in invasive cardiac procedures after first myocardial infarction in Finland in 1995. Journal of Clinical Epidemiology 57:3, 301-308
CrossRef62
Abdulla Manima. (2004) Ethical Issues in Palliative Care. Journal of Pain and Palliative Care Pharmacotherapy 17:3-4, 141-149
CrossRef63
Richard M. Hoffman, Linda C. Harlan, Carrie N. Klabunde, Frank D. Gilliland, Robert A. Stephenson, William C. Hunt, Arnold L. Potosky. (2003) Racial Differences in Initial Treatment for Clinically Localized Prostate Cancer. Results from the Prostate Cancer Outcomes Study. Journal of General Internal Medicine 18:10, 845-853
CrossRef64
Charles R Bridges. (2003) Cardiac surgery in African Americans. The Annals of Thoracic Surgery 76:4, S1356-S1362
CrossRef65
Inginia Genao, Jada Bussey-Jones, Donald Brady, William T. Branch, Giselle Corbie-Smith. (2003) Building the Case for Cultural Competence. The American Journal of the Medical Sciences 326:3, 136-140
CrossRef66
Peter Crampton, Anthony Dowell, Chris Parkin, Caroline Thompson. (2003) Combating Effects of Racism Through a Cultural Immersion Medical Education Program. Academic Medicine 78:6, 595-598
CrossRef67
JOSÉ J. ESCARCE, KANIKA KAPUR. (2003) Racial and Ethnic Differences in Public and Private Medical Care Expenditures among Aged Medicare Beneficiaries. Milbank Quarterly 81:2, 249-275
CrossRef68
Leslie R. Harrold, Julian Esteban, Darleen Lessard, Jorge Yarzebski, Jerry H. Gurwitz, Joel M. Gore, Robert J. Goldberg. (2003) Narrowing Gender Differences in Procedure Use for Acute Myocardial Infarction. Insights from the Worcester Heart Attack Study. Journal of General Internal Medicine 18:6, 423-431
CrossRef69
Niall A Herity, Sidney Lo, David P Lee, Michael R Ward, Steven D Filardo, Paul G Yock, Peter J Fitzgerald, Sharon A Hunt, Alan C Yeung. (2003) Effect of a change in gender on coronary arterial size. Journal of the American College of Cardiology 41:9, 1539-1546
CrossRef70
Carol M. Ashton, Paul Haidet, Debora A. Paterniti, Tracie C. Collins, Howard S. Gordon, Kimberly O'Malley, Laura A. Petersen, Barbara F. Sharf, Maria E. Suarez-Almazor, Nelda P. Wray, Richard L. Street. (2003) Racial and Ethnic Disparities in the Use of Health Services. Bias, Preferences, or Poor Communication?. Journal of General Internal Medicine 18:2, 146-152
CrossRef71
Vickie M. Mays, Ninez A. Ponce, Donna L. Washington, Susan D. Cochran. (2003) C
LASSIFICATION OF RACE AND ETHNICITY : Implications for Public Health*. Annual Review of Public Health 24:1, 83-110
CrossRef72
Daniel B Stryer, Robin M Weinick, Carolyn M Clancy. (2002) Reducing Racial and Ethnic Disparities in Health Care. Health Services Research 37:5, xv-xxvi
CrossRef73
Howard S. Gordon, Michael L. Johnson, Carol M. Ashton. (2002) Process of Care in Hispanic, Black, and White VA Beneficiaries. Medical Care 40:9, 824-833
CrossRef74
H. A. Taylor, G. D. Hughes, R. J. Garrison. (2002) Cardiovascular Disease Among Women Residing in Rural America: Epidemiology, Explanations, and Challenges. American Journal of Public Health 92:4, 548-551
CrossRef75
Sean M. Berenholtz, Peter J. Pronovost, Daniel Mullany, Elizabeth Garrett, Paul M. Ness, Todd Dorman, Michael J. Klag. (2002) Predictors of transfusion for spinal surgery in Maryland, 1997 to 2000. Transfusion 42:2, 183-189
CrossRef76
Laura A. Petersen, Steven M. Wright, Eric D. Peterson, Jennifer Daley. (2002) Impact of Race on Cardiac Care and Outcomes in Veterans With Acute Myocardial Infarction. Medical Care 40:Supplement, I-86-I-96
CrossRef77
MARA S. ARUGUETE. (2002) PARTICIPANTS' RATINGS OF MALE PHYSICIANS WHO VARY IN RACE AND COMMUNICATION STYLE. Psychological Reports 91:7, 793
CrossRef78
G. M. Oppenheimer. (2001) Paradigm lost: race, ethnicity, and the search for a new population taxonomy. American Journal of Public Health 91:7, 1049-1055
CrossRef79
Robert A. Lowe, Sheetal Chhaya, Kathleen Nasci, Laurence J. Gavin, Kathy Shaw, Mark L. Zwanger, Joseph A. Zeccardi, William C. Dalsey, Stephanie B. Abbuhl, Harold Feldman, Jesse A. Berlin. (2001) Effect of Ethnicity on Denial of Authorization for Emergency Department Care by Managed Care Gatekeepers. Academic Emergency Medicine 8:3, 259-266
CrossRef80
Guadagnoli, Edward, Landrum, Mary Beth, Peterson, Eric A., Gahart, Martin T., Ryan, Thomas J., McNeil, Barbara J., . (2000) Appropriateness of Coronary Angiography after Myocardial Infarction among Medicare Beneficiaries — Managed Care versus Fee for Service. New England Journal of Medicine 343:20, 1460-1466
Full Text81
(2000) Missed Diagnoses of Acute Cardiac Ischemia. New England Journal of Medicine 343:20, 1492-1494
Full Text82
(2000) “We Don't Carry That”. New England Journal of Medicine 343:6, 442-445
Full Text
