1. Cohen et al. Circulation. ePub May 17, 2010 Racial and Ethnic Differences in the Treatment of Acute Myocardial Infarction Findings From Get With The Guidelines ® -CAD Program Mauricio G. Cohen, MD; Gregg C. Fonarow, MD; Eric D. Peterson, MD, MPH; Mauro Moscucci, MD, MBA; David Dai, MHS ; Adrian F. Hernandez, MD, MHS; Robert O. Bonow, MD; Sidney C. Smith, Jr., MD

2. Cohen et al. Circulation. ePub May 17, 2010 The Get With The Guidelines– CAD (GWTG-CAD) program is provided by the American Heart Association/American Stroke Association. The data analyzed in this manuscript were collected while the GWTG program was supported in part through an unrestricted educational grant from Merck. The individual author disclosures are listed in the manuscript. Disclosures

3. Cohen et al. Circulation. ePub May 17, 2010 Background The elimination of disparate health care is one of the principal goals of Healthy People 2010. 1 Research suggests that there are differences in the use of evidence-based process performance among racial/ethnic groups. The GWTG-CAD quality improvement program may enhance hospital adherence to quality of care guidelines whereby improving ethnic and racial disparities. 1. Lillie-Blanton M, Maddox TM, Rushing O, Mensah GA. Disparities in cardiac care: rising to the challenge of Healthy People 2010. J Am Coll Cardiol. 2004;44:503-508.

4. Cohen et al. Circulation. ePub May 17, 2010 Introduction 1. Skinner J, Chandra A, Staiger D, Lee J, McClellan M. Mortality after acute myocardial infarction in hospitals that disproportionately treat black patients. Circulation. 2005;112:2634-2641. Research has shown that racial and ethnic differences exist in cardiovascular care. Among patients with acute coronary syndromes (ACS), minorities are: less likely than Caucasians to receive evidence- based care more likely to be treated at facilities with lower adherence to composite measures. 1

5. Cohen et al. Circulation. ePub May 17, 2010 Objectives The major goals of the study were to assess the racial/ethnic differences in individual and composite core CAD performance measures and to assess whether a QI program is associated with decreasing health disparities over time. Also examined was the temporal trend of the summary “defect-free care” performance measure in hospitals that treated a greater proportion of Black or Hispanic patients.

6. Cohen et al. Circulation. ePub May 17, 2010 Methods Data collected: Jan. 2002 and June 2007 443 GWTG-CAD- participating hospitals 142,593 AMI patients were analyzed (discharge diagnosis of AMI) –121,528 Caucasians –10,882 African Americans –10,183 Hispanics Outcome Sciences, Inc. served as the data collection and coordination center. Duke Clinical Research Institute served as the data analysis and coordination center.

7. Cohen et al. Circulation. ePub May 17, 2010 Methods Areas Examined The overall racial/ethnic differences in individual and composite core CAD performance measures Whether a QI program is associated with decreasing health disparities over time Examine the temporal trend of the summary “defect-free care” 1 performance measure in hospitals that treat a greater proportion of African American or Hispanic patients. 1. “defect-free care”, was defined as the proportion of patients that received all interventions for which they were eligible.

8. Cohen et al. Circulation. ePub May 17, 2010 Core Performance Measures Assessed Use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) in patients with documented left ventricular systolic dysfunction Use of aspirin within 24 hours of admission Use of aspirin at discharge Use of beta-blockers at discharge Use of lipid-lowering therapy in patients with low-density lipoprotein (LDL) cholesterol greater than 100 mg/dL Smoking cessation counseling Composite measure “defect-free care” In addition, the following “quality metrics” were analyzed in eligible patients presenting with ST-elevation myocardial infarction (STEMI) –Door-to-balloon time of less or equal than 90 minutes –Door-to-thrombolysis time of less or equal than 30 minutes

9. Cohen et al. Circulation. ePub May 17, 2010 Methods: Statistical Analysis Descriptive analyses included comparisons according to race/ethnicity (Caucasians, African Americans, and Hispanics) for –demographics, comorbidities, baseline clinical characteristics, clinical performance measures, invasive procedures, and in-hospital mortality. Trends in racial/ethnic differences according to the overall duration of the program (calendar quarters) –Each quarter enrolled ≥ 1000 pts to support steadiness of statistical conclusions To examine the association between time, race/ethnicity and performance measures, multivariable logistic regression was used to estimate the marginal effects of time and race/ethnicity. GEE with exchangeable working correlation structure was used to account for within-hospital clustering To analyze the temporal trend of “defect-free care” in hospitals that treated a greater proportion of African Americans or Hispanics, we further divided the study population into quintiles according the percent of Hispanic and African Americans treated at the site-level

10. Cohen et al. Circulation. ePub May 17, 2010 WhiteBlackHispanic (n=121,528 )(n=10,882)(n=10,183) Age (yrs)68 (56,79)61 (51, 73)65 (54, 75) Female (%)374535 BMI (%)28 (24, 32)28 (24, 33)28 (25, 31) Diabetes (%)21.731.637.1 Hypertension (%)58.972.664.4 Hyperlipidemia (%)39.534.838.9 Smoking (%)31.037.727.5 PVD (%)8.68.97.5 Prior MI (%)19.419.016.6 Prior Stroke (%)7.410.27.6 Renal Failure (%)8.614.110.2 CHF (%)13.816.814.0 Baseline Characteristics N = 142,593

11. Cohen et al. Circulation. ePub May 17, 2010 Results When compared with Caucasian and Hispanic patients, African Americans were younger, more likely female, and had a higher prevalence of hypertension, smoking, prior history of stroke, and renal insufficiency. African American and Hispanic patients were significantly more likely to be uninsured or covered by Medicaid in comparison with Caucasian patients. The geographic distribution of recruitment for the three racial/ethnic group somewhat paralleled the US census distribution. A large proportion of African American patients were recruited in the South, while Hispanic patients were mostly recruited in the Southwest. African American patients sought care at facilities that had more beds, were more likely academic, and had similar interventional and surgical capabilities compared to the other racial/ethnic groups.

12. Cohen et al. Circulation. ePub May 17, 2010 Results Percutaneous coronary intervention (PCI) was used in 74.3% of the 40,843 ST-elevation myocardial infarction patients –74.7% of whites, 69.5% of blacks, and 73.7% of Hispanics Delays in performing primary PCI were significantly longer in minority patients than in white patients. –The median door-to-balloon time in minutes was 91 in white patients, 105 in black patients,102 in Hispanic patients. As a consequence of these delays, a lower proportion of Hispanic and black patients had a door-to-balloon time of 90 minutes than white patients, even after adjustment for patient and hospital variables

13. Cohen et al. Circulation. ePub May 17, 2010 Results Use of thrombolytic therapy was low and comparable –3.5% in white, 3.4% in black, and 3.9% in Hispanic patients Black patients had greater delays in thrombolysis administration –Blacks - median door-to-thrombolysis time - 52 minutes –Whites - 38 min –Hispanics - 35 min.

14. Cohen et al. Circulation. ePub May 17, 2010 STEMI Reperfusion Quality Metrics

15. Cohen et al. Circulation. ePub May 17, 2010 Results All racial/ethnic groups had a similar median length of stay of 4 days Unadjusted hospital mortality rates were 5.7% for Caucasian, 5.0% for African American, and 5.5% for Hispanic patients Aspirin (admission & discharge) and Beta Blockers use was greater than 90% in the three groups Black patients had significantly lower use of aspirin at discharge and of smoking cessation counseling, and they were less likely to receive defect-free care than white patients.

16. Cohen et al. Circulation. ePub May 17, 2010 Individual Performance Measures Aspirin within 24 hoursLipid Lowering Therapy ACE/ARB for LVSDAspirin at Discharge Patients (%) Overall OR: 1.07 (1.03-1.12) AA vs. C OR: 1.02 (0.70-1.48) Hisp vs. C OR: 1.69 (1.09-2.61) Overall OR: 1.05 (1.03-1.06) AA vs. C OR: 1.40 (0.92-2.12) Hisp vs. C OR: 1.16 (0.74-1.82) Overall OR: 1.08 (1.06-1.10) AA vs. C OR: 1.44 (0.87-2.40) Hisp vs. C OR: 0.72 (0.42-1.27) Overall OR: 1.08 (1.06-1.10) AA vs. C OR: 1.03 (0.68-1.58) Hisp vs. C OR: 1.07 (0.69-1.68) Beta-blocker at Discharge Smoking Cessation Advice Overall OR: 1.07 (1.05-1.09) AA vs. C OR: 0.82 (0.57-1.17) Hisp vs. C OR: 1.47 (0.94-2.27) Overall OR: 1.15 (1.11-1.20) AA vs. C OR: 0.64 (0.36-1.11) Hisp vs. C OR: 1.14 (0.69-1.86)

17. Cohen et al. Circulation. ePub May 17, 2010 Defect-Free Care Patients (%) Overall OR: 1.08 (1.06-1.10) African American vs. Caucasian OR: 0.98 (0.79-1.21) Hispanic vs. Caucasian OR: 1.19 (0.93-1.53) CaucasianAfrican AmericanHispanic * * * * * § § § § § Overall, defect-free care was: - 80.9% for Caucasians - 79.5% for Hispanics - 77.7% for African Americans * p<0.01 for difference between African-American and Caucasian patients § p<0.01 for difference between Hispanic and Caucasian patients The significance level of p was changed to less than 0.01 to adjust for the multiple comparisons.

18. Cohen et al. Circulation. ePub May 17, 2010 Defect Free Care According to Minority Proportion per Hospital African-AmericansHispanics Temporal trends in the hospital use of defect-free care according to quintiles of the percent of patients of African American and Hispanic race/ethnicity

19. Cohen et al. Circulation. ePub May 17, 2010 Results Progressive improvements in performance measures and in defect-free care for all racial/ethnic groups. These positive trends were present even after adjustments for patient baseline characteristics, and patient baseline characteristics and hospital variables. Further analysis of temporal trends revealed that African Americans received lower defect-free care during the first year of the study. However, the care of African Americans improved relative to that for the other groups and the difference was no longer apparent during the remainder of the study period.

20. Cohen et al. Circulation. ePub May 17, 2010 Limitations –Observational, non-randomized study –Findings are limited to the inpatient setting –Sites are self-selected and interested in QI and may not be representative of national care patterns. –Minority patients were underrepresented in comparison with census data

21. Cohen et al. Circulation. ePub May 17, 2010 Conclusions Among hospitals engaged in a national quality monitoring and improvement program, evidence- based care for acute myocardial infarction appeared to improve over time for patients irrespective of race/ethnicity. Differences in care by race/ethnicity care were reduced or eliminated. Small remaining gaps in care may be potentially targeted by intervention programs addressing the specific needs of each racial/ethnic group.

22. Cohen et al. Circulation. ePub May 17, 2010 Clinical Implications The elimination of disparate health care is one of the principal goals of Healthy People 2010 Participation in Get With The Guideline-CAD was associated with a reduction or elimination of disparities in care quality for acute myocardial infarction regardless of race/ethnicity