Race and cardiac catheterization use in the setting of acute myocardial infarctio

描述(由申请人提供)：在美国，心血管疾病的发病率、患病率和结局的种族差异是有很好的记录的。黑人心脏病患者预后较差的一个可能因素可能是与白人患者相比，较低的手术使用率，包括心导管插入术。这一假说有一系列悬而未决的问题。首先，大多数研究中种族分类数据的准确性依赖于行政数据或其他来源，这引起了人们对潜在错误分类的担忧。这种错误分类的具体性质及其对报告的治疗率和结果的影响尚不清楚。因此，我建议将行政来源中记录的患者种族分类与Premier登记中自我报告的种族指定进行比较，Premier登记是住院治疗急性心肌梗死患者的全国性队列。除了确定自我与有记录的种族的总体一致性外，还将确定种族命名中一致性的相关因素，并确定和比较种族(行政与自我报告)与治疗和结果的关联。其次，目前尚不清楚治疗中的种族差异，特别是心肌梗塞后的心导管置入术，是反映了白人患者的过度治疗、黑人患者的治疗不足，还是两种过程的结合。因此，我将开发和验证一种方法，利用CCP的数据对心肌梗死后患者是否适合进行心导管手术进行分类。CCP是1994至1996年间因心肌梗死住院的全国医疗保险患者队列。导管术使用的种族差异将根据患者对导管术的适合性进行总体评估，以确定治疗中的种族差异是否因程序适宜性而不同，使用分层Logistic回归分析。第三，尽管治疗率较低，但据报道，患有心肌梗死的老年黑人患者比白人患者有更好的结果，包括更低的死亡率。目前尚不清楚这种模式是仅限于短期随访，还是持续较长时间的随访。因此，我将使用CCP数据库中的患者来评估黑人和白人心肌梗死患者的长期存活率，重点是死亡率和中间终点(住院、发生更多心血管合并症)。这三个项目符合AHRQ的战略研究目标，包括确定适当护理质量的障碍，以及评估AHRQ优先人群(少数族裔患者)使用的卫生服务。此外，从这个项目中获得的见解有可能为当前AHRQ、购买者和提供者提供信息，以解决卫生和医疗保健方面的差距。 公共卫生相关性：拟议的工作是对心肌梗死患者使用心导管的种族差异进行调查，这与AHRQ了解影响获得高质量医疗保健的因素的研究使命是一致的，并针对两个优先群体，少数群体和老年人。该提案的三个项目--严格评估行政数据和医疗记录中种族数据报告的质量；确定导管术使用中的种族差异是否反映了白人患者的过度治疗、黑人患者的治疗不足或多种过程的组合；以及导管术使用中的种族差异对长期存活率的影响--将有助于为当前解决卫生和医疗保健使用中的种族差异的努力提供信息

DESCRIPTION (provided by the applicant): Racial differences in the incidence, prevalence, and outcomes of cardiovascular disease in the United States are well documented. A possible contributing factor to poorer outcomes among black patients with heart disease may be lower rates of procedure use, including cardiac catheterization, compared with white patients. This hypothesis has its own series of unanswered questions. First, the accuracy of racial classification data in the majority of studies relies upon administrative data or other sources, which raises concerns of potential misclassification. The specific nature of this misclassification and its implications for reported rates of treatment and outcomes are unclear. Thus, I propose to compare patients' racial classification as documented in administrative sources vs. self-reported racial designation in the PREMIER registry, a national cohort of patients hospitalized for AMI. In addition to determining overall agreement of self vs. documented-race, correlates of concordance in racial designation will be identified, and associations of race (administrative vs. self-reported) association with treatment and outcomes will be determined and compared. Second, it is unclear whether racial variations in treatment, specifically cardiac catheterization postmyocardial infarction, reflect overtreatment of white patients, under-treatment of black patients, or a combination of processes. Thus, I will develop and validate a means for classifying patients' appropriateness of cardiac catheterization following myocardial infarction using data from the CCP, a national cohort of Medicare patients hospitalized for myocardial infarction between 1994 and 1996. Racial differences in cardiac catheterization use will be assessed overall and by patient appropriateness for cardiac catheterization to determine whether racial differences in treatment vary as a function of procedure appropriateness using hierarchical logistic regression analyses. Third, despite lower rates of treatment, elderly black patients with myocardial infarction are reported to have better outcomes, including lower mortality, than their white counterparts. It is unclear whether this pattern is limited to short-term follow-up or persists over longer follow-up. Accordingly, I will assess the long-term survival of black and white patients with myocardial infarction using patients in the CCP database, focusing on mortality and intermediate endpoints (hospitalization, development of additional cardiovascular comorbidities). The three projects are consonant with AHRQ's strategic research goals, including the identification of barriers to appropriate quality of care and assessment of health services use by an AHRQ priority population (minority patients). Further, the insights obtained from this project offer the potential to inform current AHRQ, purchaser, and provider efforts to address health and health care disparities. PUBLIC HEALTH RELEVANCE: The proposed work, an investigation of racial variations in the use of cardiac catheterization in patients with myocardial infarction, is consonant with AHRQ's research mission of understanding factors influencing access to quality health care, and addresses two priority populations, minority groups and the elderly. The proposal's three projects - rigorously evaluating the quality of race data reporting in administrative data and medical records; determining whether racial variations in cardiac catheterization use reflect overtreatment of white patients, undertreatment of black patients, or a combination of processes; and the impact of racial differences in cardiac catheterization use on long-term survival - will help inform current efforts to address racial disparities in health and health care use