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Medicare eligibility and an ongoing involvement with clinicians can equalize the numbers of invasive cardiac procedures white and black patients receive, according to researchers at Johns Hopkins Medical Institutions in Baltimore.
They found in a group of patients who later went on to develop end-stage renal disease (ESRD) and qualify for Medicare, whites first received almost three times the number of cardiovascular procedures than blacks. After they developed ESRD and had Medicare coverage, however, the procedure rates were nearly the same.
"We wanted to do this study because we had a unique data set for seven years," says Gail L. Daumit, MD, researcher and master’s candidate in health sciences and epidemiology at Johns Hopkins.
The Hopkins group used patient information collected by the United States Renal Data System for its Case Mix Severity Study of patients with end-stage renal disease. Because data were collected over several years, the Hopkins group could follow specific patients as they developed ESRD and became eligible for Medicare. "It’s sort of the before and after picture," Daumit explains.
These study subjects are special, she says, because they are kidney patients. Their condition means they better be compliant with their care. If they don’t come in for dialysis — which could be as often as three times a week — they will die. And when they come in for care so often, they bond with nurses, doctors, and other staff. There is a greater chance that a developing heart problem will be caught by one of the clinicians (who know a patient is already sick). And because connections with doctors and facilities have been made — and Medicare is available to pay — there is a better chance that patients will agree to a cardiac procedure if one is suggested.
"More than just insurance has to come together," she says, adding the team approach used in treating ESRD could be helpful in taking care of patients who are not as sick but still are at risk of cardiovascular disease, such as those with diabetes or hypertension. "It just doesn’t have to be as stringent."
But having a system in place where a nurse educator or other staff keep track of patients can prevent them from becoming lost to follow-up, she says. Even methods as simple as a phone call or letter from the doctor’s office to urge patients to continue with their care can help a lot, she says. A busy practice may have an educator, a nurse, or someone else to help keep patients from falling through the cracks, but "that infrastructure in a practice often isn’t there."
But could having insurance and a team in place to take care of patients all but erase the differences seen between black and white patients who get cardiovascular care? Commenting on the study, Richard L. Kravitz, MD, from the University of California, Davis, says the racial gap seen in the study may not be as dramatic as the team suggested.
At the beginning of the study period, the researchers did not statistically adjust for the number of years patients are at risk of developing heart disease, but they made the adjustments at the end of the study. Instead of seeing whites get nearly three times the number of cardiac procedures that blacks get, the number may be closer to 2½ times. "It’s still a very big difference, even with the correcting," Kravitz says, noting the overall methods were very good.
"I would agree that may have changed it slightly," Daumit says, "But it’s most important to look at the end point." Doing so emphasizes white and black patients have nearly the same rates of cardiovascular care if the coverage and team approach are in place.
1. Daumit GL, et al. Use of cardiovascular procedures among black persons and white persons: a seven-year nationwide study in patients with renal disease. Ann Intern Med 1999; 130:173-182.
2. Kravitz RL.Ethnic differences in use of cardiovascular procedures: New insights and new challenges. Ann Intern Med 1999; 130:231-233.