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Original Contribution |

Race, Quality of Care, and Outcomes of Elderly Patients Hospitalized With Heart Failure FREE

Saif S. Rathore, MPH; JoAnne M. Foody, MD; Yongfei Wang, MS; Grace L. Smith, MPH; Jeph Herrin, PhD; Frederick A. Masoudi, MD, MSPH; Pamela Wolfe, MS; Edward P. Havranek, MD; Diana L. Ordin, MD, MPH; Harlan M. Krumholz, MD, SM
[+] Author Affiliations

Author Affiliations: Section of Cardiovascular Medicine, Department of Internal Medicine (Messrs Rathore and Wang, Drs Foody and Krumholz, and Ms Smith) and Section of Health Policy and Administration, Department of Epidemiology and Public Health (Dr Krumholz), Yale University School of Medicine, New Haven, Conn; Flying Buttress Associates, Charlottesville, Va (Dr Herrin); Division of Cardiology, Department of Medicine, Denver Health Medical Center (Drs Masoudi and Havranek), and Divisions of Geriatric Medicine (Dr Masoudi) and Cardiology (Drs Masoudi and Havranek), Department of Medicine, University of Colorado Health Sciences Center, Denver; Colorado Foundation for Medical Care, Aurora (Drs Masoudi and Havranek and Ms Wolfe); and the Centers for Medicare & Medicaid Services, Boston, Mass (Dr Ordin).


JAMA. 2003;289(19):2517-2524. doi:10.1001/jama.289.19.2517.
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Context Black patients hospitalized with heart failure reportedly receive poorer quality of care and have worse outcomes than white patients. Because previous studies have been based on selected patient populations treated more than a decade ago, it is unclear if racial differences in quality of care and outcomes currently exist in the United States.

Objective To evaluate differences in quality of care and patient outcomes between black and white Medicare beneficiaries hospitalized with heart failure.

Design Retrospective analysis of medical record data systematically collected for the National Heart Failure Project.

Setting and Patients Nationwide US sample of 29 732 fee-for-service Medicare beneficiaries hospitalized with heart failure in 1998 and 1999.

Main Outcome Measures Prescription of angiotensin-converting enzyme (ACE) inhibitors, measurement of left ventricular ejection fraction (LVEF), readmission within 1 year of discharge, and mortality within 30 days and 1 year of admission.

Results Black patients and white patients had similar crude rates of LVEF assessment (67.8% black vs 66.6% white; P = .29). Among patients classified as ideal for ACE inhibitor use, black patients had higher crude rates of ACE inhibitor use than white patients (81.0% vs 73.8% white; P<.001) but had similar rates of ACE inhibitor or angiotensin receptor blocker (ARB) use (85.7% black vs 82.5% white; P = .08). After multivariable adjustment, black patients had comparable rates of LVEF assessment (risk ratio [RR], 0.99; 95% confidence interval [CI], 0.95-1.03). Black patients remained more likely to be prescribed ACE inhibitors (RR, 1.22; 95% CI, 1.14-1.28) than were white patients in an adjusted analysis, but there were no significant racial differences in the prescription of ACE inhibitors or ARBs (black vs white, RR, 1.03; 95% CI, 0.97-1.07). Black patients had higher rates of readmission within 1 year of discharge (68.2% vs 63.0%; P<.001) but had lower crude 30-day (6.3% vs 10.7%; P<.001) and 1-year (31.5% vs 40.1%; P<.001) mortality rates than white patients. After multivariable adjustment, black patients had a slightly higher rate of readmission than white patients (RR, 1.09; 95% CI, 1.06-1.13) but remained at lower risk of 30-day mortality (RR, 0.78; 95% CI, 0.68-0.91) and 1-year mortality (RR, 0.93; 95% CI, 0.88-0.98).

Conclusions Black Medicare patients hospitalized with heart failure received comparable quality of care and had slightly higher rates of readmission but had lower mortality rates up to 1 year after hospitalization than did white patients.

Figures in this Article

Heart failure is a national epidemic, affecting nearly 5 million persons in the United States, with an additional 550 000 diagnosed each year.1 This burden is disproportionately borne by black Americans, who have a higher incidence and prevalence of heart failure than members of other racial groups.1 Despite this greater burden, black patients may receive less intensive and poorer-quality care for heart failure than whites.25 Some studies, however, suggest that black patients receive similar quality of care as members of other racial groups.610 Because prior studies evaluated patients treated in selected centers or regions610 and assessed treatment or utilization patterns and not objective measures of quality of care,3,9,10 it is unclear if reported racial differences reflect shortfalls in care or appropriate treatment or are representative of current national practice patterns. A national evaluation of racial patterns of heart failure care is timely given the efforts under way to redress racial disparities in health care.11

Concerns about poorer outcomes, including higher rates of readmission and mortality, have paralleled reports of poorer quality of care in blacks with heart failure.6,1220 Based on a few studies,13,20,21 current American College of Cardiology/American Heart Association adult heart failure treatment guidelines state that "heart failure progresses more rapidly in black than white patients, as evidenced by a higher risk of initial hospitalization and recurrent hospitalization and death."22 However, the literature concerning race and outcomes among patients with heart failure is inconsistent. Some studies have reported that black patients hospitalized with heart failure have lower rates of rehospitalization,25 mortality during rehospitalization,20,23,24,26 after discharge than white patients.20,21,2325,27,28 In contrast, others have reported that race is not associated with mortality or readmission independent of other demographic and clinical factors.5,6,16,2934 Thus, it is unclear whether race is associated with patient survival or readmission after hospitalization for heart failure or instead reflects racial differences in clinical characteristics.

Accordingly, we evaluated racial differences in treatment and outcomes in a nationally representative cohort of Medicare patients hospitalized for heart failure in 1998 and 1999 using data from the National Heart Failure (NHF) Project. The quality-of-care measures and clinical data collected as part of the NHF Project provided us a unique opportunity to assess the associations of patient race with quality of care and outcomes in a contemporary, national cohort of heart failure patients.

NHF Project

The NHF Project is an ongoing Centers for Medicare & Medicaid Services initiative to improve quality of care for Medicare beneficiaries hospitalized with heart failure. Medicare fee-for-service beneficiaries hospitalized between March 1998 and April 1999 with a principal discharge diagnosis of heart failure (International Classification of Diseases, Ninth Revision, Clinical Modification codes 402.01, 402.11, 402.91, 404.01, 404.91, or 428)35 were identified. The NHF Project sample was restricted to single admissions of patients with valid Social Security numbers who were not receiving long-term hemodialysis and did not leave the hospital (transferred out or against medical advice) during treatment. All identified admissions within each state who met these initial criteria by screening of administrative data were sorted by age, sex, race, and hospital. Approximately 800 records were randomly sampled from each state's sorted cohort; states with fewer than 800 eligible records (Alaska, Hawaii, Idaho, Utah, Vermont, and Wyoming) were sampled in their entirety. Identified records were forwarded to 1 of 2 clinical data abstraction centers and each record underwent detailed systematic abstraction for clinical data including medical history, comorbidity, findings at admission, in-hospital course, status at discharge, medication and procedure use, and laboratory and other diagnostic evaluations. Trained reviewers, medical record abstraction software, and random record reabstraction were used to optimize data quality.36

Study Cohort

The NHF Project produced an initial random sample of 39 477 medical records. Medical records meeting NHF Project exclusion criteria (chronic hemodialysis, patient left hospital, no or invalid Social Security number, readmission) were excluded (n = 2054), leaving a cohort of 37 423 patients. Patients younger than 65 years (n = 2909), those who arrived by interhospital transfer (n = 1046), and those without heart failure on admission (n = 2324) were also excluded to ensure examination of a representative cohort of older patients directly admitted with heart failure. Patients hospitalized outside of the 50 states and the District of Columbia (n = 627) were excluded. Because we were primarily interested in examining quality-of-care differences between black patients and white patients, patients from other racial groups or those missing race data (n = 1824) were excluded. In total, 7691 patients met 1 or more of these exclusions; the remaining 29 732 patients comprised the study cohort.

Additional Data Sources

Data from the NHF Project were linked with the American Medical Association Physician Masterfile using the unique physician identification number of the attending physician for each hospitalization in the NHF Project. Physician characteristics included self-reported specialty and board certification.37 Hospital characteristics, including bed size, US census region, rural location, level of cardiac care facilities, ownership, and teaching status, were obtained by linking data from the 1998 American Hospital Association Annual Survey of Hospitals.38

Quality of Care and Outcomes

The NHF Project's evaluation of patient treatment focused on prescription of angiotensin-converting enzyme (ACE) inhibitors and evaluation of left ventricular ejection fraction (LVEF), both widely accepted measures of heart failure quality of care.36,39 Prescription of ACE inhibitor therapy at discharge was assessed among ideal candidates, defined as patients with left ventricular dysfunction who had no contraindications to ACE inhibitor therapy. To account for the possible use of angiotensin receptor blockers (ARBs) in lieu of ACE inhibitors (a substitution not supported by current clinical guidelines), we also examined the use of ACE inhibitors or ARBs among ideal candidates for ACE inhibitors. Patients were considered to have undergone evaluation of LVEF if their medical record contained an LVEF value measured prior to hospitalization, their LVEF was measured during hospitalization, or the medical record contained a note of a planned postdischarge LVEF measurement. Quality-of-care indicators are described in the Box.

Box. Quality Indicator Eligibility Criteria*

PRESCRIPTION OF ACE INHIBITORS†

Eligibility

 Patient alive at time of discharge
 Evidence of left ventricular systolic dysfunction during hospitalization (LVEF <40%)
 No moderate or severe aortic or bilateral renal artery stenoses
 No physician documentation of any reason for withholding ACE inhibitor therapy
 Patient not enrolled in ACE inhibitor or other clinical trials
 Serum creatinine level less than 2.0 mg/dL (177 µmol/L)
 Systolic blood pressure at least 100 mm Hg throughout hospitalization
 Serum potassium level less than 5.5 mEq/L

Quality of Care Measurement
 ACE inhibitor prescribed at discharge

CURRENT LVEF MEASUREMENT

Eligibility
 Patient alive at time of discharge

Quality of Care Measurement
Any 1 of the following 3:
 LVEF measured prior to hospitalization and noted in medical record
 LVEF measured during hospitalization
 Patient scheduled to have LVEF measured after discharge

*ACE indicates angiotensin-converting enzyme; LVEF, left ventricular ejection fraction.

†The same criteria were used to evaluate prescription of ACE inhibitors and angiotensin receptor blockers.

Mortality within 1 year of admission and readmission within 1 year of discharge were available for all patients and assessed using the Medicare Enrollment Database and billing records.40

Statistical Analysis

Racial differences in patients' medical history, comorbidities, admission characteristics, and quality indicator eligibility were assessed using χ2 and Wilcoxon rank sum tests.

Crude racial differences in quality of care and outcomes were evaluated using χ2 tests. Multivariable analyses were performed to determine if racial differences in quality of care or outcomes were independent of other factors. Because of the hierarchical nature of the NHF Project cohort (patients clustered within hospitals), mixed-effects multilevel modeling was conducted. Multilevel logistic regression models adjusted for patient age, sex, medical history (coronary artery disease, diabetes, hypertension, chronic obstructive pulmonary disease, dementia, LVEF, and admission source), admission characteristics (heart rate, serum sodium, and serum creatinine levels), and severity of illness as measured by a modified version of the Medicare Mortality Prediction System score (including age, cancer, mobility, prior congestive heart failure, mean arterial pressure, heart rate, serum urea nitrogen, white blood cell count, and the Acute Physiology and Chronic Health Evaluation [APACHE] II score).41 Analyses also adjusted for physician specialty, physician board certification, and hospital characteristics including number of beds, rural location, US census region, ownership, teaching status, and level of cardiac care facilities. The model intercept and patient race were initially entered into all analyses as random effects. Patient race was treated as a fixed effect if the model did not converge; all other variables were modeled as fixed effects in all analyses. Dummy variables were used to denote patients with missing physician or hospital information. Missing continuous variables (heart rate, n = 41; serum sodium level, n = 630; and serum creatinine level, n = 696) were replaced with the cohort's median value and a dummy variable indicating the replacement of missing data. Odds ratios were converted to estimated relative risks (RRs).42

Racial differences in quality of care and outcomes were assessed by stratifying by other characteristics, including patient sex, age, previous LVEF, history of coronary artery disease, hypertension, diabetes, renal failure, specialty of attending physician (cardiologist vs other specialty), hospital location (rural vs urban; US census region), teaching status, ownership, and level of cardiac care facilities. Interactions were tested in hierarchical models.

Analyses incorporated probability weights based on the inverse sampling fraction for each state. Analyses were conducted using Stata version 7.0 (Stata Corp, College Station, Tex) and MLwiN 1.10 (Institute of Education, London, England) and approved by the Yale University School of Medicine Human Investigation Committee.

Black patients accounted for nearly 12% of the study cohort, were younger than whites, and had higher rates of hypertension, diabetes, and peripheral edema but lower rates of coronary artery disease, prior revascularization, and angina compared with white patients (Table 1). Compared with white patients, black patients were hospitalized predominantly in the South and greater proportions were treated at larger urban teaching hospitals and by black and non–board-certified physicians (Table 2).

Table Graphic Jump LocationTable 2. Physician and Hospital Characteristics*

Overall, 94.8% of patients were eligible for assessment of LVEF measurement (96.5% black vs 94.5% white; P<.001) and 13.8% for evaluation of ACE inhibitor prescription (15.2% black vs 13.6% white; P = .06) or ACE inhibitor or ARB prescription among patients classified as ideal for ACE inhibitor therapy. Among patients classified as ideal for ACE inhibitor prescription (LVEF <40% with no documented contraindications), black patients had higher crude rates of ACE inhibitor prescription than did white patients (81.0% vs 73.8%; P<.001) but comparable rates of ACE inhibitor or ARB prescription (85.7% black vs 82.5% white; P = .08). There were no racial differences in the evaluation of LVEF (67.8% black vs 66.6% white; P = .29).

Although black patients had higher overall rates of ACE inhibitor use than white patients, the racial difference was larger among patients with a history of hypertension (82.8% black vs 72.9% white; P<.001) compared with nonhypertensive patients (73.7% black vs 75.2% white; P = .74) (P = .02 for interaction). Racial differences in the prescription of ACE inhibitors were otherwise comparable when analyses were repeated stratifying by age, sex, LVEF, diabetes, history of coronary artery disease, and renal dysfunction.

The association of patient race and treatment varied based on hospital characteristics. Black patients had higher rates of ACE inhibitor prescription than did white patients when treated in cardiac surgery–capable hospitals (83.4% black vs 72.9% white; P = .002) and cardiac catheterization–capable hospitals (85.5% black vs 74.5% white; P = .009) compared with hospitals with no cardiac facilities (75.4% black vs 74.5% white; P = .79) (P = .05 for interaction). Black patients in the Midwest had higher rates of LVEF measurement than did white patients (72.3% vs 64.6%; P<.001), but there were no racial differences in LVEF measurement in the Northeast (75.4% black vs 72.7% white; P = .19), West (64.8% black vs 64.8% white; P = .99), or South (64.7% black vs 64.9% white; P = .83) census regions (P = .05 for interaction). Racial differences in LVEF measurement varied based on hospital ownership, with lower rates of LVEF measurement in black patients treated at for-profit hospitals (57.3% vs 63.6%; P = .02) compared with patients treated in public (62.4% black vs 56.1% white; P = .007) and not-for-profit (71.2% black vs 68.6% white; P = .01) hospitals (P = .005 for interaction). Racial differences in LVEF measurement similarly varied by physician specialty, with black patients having lower rates of treatment than white patients when treated by cardiologists (70.8% vs 74.4%; P = .06) but higher rates when treated by internists (70.1% vs 65.7%; P<.001) and no statistically significant difference when treated by family or general practitioners (55.2% black vs 58.9% white; P = .09) (P<.001 for interaction). The effect of race on quality of care was otherwise consistent across hospital and physician characteristics.

Race had only a minimal association with quality of care after multivariable adjustment. Black patients had similar rates of LVEF measurement as white patients (black vs white, adjusted RR, 0.99; 95% confidence interval [CI], 0.95-1.03). Black patients classified as ideal for ACE inhibitor therapy were more likely to be prescribed ACE inhibitors than similarly classified white patients (black vs white, adjusted RR, 1.22; 95% CI, 1.14-1.28), even after accounting for racial differences in the prevalence of hypertension and diabetes. There were no racial differences in the composite end point of ARB or ACE inhibitor prescription among patients classified as ideal for ACE inhibitor therapy (black vs white, adjusted RR, 1.03; 95% CI, 0.97-1.07). The effect of patient race, however, varied by hospital, exhibiting a significant random effect for prescription of ACE inhibitors among ideal patients (P<.001) and measurement of LVEF (P<.001).

Black patients had higher crude 1-year readmission rates than white patients (68.2% vs 63.0%; P<.001). Racial differences in readmission rates were largest among patients aged 85 years or older (68.4% black vs 59.4% white; P<.001) compared with those younger than 75 years (68.8% black vs 64.5% white; P = .002) and those aged 75 to 84 years (67.5% black vs 64.5% white; P = .03) (P = .05 for interaction); those with an LVEF of 40% or higher (72.5% black vs 64.8% white; P<.001) vs those with an LVEF of less than 40% (66.0% black vs 62.6% white; P = .002) (P<.001 for interaction); and patients with renal failure (72.9% black vs 64.2% white; P<.001) compared with those with no renal failure (65.8% black vs 62.5% white; P = .002) (P = .002 for interaction) but were otherwise statistically comparable across patient characteristics. There were no racial differences in readmission rates among patients treated in the Northeast (64.7% black vs 64.6% white; P = .96) compared with the Midwest (69.1% black vs 61.3% white; P<.001), South (68.0% black vs 64.2% white; P = .002), and West (73.5% black vs 60.7% white; P<.001) (P = .004 for interaction). Racial differences in the risk of readmission were reduced after multivariable adjustment (black vs white, RR, 1.09; 95% CI, 1.06-1.13), although the association of race with readmission varied by individual hospital (P<.001).

Mortality rates were lower among black patients (P<.001) (Figure 1). Black patients had lower crude mortality rates than white patients at 30 days (6.3% vs 10.7%; P<.001) and 1 year (31.5% vs 40.1%; P<.001) after admission. Crude racial differences in 30-day mortality rates were greater among patients with hypertension (5.2% black vs 9.5% white; P<.001) compared with nonhypertensive patients (10.5% black vs 12.5% white; P = .12) (P = .003 for interaction) and among patients treated in cardiac surgery–capable hospitals (5.1% black vs 10.5% white; P<.001) compared with cardiac catheterization–capable hospitals (9.2% black vs 10.2% white; P = .37) and hospitals with no cardiac care facilities (6.5% black vs 11.1% white; P<.001) (P = .002 for interaction). Similarly, racial differences in 1-year mortality were larger among men (32.7% black vs 44.3% white; P<.001) than among women (30.7% black vs 37.2% white; P<.001) (P = .02 for interaction); among patients aged 65 to 74 years (23.5% black vs 32.3% white; P<.001) compared with patients aged 75 to 84 years (33.0% black vs 38.6% white; P<.001) and patients aged 85 years or older (44.8% black vs 49.6% white; P = .02) (P = .04 for interaction); among patients with an LVEF of less than 40% (30.0% black vs 40.1% white; P<.001) compared with an LVEF of 40% or higher (38.8% black vs 46.8% white; P<.001) (P = .03 for interaction); among patients with renal failure (40.2% black vs 54.0% white; P<.001) compared with patients with no renal failure (27.1% black vs 34.0% white; P<.001) (P = .004 for interaction); and among patients with diabetes (27.8% black vs 40.7% white; P<.001) compared with those without diabetes (34.7% black vs 39.7% white; P<.001) (P<.001 for interaction). Mortality risks among black patients remained lower after multivariable adjustment at 30 days (black vs white, RR, 0.78; 95% CI, 0.68-0.91) and 1 year (black vs white, RR, 0.93; 95% CI, 0.88-0.98) after admission.

Figure. Kaplan-Meier Curve for 1-Year Mortality by Race
Graphic Jump Location
Crude proportion of cohort mortality. Because the NHF Project data are representative of a weighted sample, no actual numbers of patients at risk are presented.

In contrast with previous evaluations of treatment and procedure use,25 we found no meaningful racial differences in the quality of care provided to Medicare beneficiaries hospitalized with heart failure. Black patients had modestly higher rates of ACE inhibitor use and comparable crude rates of LVEF measurement compared with white patients. Racial differences in treatment were attenuated by multivariable adjustment but also varied across individual hospitals and US census regions, indicating that the effects of race on quality of care are not consistent across all settings. Although black patients had a slightly higher risk of readmission, they had a lower risk of mortality than white patients up to 1 year after hospitalization. Our findings thus indicate that black patients hospitalized with heart failure receive comparable if not higher quality of care and have higher survival rates than white patients.

The similarity in quality of care between black patients hospitalized with heart failure and their white counterparts is reassuring and suggests that concerns about racial differences in quality of cardiovascular care2 are not an issue for Medicare patients with heart failure. The absence of racial differences in quality of care may be attributable to several factors. All patients in the study cohort had Medicare insurance (thus providing a common primary payer) and, by being hospitalized, had demonstrated access to the health care system. The quality-of-care assessments were based on treatments provided before or during hospitalization (LVEF measurement) or prescribed at discharge (ACE inhibitors), thereby providing multiple opportunities for receiving high-quality care. The higher prevalence of heart failure among blacks may make physicians particularly cognizant of providing quality care to black patients. Alternatively, race may have no independent influence on the quality of care provided to older patients hospitalized with heart failure. As such, these data would indicate that racial disparities in health care use are not observed for all clinical conditions.

Variation in racial differences in quality of care across hospitals demonstrates that the influence of race on treatment varies by individual hospital and across types of hospitals. Individual hospital variation in the association of race and treatment suggests that previous reports of racial differences in heart failure treatment35 may reflect hospital-specific practice patterns rather than a consistent phenomenon at all hospitals. The interactions between race and hospital cardiac care facilities, geographic location, and ownership suggests that some hospital attributes may accentuate or mitigate racial differences in treatment. In particular, the similarity of our findings with previous reports of geographic variations in racial differences in cardiovascular care suggests that region in particular may influence racial variations in practice.4345

Black patients had a slightly higher risk of readmission than did white patients after accounting for racial differences in other patient characteristics. Previous studies indicate that higher rates of readmission in minority populations may reflect differences in adherence to pharmacotherapy and diet regimens.46 Racial differences in heart failure symptom recognition may also result in black patients deferring care until initial problems are sufficiently advanced such that hospitalization is required.47 Either of these processes suggests that targeted educational interventions may benefit minority populations with heart failure. Alternatively, black patients may receive poorer-quality follow-up care after discharge. Race may also be a proxy for other unmeasured characteristics, including lower socioeconomic status and greater functional impairments, which are also associated with higher rates of heart failure readmission.48 However, without detailed information concerning quality of postdischarge processes of care, it is unclear whether race is independently associated with readmission or reflects poorer-quality postdischarge care.

Our data indicate that black patients have lower mortality rates after hospitalization for heart failure than white patients, even after accounting for marginally higher rates of ACE inhibitor use. Epidemiological data suggest a crossover in black and white heart failure patient mortality risks at about age 65 years, with black patients having a higher mortality risk than white patients before age 65 years but a lower mortality risk than white patients after age 65 years.19 However, Jha and colleagues' evaluation23 of veterans hospitalized for acute conditions including heart failure found lower rates of mortality among black patients younger than 65 years, although the extent to which this difference is attributable to heart failure, as opposed to other clinical conditions, was not reported. Racial differences in mortality may also reflect a survivor effect, whereby black patients who survive to age 65 years with heart failure represent a healthier cohort than white patients of the same age in ways that are unmeasured in this study. Similarly, black patients experiencing acute exacerbations of heart failure may be more likely to die before hospitalization than white patients, suggesting that black patients who are hospitalized may have less severe exacerbations than do white patients. Our analyses adjusted for history of coronary artery disease and hypertension, suggesting that racial differences in mortality are not attributable to racial differences in heart failure etiology. Alternatively, racial differences in other unmeasured clinical characteristics may account for the survival advantage of black patients. Although the source of the apparent racial difference in mortality risk is not clear, our findings do not support the hypothesis that black Medicare patients hospitalized for heart failure have poorer outcomes than white patients.

The NHF Project represents the largest contemporary evaluation of elderly patients hospitalized with heart failure. The use of quality-of-care indicators and detailed clinical data also represents significant methodological improvements on prior evaluations of racial differences in treatment. However, our study has certain issues that merit consideration. We restricted our analysis to fee-for-service Medicare patients aged 65 years or older who were hospitalized with heart failure; thus, our findings may not be applicable to patients younger than 65 years or those enrolled in Medicare managed care. However, more than 80% of heart failure patients in the United States are aged 65 years or older1 (although this proportion may be smaller for black patients who have an earlier median age of heart failure onset), and patients enrolled in Medicare managed care comprise less than 15% of Medicare beneficiaries,49 suggesting that both exclusions may result in only a minor loss in study generalizability.

Our findings may not be applicable to patients who are not hospitalized or to practice patterns in the ambulatory setting. However, acute exacerbations of heart failure requiring hospitalization are common, particularly among elderly patients.50 Patient race may influence quality of care in a manner not reflected in the quality-of-care measures we used, although these measures are currently used by the Centers for Medicare & Medicaid Services to assess quality of heart failure care.36 Finally, we were unable to assess racial differences in quality of life or patient outcomes other than mortality. Although black patients hospitalized with heart failure may have lower mortality rates than do white patients, increased survival may be offset by poorer quality of life or greater functional limitations due to heart failure.6

Black and white Medicare patients receive comparable quality of care during hospitalization for heart failure. Despite only small variations in quality of care, black patients had slightly higher readmission rates but lower mortality rates up to 1 year after hospitalization than white patients. Our findings contrast with previous reports of poorer quality heart failure care among black patients25 and suggest that elderly black patients may have a survival advantage compared with elderly white patients. Moreover, our results demonstrate that racial disparities in quality of care do not exist for all clinical conditions and thereby underscore the need to study patterns of care for individual clinical conditions. Efforts are needed to improve quality of heart failure care for both black and white patients.

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Alexander M, Grumbach K, Remy L, Rowell R, Massie BM. Congestive heart failure hospitalizations and survival in California: patterns according to race/ethnicity.  Am Heart J.1999;137:919-927.
Hunt SA, Baker DW, Chin MH.  et al.  ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary.  J Am Coll Cardiol.2001;38:2101-2113.
Jha AK, Shlipak MG, Hosmer W, Frances CD, Browner WS. Racial differences in mortality among men hospitalized in the Veterans Affairs health care system.  JAMA.2001;285:297-303.
Gordon HS, Harper DL, Rosenthal GE. Racial variation in predicted and observed in-hospital death: a regional analysis.  JAMA.1996;276:1639-1644.
Wolinsky FD, Overhage JM, Stump TE, Lubitz RM, Smith DM. The risk of hospitalization for congestive heart failure among older adults.  Med Care.1997;35:1031-1043.
Croft JB, Giles WH, Pollard RA, Casper ML, Anda RF, Livengood JR. National trends in the initial hospitalization for heart failure.  J Am Geriatr Soc.1997;45:270-275.
Croft JB, Giles WH, Pollard RA, Keenan NL, Casper ML, Anda RF. Heart failure survival among older adults in the United States: a poor prognosis for an emerging epidemic in the Medicare population.  Arch Intern Med.1999;159:505-510.
Luthi JC, McClellan WM, Fitzgerald D.  et al.  Mortality associated with the quality of care of patients hospitalized with congestive heart failure.  Int J Qual Health Care.2002;14:15-24.
Alexander M, Grumbach K, Selby J, Brown AF, Washington E. Hospitalization for congestive heart failure: explaining racial differences.  JAMA.1995;274:1037-1042.
Ibrahim SA, Burant CJ, Kent Kwoh C. Elderly hospitalized patients with diastolic heart failure: lack of gender and ethnic differences in 18-month mortality rates.  J Gerontol A Biol Sci Med Sci.2003;58:56-59.
Afzal A, Ananthasubramaniam K, Sharma N.  et al.  Racial differences in patients with heart failure.  Clin Cardiol.1999;22:791-794.
Bourassa MG, Gurne O, Bangdiwala SI.  et al.  Natural history and patterns of current practice in heart failure: the Studies of Left Ventricular Dysfunction (SOLVD) Investigators.  J Am Coll Cardiol.1993;22:14A-19A.
Vinson JM, Rich MW, Sperry JC, Shah AS, McNamara T. Early readmission of elderly patients with congestive heart failure.  J Am Geriatr Soc.1990;38:1290-1295.
Chin MH, Goldman L. Correlates of early hospital readmission or death in patients with congestive heart failure.  Am J Cardiol.1997;79:1640-1644.
 International Classification of Diseases, 9th Revision, Clinical Modification.  Los Angeles, Calif: Practice Management Information Corp; 1998.
Masoudi FA, Ordin DL, Delaney RJ, Krumholz HM, Havranek EP. The National Heart Failure Project: a Health Care Financing Administration initiative to improve the care of Medicare beneficiaries with heart failure.  Congest Heart Fail.2000;6:337-339.
Kenward K. The scope of data available in the AMA's Physician Masterfile.  Am J Public Health.1996;86:1481-1482.
American Hospital Association.  The Annual Survey of Hospitals Database: Documentation for 1998 DataChicago, Ill: American Hospital Association; 1998.
Krumholz HM, Baker DW, Ashton CM.  et al.  Evaluating quality of care for patients with heart failure.  Circulation.2000;101:E122-E140.
Fleming C, Fisher ES, Chang CH, Bubolz TA, Malenka DJ. Studying outcomes and hospital utilization in the elderly: the advantages of a merged data base for Medicare and Veterans Affairs hospitals.  Med Care.1992;30:377-391.
Daley J, Jencks S, Draper D, Lenhart G, Thomas N, Walker J. Predicting hospital-associated mortality for Medicare patients: a method for patients with stroke, pneumonia, acute myocardial infarction, and congestive heart failure.  JAMA.1988;260:3617-3624.
Zhang J, Yu KF. What's the relative risk? a method for correcting the odds ratio in cohort studies of common outcomes.  JAMA.1998;280:1690-1691.
Rathore SS, Frederick PD, Every NR, Barron HV, Krumholz HM. Racial differences in acute reperfusion therapy use in patients hospitalized with acute myocardial infarction: a regional phenomenon [abstract].  J Am Coll Cardiol.2003;41:518A.
Goldberg KC, Hartz AJ, Jacobsen SJ, Krakauer H, Rimm AA. Racial and community factors influencing coronary artery bypass graft surgery rates for all 1986 Medicare patients.  JAMA.1992;267:1473-1477.
Gatsonis CA, Epstein AM, Newhouse JP, Normand SL, McNeil BJ. Variations in the utilization of coronary angiography for elderly patients with an acute myocardial infarction: an analysis using hierarchical logistic regression.  Med Care.1995;33:625-642.
Ghali JK, Kadakia S, Cooper R, Ferlinz J. Precipitating factors leading to decompensation of heart failure: traits among urban blacks.  Arch Intern Med.1988;148:2013-2016.
Evangelista LS, Dracup K, Doering LV. Racial differences in treatment-seeking delays among heart failure patients.  J Card Fail.2002;8:381-386.
Philbin EF, Dec GW, Jenkins PL, DiSalvo TG. Socioeconomic status as an independent risk factor for hospital readmission for heart failure.  Am J Cardiol.2001;87:1367-1371.
Iglehart JK. The Centers for Medicare and Medicaid Services.  N Engl J Med.2001;345:1920-1924.
O'Connell JB, Bristow MR. Economic impact of heart failure in the United States: time for a different approach.  J Heart Lung Transplant.1994;13:S107-S112.

Figures

Figure. Kaplan-Meier Curve for 1-Year Mortality by Race
Graphic Jump Location
Crude proportion of cohort mortality. Because the NHF Project data are representative of a weighted sample, no actual numbers of patients at risk are presented.

Tables

Table Graphic Jump LocationTable 2. Physician and Hospital Characteristics*

References

American Heart Association.  2002 Heart and Stroke Statistical UpdateDallas, Tex: American Heart Association; 2001.
Institute of Medicine.  Unequal Treatment: Confronting Racial and Ethnic Disparities in Health CareWashington, DC: Institute of Medicine; 2002.
Stafford RS, Saglam D, Blumenthal D. National patterns of angiotensin-converting enzyme inhibitor use in congestive heart failure.  Arch Intern Med.1997;157:2460-2464.
Ayanian JZ, Weissman JS, Chasan-Taber S, Epstein AM. Quality of care by race and gender for congestive heart failure and pneumonia.  Med Care.1999;37:1260-1269.
Kahn KL, Pearson ML, Harrison ER.  et al.  Health care for black and poor hospitalized Medicare patients.  JAMA.1994;271:1169-1174.
Vaccarino V, Gahbauer E, Kasl SV, Charpentier PA, Acampora D, Krumholz HM. Black-white differences in the outcome of heart failure: evidence for greater functional decline in blacks.  Am Heart J.2002;143:1058-1067.
Vaccarino V, Chen YT, Wang Y, Radford MJ, Krumholz HM. Sex differences in the clinical care and outcomes of congestive heart failure in the elderly.  Am Heart J.1999;138:835-842.
Ventura HO, Oren RM, Ghali JK.  et al.  Racial differences in heart failure presentation but not therapy: report from the UNITE-HF multicenter heart failure database [abstract].  J Am Coll Cardiol.2001;37:209A.
Sueta CA, Schenck A, Chowdhury M, Hall R, Simpson RJ. Effect of angiotensin-converting enzyme inhibitor therapy on 30-day outcome in patients >65 years of age with chronic congestive heart failure.  Am J Cardiol.2000;86:1151-1153.
Sueta CA, Russo A, Schenck A, Brown DW, Simpson RJ. Effect of angiotensin-converting inhibitor or angiotensin receptor blocker on one-year survival in patients >65 years hospitalized with a left ventricular ejection fraction >50%.  Am J Cardiol.2003;91:363-365.
Agency for Healthcare Research and Quality.  Program brief: Excellence Centers to Eliminate Ethnic/Racial Disparities (EXCEED). Available at: http://www.ahrq.gov/research/exceed.htm. Accessed September 8, 2002.
Exner DV, Dries DL, Domanski MJ, Cohn JN. Lesser response to angiotensin-converting-enzyme inhibitor therapy in black as compared with white patients with left ventricular dysfunction.  N Engl J Med.2001;344:1351-1357.
Dries DL, Exner DV, Gersh BJ, Cooper HA, Carson PE, Domanski MJ. Racial differences in the outcome of left ventricular dysfunction.  N Engl J Med.1999;340:609-616.
McCullough PA, Philbin EF, Spertus JA, Kaatz S, Sandberg KR, Weaver WD. Confirmation of a heart failure epidemic: findings from the Resource Utilization Among Congestive Heart Failure (REACH) Study.  J Am Coll Cardiol.2002;39:60-69.
Yancy CW, Fowler MB, Colucci WS.  et al.  Race and the response to adrenergic blockade with carvedilol in patients with chronic heart failure.  N Engl J Med.2001;344:1358-1365.
Krumholz HM, Parent EM, Tu N.  et al.  Readmission after hospitalization for congestive heart failure among Medicare beneficiaries.  Arch Intern Med.1997;157:99-104.
Dries DL, Strong MH, Cooper RS, Drazner MH. Efficacy of angiotensin-converting enzyme inhibition in reducing progression from asymptomatic left ventricular dysfunction to symptomatic heart failure in black and white patients.  J Am Coll Cardiol.2002;40:311-317.
Gillum RF. Heart failure in the United States 1970-1985.  Am Heart J.1987;113:1043-1045.
Gillum RF. Epidemiology of heart failure in the United States.  Am Heart J.1993;126:1042-1047.
Philbin EF, DiSalvo TG. Influence of race and gender on care process, resource use, and hospital-based outcomes in congestive heart failure.  Am J Cardiol.1998;82:76-81.
Alexander M, Grumbach K, Remy L, Rowell R, Massie BM. Congestive heart failure hospitalizations and survival in California: patterns according to race/ethnicity.  Am Heart J.1999;137:919-927.
Hunt SA, Baker DW, Chin MH.  et al.  ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary.  J Am Coll Cardiol.2001;38:2101-2113.
Jha AK, Shlipak MG, Hosmer W, Frances CD, Browner WS. Racial differences in mortality among men hospitalized in the Veterans Affairs health care system.  JAMA.2001;285:297-303.
Gordon HS, Harper DL, Rosenthal GE. Racial variation in predicted and observed in-hospital death: a regional analysis.  JAMA.1996;276:1639-1644.
Wolinsky FD, Overhage JM, Stump TE, Lubitz RM, Smith DM. The risk of hospitalization for congestive heart failure among older adults.  Med Care.1997;35:1031-1043.
Croft JB, Giles WH, Pollard RA, Casper ML, Anda RF, Livengood JR. National trends in the initial hospitalization for heart failure.  J Am Geriatr Soc.1997;45:270-275.
Croft JB, Giles WH, Pollard RA, Keenan NL, Casper ML, Anda RF. Heart failure survival among older adults in the United States: a poor prognosis for an emerging epidemic in the Medicare population.  Arch Intern Med.1999;159:505-510.
Luthi JC, McClellan WM, Fitzgerald D.  et al.  Mortality associated with the quality of care of patients hospitalized with congestive heart failure.  Int J Qual Health Care.2002;14:15-24.
Alexander M, Grumbach K, Selby J, Brown AF, Washington E. Hospitalization for congestive heart failure: explaining racial differences.  JAMA.1995;274:1037-1042.
Ibrahim SA, Burant CJ, Kent Kwoh C. Elderly hospitalized patients with diastolic heart failure: lack of gender and ethnic differences in 18-month mortality rates.  J Gerontol A Biol Sci Med Sci.2003;58:56-59.
Afzal A, Ananthasubramaniam K, Sharma N.  et al.  Racial differences in patients with heart failure.  Clin Cardiol.1999;22:791-794.
Bourassa MG, Gurne O, Bangdiwala SI.  et al.  Natural history and patterns of current practice in heart failure: the Studies of Left Ventricular Dysfunction (SOLVD) Investigators.  J Am Coll Cardiol.1993;22:14A-19A.
Vinson JM, Rich MW, Sperry JC, Shah AS, McNamara T. Early readmission of elderly patients with congestive heart failure.  J Am Geriatr Soc.1990;38:1290-1295.
Chin MH, Goldman L. Correlates of early hospital readmission or death in patients with congestive heart failure.  Am J Cardiol.1997;79:1640-1644.
 International Classification of Diseases, 9th Revision, Clinical Modification.  Los Angeles, Calif: Practice Management Information Corp; 1998.
Masoudi FA, Ordin DL, Delaney RJ, Krumholz HM, Havranek EP. The National Heart Failure Project: a Health Care Financing Administration initiative to improve the care of Medicare beneficiaries with heart failure.  Congest Heart Fail.2000;6:337-339.
Kenward K. The scope of data available in the AMA's Physician Masterfile.  Am J Public Health.1996;86:1481-1482.
American Hospital Association.  The Annual Survey of Hospitals Database: Documentation for 1998 DataChicago, Ill: American Hospital Association; 1998.
Krumholz HM, Baker DW, Ashton CM.  et al.  Evaluating quality of care for patients with heart failure.  Circulation.2000;101:E122-E140.
Fleming C, Fisher ES, Chang CH, Bubolz TA, Malenka DJ. Studying outcomes and hospital utilization in the elderly: the advantages of a merged data base for Medicare and Veterans Affairs hospitals.  Med Care.1992;30:377-391.
Daley J, Jencks S, Draper D, Lenhart G, Thomas N, Walker J. Predicting hospital-associated mortality for Medicare patients: a method for patients with stroke, pneumonia, acute myocardial infarction, and congestive heart failure.  JAMA.1988;260:3617-3624.
Zhang J, Yu KF. What's the relative risk? a method for correcting the odds ratio in cohort studies of common outcomes.  JAMA.1998;280:1690-1691.
Rathore SS, Frederick PD, Every NR, Barron HV, Krumholz HM. Racial differences in acute reperfusion therapy use in patients hospitalized with acute myocardial infarction: a regional phenomenon [abstract].  J Am Coll Cardiol.2003;41:518A.
Goldberg KC, Hartz AJ, Jacobsen SJ, Krakauer H, Rimm AA. Racial and community factors influencing coronary artery bypass graft surgery rates for all 1986 Medicare patients.  JAMA.1992;267:1473-1477.
Gatsonis CA, Epstein AM, Newhouse JP, Normand SL, McNeil BJ. Variations in the utilization of coronary angiography for elderly patients with an acute myocardial infarction: an analysis using hierarchical logistic regression.  Med Care.1995;33:625-642.
Ghali JK, Kadakia S, Cooper R, Ferlinz J. Precipitating factors leading to decompensation of heart failure: traits among urban blacks.  Arch Intern Med.1988;148:2013-2016.
Evangelista LS, Dracup K, Doering LV. Racial differences in treatment-seeking delays among heart failure patients.  J Card Fail.2002;8:381-386.
Philbin EF, Dec GW, Jenkins PL, DiSalvo TG. Socioeconomic status as an independent risk factor for hospital readmission for heart failure.  Am J Cardiol.2001;87:1367-1371.
Iglehart JK. The Centers for Medicare and Medicaid Services.  N Engl J Med.2001;345:1920-1924.
O'Connell JB, Bristow MR. Economic impact of heart failure in the United States: time for a different approach.  J Heart Lung Transplant.1994;13:S107-S112.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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