RACIAL DISPARITIES IN PRESCRIPTION DRUG UTILIZATION AN ANALYSIS OF BETA-BLOCKER AND STATIN USE...
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RACIAL DISPARITIES IN PRESCRIPTION DRUG UTILIZATION
AN ANALYSIS OF BETA-BLOCKER AND STATIN USE FOLLOWING HOSPITALIZATION FOR ACUTE
MYOCARDIAL INFARCTION
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JEROME WILSON, MA, Ph.D.Associate Professor
Department of Family Medicine and the National Center for Primary Care
Morehouse School of Medicine
Atlanta, GA
June 24, 2004
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BACKGROUND
• Long-term beta-blocker drug treatment is recommended following acute myocardial infarction (AMI) (Ryan 1999
• For many patients, lipid-lowering therapy is also recommended for secondary prevention (Ryan 1999; Qurishi 2001)
• Disparities in the use of cardiovascular procedures have been observed by gender and race/ethnicity (Ding 2003; Giles 1995; Petersen 1194)
• Research on disparities in drug use for cardiovascular conditions is more limited
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OBJECTIVE
• To assess whether the use of beta-blockers and statins following hospitalization for an acute myocardial infarction (AMI) varies by race/ethnicity among Medicaid recipients
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METHODS
• PATIENTSPatients were selected if they were:
> 18+ years of age> Hospitalized with AMI (ICD-9-CM 410.XX) between January 1, 1998 and December 31, 2000 and> Eligible for non-capitated medical and pharmacy services for at least 3 months after their hospitalization
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DATA SOURCES
• Study patients were drawn from a 20% random sample of California Medicaid “Medi-Cal” recipients (approximately 1.3 million recipients) from four files:
> Inpatient medical services> Prescription drugs
> Outpatient medical services > Eligibility (e.g., age, gender, race, monthly eligibility status)
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OUTCOME MEASURES
• The likelihood of being treated with beta-blockers or statins within 30, 60, and 90 days following a live discharge after AMI
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DATA ANALYSIS
• Unadjusted odds ratios for treatment with beta-blockers or statins within 30, 60, and 90 days of the inpatient stay were assessed descriptively by race/ethnicity
• Adjusted odds ratios for treatment with beta-blockers or statins within 90 days for each race/ethnicity category (versus white recipients) were estimated via logistic regression controlling for patient demographics and comorbidities
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RESULTS
• Patient CharacteristicsWe identified 2,069 patients who met
the cohort selection criteria, with a mean age of 71 years; 14% were African-American, 23% were Asian, 5% were Hispanic, and 58% were white
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Table 1. Sociodemographic characteristics of patients hospitalized for myocardial infarction
Characteristic Study Patients (n=2,069)
Age
Less than 65 27.8%
65-74 28.3%
75-84 28.5%
85+ 15.5%
Mean ± SD 71.3 ± 13.0
Percent male 45.5
Race/Ethnicity
African American 13.9
Asian/Pacific Islander 22.6
Hispanic 5.2
White 58.3
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RESULTS (2)
• The mean Charlson comorbidity index was 1.8,
• The most common Charlson conditions included CHF (26%), diabetes (25%), COPD (18%), vascular disease (14%), and renal disease (6%)
• Hypertension was diagnosed in approximately one-third of the study patients
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Table 2. Comorbid conditions for patients hospitalized for myocardial infarction
Measure Study Patients (n=2,069)
Selected Charlson Comorbidities (%):
Congestive heart failure 26.0%
Vascular Disease 14.0%
COPD 17.8%
Diabetes 25.0%
Renal disease 6.2%
Any malignancy 2.3%
Hypertension 32.1%
Hyperlipidemia 6.1%
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RESULTS (3)
• Between 30% and 50% of patients were treated with beta-blockers and fewer (13% to 36%) with statins, depending on race/ethnicity and the number of days post hospitalization
• For both therapies, African American and Hispanic patients had lower treatment rates relative to Asians and whites
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Figure 1. Percent of patients receiving beta- blocker therapy following MI, by race/ethnicity
0%
20%
40%
60%
30 days 60 days 90 days
White
African American
Hispanic
Asian
Source: California Medicaid program 1998 to 2000.
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Figure 2. Percent of patients receiving astatin medication following MI, by race/ethnicity
0%
20%
40%
60%
30 days 60 days 90 days
White
African American
Hispanic
Asian
Source: California Medicaid program 1998 to 2000
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RESULTS (4)
• Factors associated with a decreased likelihood of beta-blocker therapy included being African American and increasing age
• Beta-blocker therapy was more likely among patients diagnosed with hypertension and hyperlipidemia and those with higher Charlson comorbidity scores
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0.0 1.0 2.0 3.0 4.0 5.0
Hyperlipidemia
Hypertension
CCI* = 2+ (vs. CCI*=0)
CCI*=1 (vs. CCI*=0)
Male
75+ years (vs. <65 years)
65 to 74 years (vs. <65 years)
Asian (vs. White)
Hispanic (vs. White)
African American (vs. White)
Relative Odds (95% CI)
Less likely to be treated
Figure 3. Factors associated with beta-blocker therapy within 90 days following MI
More likely to be treated
Source: California Medicaid program 1998 to 2000.* Charlson comorbidity index
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RESULTS (5)
• Factors associated with a decreased likelihood of statin therapy included being African American or Hispanic and increasing age
• Statin therapy was more likely among patients diagnosed with hyperlipidemia
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0.0 1.0 2.0 3.0 4.0 5.0
Hyperlipidemia
Hypertension
CCI* = 2+ (vs. CCI*=0)
CCI*=1 (vs. CCI*=0)
Male
75+ years (vs. <65 years)
65 to 74 years (vs. <65 years)
Asian (vs. White)
Hispanic (vs. White)
African American (vs. White)
Relative Odds (95% CI)
Less likely to be treated
Figure 4. Factors associated with statin therapy within 90 days following MI
More likely to be treated
Source: California Medicaid program 1998 to 2000.* Charlson comorbidity index
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LIMITATIONS
• Validity of ICD-9CM codes to confirm diagnosis
• Limited geographical diversity• Further research on pharmacotherapy is
needed to better understand the observed disparities
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SUMMARY
• In this Medicaid population, a relatively low proportion of patients were dispensed beta-blockers or statins following an AMI hospitalization
• African-Americans and to a lesser extent, Hispanics were the least likely to receive treatment