Elsevier

The American Journal of Medicine

Volume 119, Issue 2, February 2006, Pages 167.e17-167.e21
The American Journal of Medicine

Clinical research study
Disparities in the Use of Primary Prevention and Defibrillator Therapy Among Blacks and Women

https://doi.org/10.1016/j.amjmed.2005.08.021Get rights and content

Abstract

Objectives

This study determines whether there are racial or gender disparities in the use of implantable cardioverter-defibrillator therapy for primary prevention of sudden cardiac death.

Background

Primary prevention of sudden death with implantable cardioverter-defibrillator therapy has been shown to improve survival for high-risk patients with coronary artery disease and left ventricular dysfunction.

Methods

The Center for Medicare and Medicaid Services Medicare database from the year 2002 was used to identify patients who were potential candidates for implantable cardioverter-defibrillator therapy on the basis of a combination of International Classification of Diseases, Ninth Revision, Clinical Modification codes that reflected the presence of an ischemic cardiomyopathy. This cohort was analyzed to determine which patients received implantable cardioverter-defibrillator therapy during the same year. The clinical characteristics of the potential implantable cardioverter-defibrillator candidates were compared with those who actually received an implantable cardioverter-defibrillator.

Results

A total 132 565 Medicare patients hospitalized during 2002 were identified as having an ischemic cardiomyopathy; 10 370 (8%) of these patients underwent implantable cardioverter-defibrillator implantation during the same year. The percentage of patients who underwent implantable cardioverter-defibrillator implantation was higher for men compared with women (10.2% vs 3.5%; P<.001) and whites compared with blacks (8.1 vs 5.4; P<.001). After multivariate analysis, age, gender, and race remained independent predictors of implantable cardioverter-defibrillator implantation. Women with an ischemic cardiomyopathy were 65% less likely to receive implantable cardioverter-defibrillator therapy compared with men (P<.001), and black patients were 31% less likely to receive implantable cardioverter-defibrillator therapy compared with patients of other races (P < .001).

Conclusions

Use of implantable cardioverter-defibrillator therapy for primary prevention of sudden death among the elderly population identified as having an ischemic cardiomyopathy was significantly lower among women compared with men, and among blacks compared with whites. Further exploration of gender and racial barriers to appropriate implantable cardioverter-defibrillator use for primary prevention is needed.

Section snippets

Study Design and Patient Identification

The Provider Analysis and Review files from the Center for Medicare and Medicaid Services database of hospital admissions in the United States during the year 2002 were used to compare the clinical characteristics of all patients who were potential candidates for implantable cardioverter-defibrillator therapy for primary prevention with those of patients who actually underwent implantable cardioverter-defibrillator implantation.

In the year 2002, implantable cardioverter-defibrillator therapy

Results

Among all Medicare patients who were admitted to a hospital in the United States during the year 2002, 132 565 patients were identified as having an ischemic cardiomyopathy. The clinical characteristics of the patients are summarized in Table 1. Eighty-eight percent of patients were categorized as white, 8.0% as black, 0.5% as Asian, 1.5% as Hispanic, 0.4% as North American Native, and 1.2% as other.

Among these potential implantable cardioverter-defibrillator candidates, 10 370 (8%) underwent

Main Findings

This is the first study that has attempted to identify racial and gender discrepancies in the use of implantable cardioverter-defibrillator therapy for primary prevention. Potential candidates were identified using hospital admission diagnostic codes that reflected the presence of an ischemic cardiomyopathy. The main findings of this study are that women and black patients are significantly underrepresented among Medicare patients with an ischemic cardiomyopathy who receive implantable

Limitations

The indications for defibrillator therapy for primary prevention of sudden death are largely based on the left ventricular ejection fraction. However, the Center for Medicare and Medicaid Services database does not contain information regarding left ventricular function. Therefore, the presence of coronary artery disease and heart failure was used as a surrogate for left ventricular dysfunction. However, it is possible that the use of diagnostic codes to identify patients with an ischemic

Conclusions

Use of implantable cardioverter-defibrillator therapy for primary prevention of sudden death among the elderly population identified as having an ischemic cardiomyopathy was significantly lower among women compared with men and was lower among blacks compared with whites. Further exploration of gender and racial barriers to appropriate implantable cardioverter-defibrillator use for primary prevention is needed.

References (22)

  • A.J. Moss et al.

    Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction

    N Engl J Med

    (2002)
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    This study was supported by an unrestricted grant from Guidant Inc., St. Paul, Minn.

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