When you roll into the ER with crushing chest pain, does your skin color determine the care you get?
A new study in this week's Journal of the American Medical Association suggests it very well might, though experts continue to be at odds over the impact of race in heart disease treatment.
Lead study author Dr. Ioana Popescu and colleagues at the University of Iowa Medical School reported on a five-year study of what happened to more than 1 million elderly black and white Medicare patients after they had heart attacks.
What Popescu found was that that black patients were less likely to receive invasive, aggressive treatments following a heart attack -- procedures like bypass surgery or receiving an artery-opening stent.
Though the study did not examine certain other factors that could influence death rates -- such as obesity and smoking -- Popescu cited consistently higher death rates for black patients between one month and one year after their episode.
The importance of the findings was echoed by other cardiologists and heart surgeons not affiliated with the study.
Dr. Carl Pepine, chief of cardiology at the University of Florida, noted, "These are very important findings that emphasize that we have much important work remaining in the battle against heart disease that is not linked simply to insurance status."
When dealing with a patient who has suffered heart problems, doctors have an array of options, some more aggressive than others.
A stent is a sort of scaffolding that props a clogged artery open. In a bypass surgery, a nonessential vein (like one from the leg) is cut out and used to reroute blood away from the blocked artery that caused the heart attack.
Both can be done on an emergency basis, or can be scheduled if an artery is dangerously close to closing off.
Heart patients who do not receive these treatments instead take medications, such as beta-blockers and aspirin, to prevent another heart attack.
Since not all hospitals have the facilities or the specialists needed to do these procedures, patients who need the treatments are normally transferred to centers that offer this level of care.
But Popescu showed that black patients in these hospitals were less likely to be transferred -- and were not transferred as quickly -- to a hospital that could do bypass or stent procedures. This was true even when they were compared with white patients who had similar pre-existing illnesses and were of the same socioeconomic status.
And no matter what kind of hospital they went to first, black patients still received fewer procedures.
Since all patients were Medicare patients, there was no question of discrimination based on ability to pay for the expensive procedures.
So what could be the reason for the treatment gap?
While researchers have known for a while that black and white patients do not receive the same levels of care in many circumstances, they hotly debate why these differences exist in the current study.
On one side, some experts said that the data can be explained by patient preference.
"Blacks are twice as likely to refuse procedures as nonblacks," said Dr. Peter McCullough of William Beaumont, a teaching hospital near Detroit. "So that explains the lower transfer and revascularization rates."
Pepine acknowledged that, in his experience, some black patients did refuse more aggressive treatment.