Racial Disparities in Prescriptions for Cardioprotective Drugs and Cardiac Outcomes in Veterans Affairs Hospitals

Racial Disparities in Prescriptions for Cardioprotective Drugs and Cardiac Outcomes in Veterans Affairs Hospitals Jawahar L. Mehta, MD, PhDa,*, Zoran Bursac, PhDa, Paulette Mehta, MD, MPHa, Darpan Bansal, MDa, Louis Fink, MDb, James Marsh, MDa, Rishi Sukhija, MDa, and Rajesh Sachdeva, MDa Previous reports have suggested that blacks receive life-saving cardioprotective therapies less often than whites, probably because of a lower socioeconomic status, which leads to poor access to physicians. We questioned whether racial disparity existed in the Veterans Affairs Healthcare System. We examined the Veterans’ Integrated Service Network (VISN 16) database with regard to the prescription rates for 4 cardiovascular agents—aspirin, ␤ blockers, statins, and angiotensin-converting enzyme inhibitors. The database, encompassing 474,565 patients (117,071 blacks and 357,494 whites), was analyzed. Cardioprotective drugs were prescribed significantly less often to black patients than compared to white patients (␤ blockers 19.7% vs 24.8%, odds ratio [OR] 0.74, 95% confidence interval [CI] 0.72 to 0.75; statins 20.5% vs 30.2%, OR 0.54, 95% CI 0.52 to 0.55; and angiotensinconverting enzyme inhibitors 27.7% vs 30.0%, OR 0.94, 95% CI 0.92 to 0.96; all p <0.0001, after adjustment for all covariates used in the analysis). Nonetheless, the prescription rates for aspirin were greater among the black patients than among the white patients (OR 1.31, 95% CI 1.27 to 1.35, p <0.001) after adjustment. The black patients received coronary artery bypass grafting less often than did the white patients (0.4% vs 1.21%, OR 0.40% to 0.48%, 95% CI 1.34 to 1.42, p <0.001). After adjustment for the use of cardioprotective drugs and coronary artery bypass grafting, black patients still had greater odds of developing angina (OR 1.38, 95% CI 1.34 to 1.42, p <0.001) and acute myocardial infarction (OR 1.11, 95% CI 1.03 to 1.19, p <0.006) than did white patients in the Department of Veterans Affairs Veterans’ Integrated Service Network 16 hospitals. In conclusion, the lower prescription rates of cardioprotective drugs and lower rates of coronary artery bypass grafting might be a partial basis for the high rates of cardiac morbidity among black patients. Published by Elsevier Inc. (Am J Cardiol 2010;105:1019 –1023)

It has been suggested that a racial bias might exist in the prescription of cardioprotective drugs that would account for the smaller decrease in coronary heart disease (CHD) mortality in black than in white patients. A very large number of patients are treated at the Department of Veterans Affairs hospitals. The patients in the Department of Veterans Affairs hospitals frequently return to their physicians for management of cardiac conditions, such as angina and acute myocardial infarction (AMI). If the veterans need cardiac procedures, such as cardiac catheterization or coronary artery bypass grafting (CABG), they are provided these at the nearest available Department of Veterans Affairs hospital. The healthcare providers in these hospitals have no financial incentive to withhold care from certain patients. The patients are often elderly and sick and have been receiving a number of drugs for a long period. On the basis of these considerations, we hypothesized that the discrepancies in the prescriptions of cardioprotective drugs and, hence, differences a Central Arkansas Veterans Healthcare System and Department of Internal Medicine, University of Arkansas for Medical Sciences, and Department of Biostatistics, College of Public Health, Little Rock, Arkansas; and bNevada Cancer Institute, Las Vegas, Nevada. Manuscript received September 16, 2009; revised manuscript received and accepted November 10, 2009. *Corresponding author: Tel: (501) 296-1401; fax: (501) 686-6180. E-mail address: [email protected] (J.L. Mehta).

0002-9149/10/$ – see front matter Published by Elsevier Inc. doi:10.1016/j.amjcard.2009.11.031

in outcome, would not be observed in the Department of Veterans Affairs hospitals, because all patients receive the same therapy at no or minimal cost to the patient. Methods The United States Veterans Affairs Healthcare System (Veterans Integrated Service Network [VISN] 16) provides care to ⬎400,000 veterans annually. These patients receive their medical care and drugs free of charge or at minimal cost, ensuring a high degree of compliance with physician recommendations and follow-up visits. Furthermore, the Veterans Affairs Computerized Patient-Care Review System provides detailed information of patient demographics, co-morbidities, laboratory findings, and treatment to all caregivers. This computerized system also provides a unique opportunity to collect data from a large group of patients followed up for a prolonged period. The objective of the present study was to examine the VISN 16 patient care database with regard to use of cardioprotective drugs in blacks and whites. The data were obtained from the VISN 16 Data Warehouse. The VISN 16 Data Warehouse contains clinical and demographic information for all patients cared for at the 10 medical centers included in the South Central Veterans Affairs Healthcare Network in the mid-south region of the United States. The Data Warehouse, implemented in 1996, electronically and automatically retrieves and stores data www.AJConline.org

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Table 1 Patient demographics, coronary risk factors, prescriptions for cardiac medications, and cardiac outcomes

Table 2 Prescriptions for cardioprotective drugs, cardiac outcomes, and coronary artery bypass grafting

Variable

Variable

Age (years) Men Income ($1,000/year) Body mass index (kg/m2) Total cholesterol (mg/dl) Diabetes mellitus Hypertension Depression Angina pectoris Acute myocardial infarction Coronary bypass ␤ Blockers Statins Angiotensin-converting enzyme inhibitors

Whites (n ⫽ 357,494)

Blacks (n ⫽ 117,071)

p Value

65.1 ⫾ 13.8 96.4% 19.7 ⫾ 19.9 28.5 ⫾ 5.6 195 ⫾ 42.1 17.5% 43.7% 14.5% 5.8% 0.92%

58.1 ⫾ 14.8 94.3% 15.2 ⫾ 17.2 28.1 ⫾ 5.8 194.7 ⫾ 43 16.9% 44.5% 14.2% 6.7% 0.94%

⬍0.0001 ⬍0.0001 ⬍0.0001 ⬍0.0001 0.1312* ⬍0.0001 ⬍0.0001 0.0031 ⬍0.0001 0.5489

1.21% 24.8% 30.2% 30%

0.4% 19.7% 20.5% 27.7%

⬍0.0001 ⬍0.0001 ⬍0.0001 ⬍0.0001

Aspirin ␤ Blockers Statins Angiotensin-converting enzyme inhibitors Angina pectoris Acute myocardial infarction Coronary artery bypass grafting

Adjusted OR (Blacks vs Whites)

95% CI

p Value

1.31 0.74 0.54 0.94

1.27–1.35 0.72–0.75 0.52–0.55 0.92–0.96

⬍0.0001 ⬍0.0001 ⬍0.0001 ⬍0.0001

1.38 1.11 0.44

1.34–1.42 1.03–1.19 0.4–0.48

⬍0.0001 0.0061 ⬍0.0001

CI ⫽ confidence interval; OR ⫽ odds ratio.

* Not used in model because of insufficient data.

from all patients entered into the Veterans Affairs computerized system. These data include patient demographics, laboratory test results, vital signs, drugs prescribed, outpatient visit findings, hospitalizations, and International Classification of Diseases (ICD), Ninth Revision and Diagnosis Related Groups codes. The database contained data for approximately 1.5 million patients. Access to the Data Warehouse is monitored and controlled by dedicated data administrators. The institutional review boards of the Central Arkansas Veterans Healthcare System, the related Research and Development Committee, and the VISN-wide committee, which regulates access to the Data Warehouse approved the present study. The pertinent terms used in this study were aspirin, ␤ blocker, statin, and angiotensin-converting enzyme (ACE) inhibitor users—patients in the cohort with a prescription for any of these drugs; hypertension—patients documented to have hypertension on chart review (generally systolic blood pressure ⱖ140 mm Hg or diastolic blood pressure ⱖ90 mm Hg); diabetes mellitus—patients with a diagnosis with an ICD, Ninth Revision, code 250 prefix or a diagnosis with a 401, 405, or 458 prefix; dyslipidemia—patients with a diagnosis with a prefix of 272, including pure hypercholesterolemia, pure hypertriglyceridemia, mixed hyperlipidemia, and hyperchylomicronemia; smoker—patients who reported being a current or previous smoker; CABG—patients with a diagnosis with an ICD code 36.10 to 36.19; angina—patients with a diagnosis with an ICD code of 411.1 to 411.9 and 413.1 to 413.9; and AMI—patients with a diagnosis with an ICD code 410.0 to 410.9. All analyses were performed using Statistical Analysis Systems, version 9.2, software (SAS Institute, Cary, North Carolina). An ␣ level of 0.05 was established as a level of significance for all tests. Baseline comparisons between the 2 race groups and all univariate associations were performed using the 2-sample t test and chi-square test. Seven analytic models were constructed to examine the associations between race and cardiac drug prescriptions and mor-

Figure 1. Odds ratio (and 95% confidence intervals) of use of cardioprotective medications and cardiac outcome in blacks versus whites.

bidities and CABG. Each model consisted of cardiac drug prescription, morbidity (angina and AMI) or CABG as a binary outcome, race as the main independent variable under consideration, and other covariates that were used for adjustment purposes as independent or confounding factors. Multivariate associations between the selected covariates and 7 variables treated as outcomes were therefore examined using logistic regression models. The covariates used in the model included age, gender, income, depression, diabetes, hypertension, smoking status, and cardiac medications, as well as morbidities and CABG, and were not the outcome measure for a given model. Some covariates were used for adjustment purposes across all 7 models for consistency. The nesting of patients within sites was examined using the general estimating equation approach to a logistic model, with compound symmetry as a correlation structure. However, it did not improve any of the models significantly. Therefore, simpler models were adequate and were applied as such without the site variable. Results A total of 1,483,966 patients had data available. We excluded patients for whom the data on demographics were incomplete. We also excluded patients who reported they

Miscellaneous/Race, Cardioprotective Drugs, Outcome Among Veterans

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Table 3 Relation of prescription of cardioprotective drugs with patient demographics, cardiac outcome, cardiac risk factors, and other cardioprotective drugs Variable

Race Age (5 years) Income Acute myocardial infarction Angina Coronary artery bypass grafting Depression Diabetes Hypertension Smoker Aspirin ␤ Blockers Statins Angiotensin-converting enzyme inhibitors

␤ Blocker Use

Aspirin Use

Statin Use

AngiotensinConverting Enzyme Inhibitor Use

OR

95% CI

OR

95% CI

OR

95% CI

OR

95% CI

1.31 1.13 0.90 4.5 3.58 1.56 1.44 1.37 2.04 1.97

1.27–1.35 1.12–13 0.89–0.91 3.95–5.13 3.42–3.74 1.41–1.72 1.39–1.48 1.34–1.42 1.98–2.11 1.88–2.07

0.74 1.02 0.99 4.55 2.98 3.39 1.24 0.91 4.76 1.17 2.49

0.72–0.75 1.01–1.02 0.98–0.99 4.15–4.99 2.88–3.07 3.13–3.67 1.21–1.26 0.9–0.93 4.66–4.86 1.13–1.21 2.44–2.53

2.44 2.24 1.89

2.38–2.51 2.18–2.3 1.84–1.95

0.54 1.02 1.12 1.51 1.69 3.14 1.4 2.11 3.26 1.36 2.22 2.36

0.52–0.55 1.01–1.02 1.11–1.12 1.35–1.68 1.62–1.77 2.79–3.52 1.36–1.44 2.06–2.17 3.17–3.35 1.29–1.42 2.16–2.27 2.29–2.42

2.39 1.76

2.34–2.43 1.73–1.8

0.94 1.05 0.99 2.18 1.25 1.34 0.99 4.54 9.31 0.94 1.85 1.73 1.98

0.92–0.96 1.04–1.05 0.99–0.99 1.99–2.38 1.21–1.29 1.24–1.44 0.97–1.02 4.44–4.63 9.11–9.51 0.91–0.98 1.82–1.89 1.7–1.77 1.94–2.01

1.99

1.94–2.04

Abbreviations as in Table 2.

Table 4 Relation of cardiac outcome to patient demographics, cardiac risk factors, and prescription of cardioprotective drugs Variable

Race Age (5 years) Income Acute myocardial infarction Angina pectoris Coronary artery bypass grafting Depression Diabetes mellitus Hypertension Aspirin ␤ Blockers Statins Angiotensin-converting enzyme inhibitors

AMI

Angina Pectoris

CABG

OR

95% CI

OR

95% CI

OR

95% CI

1.11 1.01 0.92

1.03–1.19 0.99–1.02 0.9–0.95

1.38 1 0.94 2.94

1.34–1.42 0.99–1.01 0.93–0.95 2.75–3.13

2.9 1.62 0.97 0.96 0.86 4.58 4.47 1.59 2.04

1.71–3.11 1.44–1.83 0.9–1.05 0.9–1.03 0.78–0.94 4.19–5.01 4.07–4.9 1.47–1.72 1.87–2.22

0.44 1.18 1.05 1.67 2.68

0.4–0.48 1.17–1.20 1.04–1.06 1.5–1.86 2.52–2.84

2.7 1.35 1.1 1.63 3.67 3.05 1.81 1.36

2.53–2.89 1.3–1.39 1.07–1.13 1.57–1.7 3.56–3.78 2.95–3.15 1.76–1.87 1.32–1.41

1.01 1.19 1.10 1.77 3.50 3.55 1.44

0.94–1.08 1.12–1.26 1.02–1.20 1.66–1.88 3.25–3.76 3.29–3.83 1.35–1.54

Abbreviations as in Table 2.

were Hispanic, Asian, Native American, or other and those who did not reveal their race. Complete data were available for 474,565 patients (117,071 blacks and 357,494 whites). The demographic patient characteristics (age, gender, and annual income), CHD risk factors, cardiac medications, cardiac outcome (angina, AMI, and CABG) are listed in Table 1. Black patients were younger (by 6.5 years) and had a lower income than did white patients. The black patients had a lower body mass index and a lower incidence of depression than the white patients. As expected, the black patients had greater rates of hypertension than the white patients. Before adjustment for covariates, the crude rates of prescriptions for ␤ blockers, statins, and ACE inhibitors were significantly lower among blacks than among whites, but the prescription rates for aspirin were similar in the 2 groups. Cardiac events such as angina and AMI occurred more often in blacks than in whites. The black patients had also undergone CABG less often than had the white patients.

Next, we adjusted the rates for the prescription of cardiac medications, cardiac events, and CABG for all variables mentioned in the analysis section. The data (Table 2) showed that the odds of blacks receiving prescriptions for ␤ blockers, statins, and ACE inhibitors were 26%, 46%, and 6% lower than for whites (all p ⬍0.0001); however, but the odds of receiving a prescription for aspirin were 31% greater than that for whites (p ⬍0.001). Black patients had a risk of experiencing angina and AMI that was 38% and 11% greater than for white patients (p ⬍0.0001 and p ⬍0.006, respectively). Finally, the risk of black patients undergoing CABG was 56% lower than that of white patients (p ⬍0.0001). The differences in the prescription of cardioprotective drugs, cardiac events, and CABG rates between blacks and whites are shown in Figure 1. The odds of receiving a prescription for aspirin, ␤ blockers, statins, and ACE inhibitors increased with patient age. Increases in income, or a greater income, were associated

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with greater odds of statin prescriptions. In contrast, it was just the opposite for prescriptions of aspirin, ␤ blockers, and ACE inhibitors (Table 3). The odds of receiving a prescription for aspirin, ␤ blockers, statins, and ACE inhibitors increased with the diagnosis of angina or AMI or with the use of CABG (all p ⬍0.001). Furthermore, the odds of prescriptions for aspirin, statins, and ACE inhibitors increased, but that for ␤ blockers decreased, with the diagnosis of diabetes (p ⬍0.001). The prescriptions for aspirin were positively associated with patients receiving the other 3 drugs. This pattern was observed with each cardioprotective drug (Table 3), suggesting that physicians tended to prescribe combinations of these 4 drugs to their patients. The odds of angina and AMI were greater in the black patients and showed an inverse relation with the patient’s annual income (p ⬍0.001; Table 4). The odds of angina increased with the presence of depression, diabetes, and hypertension (all p ⬍0.001). Even after adjustments for the multiple variables mentioned, the odds of black patients undergoing CABG were significantly lower than the odds for the white patients (p ⬍0.001). Unlike angina and AMI, the odds of undergoing CABG increased with greater income. CABG was also associated with the diagnosis of angina and AMI and the prevalence of diabetes (all p ⬍0.001). The diagnosis of angina or AMI and CABG were associated with significantly greater odds of the use of aspirin, ␤ blockers, statins, and ACE inhibitors (all p ⬍0.001; Table 4). Discussion This very large database of United States Veteran patients has provided evidence of major disparity in the prescription of cardioprotective drugs, such as aspirin, ␤ blockers, statins, and ACE inhibitors. We also found evidence for greater rates of angina and AMI and lower rates of CABG among the black patients. We found that the rates of diabetes and depression were lower and of hypertension were higher in the black patients than in white patients. Black patients had a significantly lower income than the white patients. The racial differences in income and the prevalence of diabetes, depression, and hypertension are consistent with previous studies.1,2 The striking observation was the low prescription rates for ␤ blockers, statins, and ACE inhibitors in black patients. The prescription of these drugs, especially statins, correlated independently with white race and greater patient income. However, blacks who often have lower income received prescriptions for aspirin more often did whites. This is particularly intriguing that these differences between blacks and whites in the prescription of cardioprotective drugs took place in the Department of Veterans Affairs hospitals, where caregivers have no financial reason to show a bias toward patients according to race or income. It is noteworthy that the prescription rates of aspirin to blacks were greater that would further confirm our supposition that healthcare providers might be treating blacks with aspirin rather than using more “expensive” medications. The greater rates of angina or AMI diagnosis and lower rates of CABG in blacks than in whites in the Department of Veterans Affairs hospitals are also noteworthy. The diagnosis of angina and need for CABG were associated with

several known CHD risk factors. Patients with the diagnosis of angina or AMI and those undergoing CABG were associated with increased odds of receiving cardiac medications. These observations indirectly suggest that the lower rates of prescriptions for cardioprotective drugs, aspirin, ␤ blockers, statins, and ACE inhibitors, might relate to the more frequent diagnosis of angina and AMI. CABG provides relief from angina symptoms and might prolong life in selected patients.3–5 Lower rates of CABG in blacks might relate to the more frequent diagnosis of angina and AMI. Because the racial disparity remained for the cardiac outcomes and CABG, even after the adjustments for cardioprotective drugs and other covariates, it is likely that some other factors, such as genetic differences in the biology of the disease and its natural history are involved that could further explain the gap. The racial differences identified in this large database are comparable to previous reports of lower prescription rates of cardioprotective drugs in blacks and Hipanics.6 –9 Stern et al10 first examined 1970 and 1980 census data to compute the death rates in Mexican Americans and non-Hispanic whites from Texas for the periods 1969 to 1971 and 1979 to 1981. They found that the decrease in the death from AMI was least marked in Mexican-American men. This ethnic group was also the only one that failed to show a decrease in death rates secondary to chronic CHD. Among women, CHD mortality was greater among blacks at the beginning of this period, and the average annual percentage of decrease was only 2/3 that of whites. As a result, the absolute mortality gap between blacks and whites steadily increased from 19% to 33% (1980 to 1991). The Centers for Disease Control found that CHD death rates decreased for all age groups during 1981 to 1995; however, the decrease was greater for whites than for blacks, causing an increase in the black/white CHD mortality ratios. Furthermore, the disparity in CHD death rates between blacks and whites in the younger age groups increased and extended into older age groups during this period. By 1991 to 1995, the black/white mortality ratios were ⬍1.0 only in the 75- to 84-age group and ⱖ85-yearage groups for men and in the ⱖ85-year-age group for women. In addition, among the older age groups, for which death rates for whites exceeded those for blacks, the gap appeared to be closing over time, with the black/white mortality ratios increasing toward 1.0. An analysis of data released by the National Center for Health Statistics does not explain why death rates continue to decrease. Studies have suggested that people are eating better, smoking less, and receiving better medical care than Americans of previous generations. These advances did not benefit everyone. The death rate for blacks decreased by 23.8% compared to 25.6% for whites.11,12 Peterson and Yancy13 have commented on the racial or ethnic disparities in healthcare with special regard to expensive cardiac invasive procedures such as cardiac catheterization, percutaneous coronary intervention, CABG, cardiac transplantation, and the implantation of resynchronization devices and defibrillators. Also, delayed use of device therapy for heart failure and drug-eluting stents was present for black patients compared to white patients.

Miscellaneous/Race, Cardioprotective Drugs, Outcome Among Veterans

The reasons for a smaller decline in CHD mortality in blacks are many. Any observed ethnic differences are likely to be caused by a complex of cultural, sociodemographic, and genetic factors. Blacks tend to be of lower socioeconomic status than whites. Lower socioeconomic status is a strong correlate of greater CHD morbidity and mortality rates. Clark et al14 showed that among patients receiving treatment for dyslipidemia, blacks were more likely to be in the greatest risk category and less likely to be using lipidlowering therapy, taking high-efficacy statins and receiving care from a subspecialist; however, the difference in goal achievement remained significant (p ⬍0.001) after adjustment for these and other predictors of treatment success. Nevertheless, studies have shown that blacks with AMI are less likely than whites to be diagnosed, to receive appropriate drug therapy, or to undergo CABG. However, no data have suggested established treatments and secondary prevention strategies are less effective in blacks. Appropriate therapy for secondary prevention—including thrombolysis, antiplatelet strategies, ACE inhibition, ␤ blockade, and lipid-lowering therapies—results in significant reductions in mortality for all patients.15 To us, the most striking part of the observations made in the present study was these racial differences were taking place in the Veterans Affairs hospitals, which represent perhaps the model of equal access care system in the United States. A number of other factors, in addition to the prescription and use of cardioprotective drugs that could have affected the incidence of CHD events and CABG in our study population. Black patients in our large database were somewhat younger and had lower body mass index than the whites. These differences in blacks and whites are at variance from previous studies. However, the data were collected in an unbiased fashion by those other than the investigators. It is possible that lower body mass index in blacks can be attributed to their younger age than whites. We performed multivariate analysis to rule out the effect of the demographics and risk factors on angina and AMI diagnosis or CABG. After the analysis of data, we think that the smaller use of cardioprotective drugs and increase in the odds for the diagnosis of angina and AMI among blacks were not chance observations. Our study was determined using data mining, which has inherent limitations. The main disadvantage of data mining is that the information is only as good as the data that goes into the database. The mining procedure itself is fraught with pitfalls. Because of the enormous sample size, even the smallest effect, although not clinically meaningful might be highly statistically significant. A major advantage of data mining-based studies is that unbiased information can be obtained on data sets that are so large that they would be inconceivable in a traditional patient-based setting. Thus, data mining offers an opportunity to examine clinically important questions with unparalleled statistical power in the present study, the aggregate data were validated by querying the database through different models to obtain relevant information and yet the relationships remained consistent. One of the major limitations of the present study was the absence of data on the time patterns for the relation between the use of cardioprotective drugs and the occurrence of

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angina and AMI or CABG; therefore, we would not make any causal inferences. However, because patients with angina and AMI had greater odds of receiving cardioprotective drugs, it appears that the underuse of cardioprotective drugs was related to the diagnosis of angina and AMI. Underuse of CABG might also have been related to more frequent diagnosis of angina and AMI in the black patients. Another limitation of the study was the precise definition of black and white. It is well recognized that the American black and white gene pool has a number of commonalities because of racial intermixing over centuries. We chose patients’ self-definition of race when considering the use of cardioprotective medications and clinical outcomes. Although this might not be entirely accurate, some characteristics were well-defined, such as differences in risk factors and income in blacks and whites that became readily apparent. 1. Brown AF, Gregg EW, Stevens MR, Karter AJ, Weinberger M, Safford MM, Gary TL, Caputo DA, Waitzfelder B, Kim C, Beckles GL. Race, ethnicity, socioeconomic position, and quality of care for adults with diabetes enrolled in managed care: the Translating Research Into Action for Diabetes (TRIAD) study. Diabetes Care 2005;28:2864 –2870. 2. Liao Y, Cooper RS. Continued adverse trends in coronary heart disease mortality among blacks, 1980 –91. Public Health Rep 1995;110: 570 –572. 3. Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, Stahle E, Feldman TE, van den Brand M, Bass EJ, Van Dyck N, Leadley K, Dawkins KD, Mohr FW. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med 2009;360:961–972. 4. Lawrie GM, Morris GC Jr, Glaeser DH. Influence of diabetes mellitus on the results of coronary bypass surgery: follow-up of 212 diabetic patients ten to 15 years after surgery. JAMA 1986;256:2967–2971. 5. Coronary angioplasty versus coronary artery bypass surgery: the Randomized Intervention Treatment of Angina (RITA) trial. Lancet 1993; 341:573–580. 6. Briesacher B, Limcangco R, Gaskin D. Racial and ethnic disparities in prescription coverage and medication use. Health Care Financ Rev 2003;25:63–76. 7. Scirica BM, Moliterno DJ, Every NR, Anderson HV, Aguirre FV, Granger CB, Lambrew CT, Rabbani LE, Sapp SK, Booth JE, Ferguson JJ, Cannon CP. Racial differences in the management of unstable angina: results from the multicenter GUARANTEE registry. Am Heart J 1999;138:1065–1072. 8. Trivedi AN, Zaslavsky AM, Schneider EC, Ayanian JZ. Trends in the quality of care and racial disparities in Medicare managed care. N Engl J Med 2005;353:692–700. 9. Holm S. Pharmacogenetics, race and global injustice. Dev World Bioeth 2008;8:82– 88. 10. Stern MP, Bradshaw BS, Eifler CW, Fong DS, Hazuda HP, Rosenthal M. Secular decline in death rates due to ischemic heart disease in Mexican Americans and non-Hispanic whites in Texas, 1970 –1980. Circulation 1987;76:1245–1250. 11. National Heart, Lung, and Blood Institute. Highlights of success and accomplishments. Seventh Annual Public Interest Organization Meeting, January 30 –31, 2006, Bethesda, Maryland. Available at: www. usatoday.com/news/health/2008-01-22-heart-disease_N.htm. Accessed: January 24, 2008. 12. Kung H-S, Hoyert DL, Xu J, Murphy SL. Deaths: final data for 2005. Natl Vital Stat Rep 2008;56:1–120. 13. Peterson E, Yancy CW. Eliminating racial and ethnic disparities in cardiac care. N Engl J Med 2009;60:1172–1174. 14. Clark LT, Maki KC, Galant R, Maron DJ, Pearson TA, Davidson MH. Ethnic differences in achievement of cholesterol treatment goals: results from the National Cholesterol Education Program Evaluation Project Utilizing Novel E-Technology II. J Gen Intern Med 2006;21: 320 –326. 15. Yancy CW. Improving outcomes in the post-myocardial infarction setting. J Clin Hypertens 2004;6:34 – 41.