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Disparity and Delay to Chest Pain Treatment Among Minorities

Acute coronary syndrome (ACS) is a leading cause of morbidity and mortality across the globe and particularly in industrialized countries.1 Each year in the United States, approximately 5.5 million people are evaluated at a hospital for chest pain. Chest pain is also one of the most common symptoms associated with acute coronary syndrome.2,3,4 Typical chest pain patients describe a feeling of aching, crushing, stabbing, burning, or squeezing pain that may be accompanied by diaphoresis, jaw pain, arm pain, or back pain.5,6

Delay in response to chest pain symptoms has a profound impact on a patient’s potential outcome. Boersma et al. found that 65 out of 1,000 lives are saved when patients are treated within the first 60 minutes of symptom onset.7 Despite this evidence, researchers have concluded that socio-demographics and clinical factors play a significant role in the delay of definitive care for emergency room visits and requests for pre-hospital care, which impacts a large number of minorities.8,9 There is also evidence for disparity in patient care, which may exacerbate a delay in treatment.

The Institute of Medicine defines health disparities as “differences in the quality of healthcare that are not due to access-related factors or clinical needs, preferences, and appropriateness of interventions.”10 Health disparities in the US exist in several categories, including ethnicity, race, geography, and socioeconomic status. Contributing delays at the health systems level can include access to care, insurance coverage, cultural competency, and the kinds of infrastructure required to address the needs of diverse patients. It has been documented that some of these healthcare system disparities persist after controlling for both socioeconomic and clinical variables.11

To make matters worse, a study focused on minority death rates from ACS showed a 30% increase among African Americans than in non-Hispanic whites.12 Also, patients from racial/ethnic minority groups are generally younger, have another comorbidity (e.g., hypertension, diabetes, obesity), and are more likely to be women.12,13,14 It is also worth mentioning that minority patients with ACS are at greater risk of myocardial infarction (MI), rehospitalization, as well as death from ACS and are less likely to receive potentially beneficial treatments, such as angiography or percutaneous coronary intervention than non-minority patients.15 Data also shows that among African American, Hispanic, and Asian patients who underwent percutaneous coronary intervention, only African Americans had a significant reduction in event-free survival 2-years post-procedure.16 African Americans with acute MI are also younger and are not as likely to receive evidence-based treatments.15 This information demonstrates that a decreased likelihood of undergoing appropriate treatment, compounded by a decreased access to patient care, may intensify disparities in acute MI care.17

In conclusion, eliminating disparities and diminishing a delay in treatment must be a significant goal of the patient, provider, and the healthcare system.18 Improvement will require proactive efforts focused on risk assessment, guideline adherence, and risk-factor control in at-risk populations.19

References

  1. The GRACE Investigators. Rationale and design of the GRACE (Global Registry of Acute
    Coronary events) project: A multinational registry of patients hospitalized with acute coronary syndromes. American Heart Journal. 2001; 141(2): 190-9.
  2. Mittal S. Coronary heart disease in clinical pratice. London: Springer; 2005.
  3. Weber SM, editor. Chest pain: causes, diagnosis, and treatment. New York: Nova Science
    Publishers; 2010.
  4. Australian Institute of Health and Welfare. Australian hospital statistics 2012-13: e emergency department care. Canberra: Australian Unstitite of Health and Welfare, 2013.
  5. DeVon HA, Ryan CJ. Chest pain and associated symptoms of acute coronary syndromes. Journal of Cardiovascular Nursing. 2005; 20 (4):232-8.
  6. Hanson MA, Fareed MT, Argenio SL, Agunwamba AO, Hanson TR. Coronary heart disease. Primary Care: Clinic in Office Practice. 2013; 40:1-16.
  7. Boersma E, Maas ACP, Deckers JW, Simoons ML. Early thrombolytic treatment in acute myocardial infarction: reappraial of the golden hour. Lancet. 1996; 348: 771-75.
  8. Herlitz J, Thuresson M, Svensson L, Lindqvist J, Lindahl B, Zedigh C, et al. Factors of importance for patients’s decision time in acute coronary syndrome. International Journal of Cardiology. 2010; 141: 236-42.
  9. Perkins-Porras L, Whitehead DL, Strike PC, Steptoe A. pre-hospital delay in patients with acute coronary syndrome: factors associated with patient decision time and home-to-hospital delay. European Journal of Cardiovascular Nursing. 2009; 8: 26-33.
  10. Mayberry R, Boone L., Kaiser Henry J. Racial/Ethnic Differences in Cardiac Care: The Weight of the Evidence. Family Foundation. [October 2002].
  11. Vivo RP, Krim SR, Liang L, Neely M, Hernandez AF, Eapen ZJ, Peterson ED, Bhatt DL, Heidenreich PA, Yancy CW, Fonarow GC. Short- and long-term rehospitalization and mortality for heart failure in 4 racial/ethnic populations. J. Am. Heart Assoc. 2014; 3(5):e001134. doi: 10.1161/JAHA.114.001134.
  12. Nasir K, Shaw LJ, Liu ST, Weinstein SR, Mosler TR, Flores PR, Flores FR, Raggi P, Berman DS, Blumenthal RS, Budoff MJ. Ethnic differences in the prognostic value of coronary artery calcification for all-cause mortality. J. Am. Coll. Cardiol. 2007;50(10):953–960. doi: 10.1016/j.jacc.2007.03.066.
  13. Yeo K, Li Z, Amsterdam EA. Abstract 3117: Clinical Characteristics and Operative Mortality Among Whites, Hispanics, Asians and Blacks in the 2003 California Coronary Artery Bypass Graft Surgery Outcomes Reporting Program. Circulation. 2006;114:11–658.
  14. Van Ryn M, Burgess D, Malat J, Griffin J. Physicians’ perceptions of patients’ social and behavioral characteristics and race disparities in treatment recommendations for men with coronary artery disease. Am. J. Public Health. 2006;96(2):351–357. doi: 10.2105/AJPH.2004.041806.
  15. Bonow RO, Grant AO, Jacobs AK. The cardiovascular state of the union: confronting healthcare disparities. Circulation. 2005;111(10):1205–1207. doi: 10.1161/01.CIR.0000160705.97642.92.
  16. Slater J, Selzer F, Dorbala S, Tormey D, Vlachos HA, Wilensky RL, Jacobs AK, Laskey WK, Douglas JS, Williams DO, Kelsey SF. Ethnic differences in the presentation, treatment strategy, and outcomes of percutaneous coronary intervention (a report from the National Heart, Lung, and Blood Institute Dynamic Registry). Am. J. Cardiol. 2003;92(7):773–778. doi: 10.1016/S0002-9149(03)00881-6.
  17. Popescu I, Cram P, Vaughan-Sarrazin MS. Differences in admitting hospital characteristics for black and white Medicare beneficiaries with acute myocardial infarction. Circulation. 2011;123(23):2710–2716. doi: 10.1161/CIRCULATIONAHA.110.973628.
  18. Lurie N, Fremont A, Jain AK, Taylor SL, McLaughlin R, Peterson E, Kong BW, Ferguson TB. Racial and ethnic disparities in care: the perspectives of cardiologists. Circulation. 2005;111(10):1264–1269. doi: 10.1161/01.CIR.0000157738.12783.71.
  19. Watkins LO. Epidemiology and burden of cardiovascular disease. Clin. Cardiol. 2004;27(6) Suppl. 3:III2–III6. doi: 10.1002/clc.4960271503.

Spencer Edwards Spencer Edwards became a certified paramedic in 2000 and has over 20 years of experience in the fire and EMS industries. During most of that time, he has worked for two agencies simultaneously, one in a full-time capacity and the other as a part-time employee. He started his full-time career as a firefighter/paramedic and advanced to the rank of captain. In this position, he has had the opportunity to supervise younger paramedics and yet still has time for hands-on experience. In his part-time role, he started as a firefighter/paramedic. He then was promoted to captain and shortly after that he was promoted to assistant chief. He served in that position for 6 years and gained valuable experience, including taking on the roles and responsibilities of the training officer. Spencer has a passion for teaching and learning and was an adjunct instructor for the Utah Valley University paramedic program for 5 years. In 2013, Spencer received a bachelor’s degree from UVU in emergency services management. He is currently working on a master’s degree in organizational leadership.

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