Higgins R S, Paone G, Borzak S, Jacobsen G, Peterson E, Silverman N A
Division of Cardiac and Thoracic Surgery, Henry Ford Hospital, Detroit, MI 48202, USA.
Circulation. 1998 Nov 10;98(19 Suppl):II46-9; discussion II49-50.
Black patients with coronary artery disease have a higher mortality rate than white Americans. They also have a higher prevalence of hypertension, diabetes mellitus, and renal disease, which may have an effect on mortality rates. The deleterious effect of these comorbidities may be exacerbated by impaired access to secondary prevention strategies and longitudinal care. Therefore, the presence or absence of comprehensive care as indicated by payer status may then affect survival on surgically treated patients. In this study we examined the role of cardiovascular risk factors and insurance carrier status on early outcomes of coronary artery bypass grafting (CABG) surgery in blacks versus white Americans.
From January 1990 to December 1996, 2776 patients (2003 men, 773 women; mean age 63 +/- 10 years), underwent isolated CABG in a multispecialty practice serving a major metropolitan population. There were 494 (17.8%) black patients and 2282 (82.2%) white patients. The proportion of black patients in each payer category was 17.8% commercial, 14.1% managed care, 52.9% Medicaid, and 19.5% Medicare. The effect of preoperative risk factors, including status of operation (elective, urgent, or emergent), sex, race, redo CABG, presence of renal disease, diabetes mellitus, congestive heart failure, myocardial infarction, the completeness of revascularization, age, and left ventricular ejection fraction were analyzed with the chi 2 test for categorical variables and the Student t test for age and ejection fraction. A multiple logistic regression analysis was performed to assess the effect of all variables on mortality rates simultaneously. Black patients had a higher incidence of diabetes mellitus, hypertension, and renal disease than white patients (P < 0.001). Overall, 30-day mortality rate was 2.5% (58 of 2282) in white patients versus 5.5% (25 of 494) for black patients (P < 0.003). Multivariate analysis showed that only emergency surgery status (OR 3.59, P < 0.01), redo CABG (OR 3.78, P < 0.001), hypertension (OR 2.32, P < 0.03), history of congestive heart failure (OR 2.1, P < 0.004), older age (OR 1.07, P < 0.001), and low ejection fraction (OR 0.98, P < 0.003) correlated with mortality rates. Race and payer status were not significant predictors of death.
These data on CABG surgery in black patients suggest that early death is due to associated risk factors and not due to race or insurance payer status.
患有冠状动脉疾病的黑人患者死亡率高于美国白人。他们患高血压、糖尿病和肾病的比例也更高，这些疾病可能对死亡率产生影响。获得二级预防策略和长期护理的机会受损可能会加剧这些合并症的有害影响。因此，付款人身份所表明的全面护理的有无可能会影响接受手术治疗患者的生存率。在本研究中，我们探讨了心血管危险因素和保险承保人身份对黑人与美国白人冠状动脉旁路移植术（CABG）早期结局的作用。
1990年1月至1996年12月，2776例患者（2003例男性，773例女性；平均年龄63±10岁）在一家为大城市人口服务的多专科诊所接受了单纯CABG手术。其中有494例（17.8%）黑人患者和2282例（82.2%）白人患者。每个付款人类别中的黑人患者比例分别为：商业保险17.8%，管理式医疗14.1%，医疗补助52.9%，医疗保险19.5%。术前危险因素的影响，包括手术状态（择期、紧急或急诊）、性别、种族、再次CABG、肾病、糖尿病、充血性心力衰竭、心肌梗死、血运重建的完整性、年龄和左心室射血分数，对于分类变量采用卡方检验，对于年龄和射血分数采用学生t检验进行分析。进行多因素逻辑回归分析以同时评估所有变量对死亡率的影响。黑人患者患糖尿病、高血压和肾病的发生率高于白人患者（P<0.001）。总体而言，白人患者的30天死亡率为2.5%（2282例中的58例），而黑人患者为5.5%（494例中的25例）（P<0.003）。多变量分析显示，只有急诊手术状态（比值比3.59，P<0.01）、再次CABG（比值比3.78，P<0.001）、高血压（比值比2.32，P<0.03）、充血性心力衰竭病史（比值比2.1，P<0.004）、年龄较大（比值比1.07，P<0.001）和射血分数较低（比值比0.98，P<0.003）与死亡率相关。种族和付款人身份不是死亡的显著预测因素。
这些关于黑人患者CABG手术的数据表明，早期死亡是由于相关危险因素，而非种族或保险付款人身份。
