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CLINICAL RESEARCH: CARDIAC RHYTHM DISORDERS

Trends in implantable cardioverter-defibrillator racial disparity

The importance of geography

Peter W. Groeneveld, MD, MS^*,,,*, Paul A. Heidenreich, MD, MS^,|| and Alan M. Garber, MD, PhD^,||,¶

^* Center for Health Equity Research and Promotion, Veterans Affairs Medical Center, Philadelphia, Pennsylvania
Division of General Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
Veterans Affairs Palo Alto Health Care System, Palo Alto, California
^|| Center for Primary Care and Outcomes Research, Stanford University, Stanford, California
^¶ National Bureau of Economic Research, Stanford, California

Manuscript received April 28, 2004; revised manuscript received July 19, 2004, accepted July 28, 2004.

^* Reprint requests and correspondence: Dr. Peter W. Groeneveld, 1122 Blockley Hall, 423 Guardian Drive, Philadelphia, Pennsylvania 19104-6021 (Email: peter.groeneveld{at}med.va.gov).

OBJECTIVES: The study was designed to determine whether racial disparity in utilization of the implantable cardioverter-defibrillator (ICD) has improved over time, and whether small-area geographic variation in ICD utilization contributed to national levels of racial disparity.

BACKGROUND: Although racial disparities in cardiac procedures have been well-documented, it is unknown whether there has been improvement over time. Low ICD utilization rates in predominantly black geographic areas may have exacerbated national levels of disparity.

METHODS: Discharge abstracts from elderly black and white Medicare beneficiaries hospitalized with ventricular arrhythmias from 1990 to 2000 were analyzed to determine if ICD implantation occurred within 90 days of initial hospitalization. Multivariate logistic regression models were constructed to assess the relationship between ICD implantation, year of admission, and the percentage of black inhabitants in each patient's county of hospitalization while controlling for clinical, hospital, and demographic characteristics.

RESULTS: There was improvement in ICD implantation racial disparity: In the period 1990 to 1992, black patients had an odds ratio of 0.52 (95% confidence interval [CI] 0.42 to 0.64) for receiving an ICD compared with whites. However, by 1999 to 2000, the odds ratio for blacks had risen to 0.69 (95% CI 0.61 to 0.78) (test-for-trend p = 0.01). Approximately 20% of this trend could be explained by reduction in geographic variation in ICD use between areas with larger black and predominantly white populations.

CONCLUSIONS: Rates of ICD implants became more equal among whites and blacks during the 1990s, although persistent disparity remained at the decade's end. Geographic equalization in cardiovascular procedure rates may be an essential mechanism in rectifying disparities in health care.

Abbreviations and Acronyms   CI = confidence interval   ICD = implantable cardioverter-defibrillator   MEDPAR = Medicare Provider Analysis and Review   ZIP = Zoning Improvement Plan

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