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This Article Figures Only Full Text Full Text (PDF) View Online Appendix All Versions of this Article: j.jacc.2005.06.071v1 46/8/1526    most recent Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via ISI Web of Science (3) Citing Articles via Google Scholar Google Scholar Articles by Zacharias, A. Articles by Habib, R. H. Search for Related Content PubMed PubMed Citation Articles by Zacharias, A. Articles by Habib, R. H.

CLINICAL RESEARCH: CARDIAC SURGERY

Operative and Late Coronary Artery Bypass Grafting Outcomes in Matched African-American Versus Caucasian Patients

Evidence of a Late Survival-Medicaid Association

Anoar Zacharias, MD^_*,, Thomas A. Schwann, MD^_*,, Christopher J. Riordan, MD^_*,, Samuel J. Durham, MD^_*,, Aamir Shah, MD^_*, and Robert H. Habib, PhD^_*,,_*

^_* Division of Cardiovascular Surgery, St. Vincent Mercy Medical Center
Department of Surgery, College of Medicine, The Medical University of Ohio, Toledo, Ohio
Department of Medicine, College of Medicine, The Medical University of Ohio, Toledo, Ohio

Manuscript received April 5, 2005; revised manuscript received June 21, 2005, accepted June 27, 2005.

^_* Reprint requests and correspondence: Dr. Robert H. Habib, Cardiopulmonary Research, St. Vincent Mercy Medical Center, 2213 Cherry Street, ACC Bldg, Suite 309, Toledo, Ohio 43608. (Email: Robert_Habib{at}mhsnr.org).

OBJECTIVES: This study sought to determine whether African-American versus Caucasian race is a determinant of early or late coronary artery bypass surgery (CABG) outcomes.

BACKGROUND: African Americans are referred to CABG less frequently than Caucasians and Medicaid coverage is disproportionately common among those who are referred. How these factors affect the relative early and late CABG outcomes in these groups is incompletely elucidated.

METHODS: A retrospective cohort comparison of operative and 12-year outcomes for 304 African-American and 6,073 Caucasian consecutive patients who underwent isolated CABG (1991 to 2003) at an urban community hospital was used. Results were further confirmed in propensity-matched subgroups (n = 301 each).

RESULTS: African Americans were younger (62 vs. 64 years, median), more were female (46% vs. 30%), more were on Medicaid (29% vs. 6.3%) and had more comorbidities. These differences were eliminated after matching. A total of 161 operative and 1,080 late deaths have been documented. Operative mortality was similar (African American versus Caucasian: 3.0% vs. 2.5%; p = 0.81). Unadjusted Kaplan-Meier survival at 1, 5, and 10 years (93.4%, 80.3%, and 66.1% vs. 94.8%, 86.5%, and 71.7%) was worse in African Americans (hazard ratio [HR] = 1.38; p = 0.004), but similar for matched groups (HR = 1.03; p = 0.97). After risk adjustment, race did not predict operative (odds ratio = 1.17; p = 0.69) or late (HR = 1.15; p = 0.28) mortality. However, Medicaid status (HR = 1.54; p < 0.005) predicted worse survival, which was verified in a case-matched Medicaid (n = 469) versus non-Medicaid analysis. The latter showed that in younger Medicaid patients without companion Medicare coverage, late mortality was nearly doubled (HR = 1.96; p = 0.003) with systematically increasing death hazard after the second year.

CONCLUSIONS: African-American race per se is not associated with worse operative or late outcomes underscoring that CABG should be based on clinical characteristics only. Alternatively, Medicaid status, which is more prevalent among African Americans, is associated with worse late survival, especially in non-Medicare patients. Studies are needed to elucidate this late Medicaid-CABG outcome association.

Abbreviations and Acronyms   CABG = coronary artery bypass surgery   CAD = coronary artery disease   CPB = cardiopulmonary bypass   HR = hazard ratio   OM = operative mortality   OR = odds ratio   STS = Society of Thoracic Surgeons   VHA = Veterans Health Administration

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