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  • Quality of Life in Veterans with Ischemic Heart Disease: DISCUSSION


Numerous published reports have documented ethnic differences in the receipt and outcomes of care between African-American and Caucasian patients in a variety of settings. Many of these studies have been based upon administrative data relating to hospitalization. This analysis represents one of the few attempts to investigate the existence of such differences in the primary care setting using data collected directly from patients. We found that African Americans with ischemic heart disease had higher levels of self-reported risk factors for ischemic heart disease, such as smoking, diabetes and hypertension but reported having received fewer cardiac procedures. Surprisingly, however, African Americans reported better physical function, vitality, and angina stability than Caucasians—a difference that persisted after adjustment for socioeconomic covariates and stratification by site. We also observed lower scores on the mental health scales of the SF-36 among African Americans compared with Caucasians, but these differences did not persist consistently across sites after adjustment. Notably, African Americans reported significantly lower satisfaction with the care for their IHD compared to Caucasian patients, and these differences persisted at half of our sites after adjustment.

Although many studies have evaluated health-related quality of life in veteran patients, few studies have examined ethnic differences. In a longitudinal study conducted in the general veteran population, Kazis and colleagues found that, taken together, the covariates ethnicity, age, marital status, education, and income accounted for only 4% of the variability of the PCS and 10% of the variability of the MCS. The population studied, however, was 92% Caucasian. In our study, African-American veterans represented 16% of the study sample. Of interest, mean and predicted values for both African Americans and Caucasians were substantially lower than those values reported from both a general VA population, and a national sample of patients with a history of myocardial infarction studied as part of the Medical Outcomes Study, which reflects the high level of chronic illness among patients who receive primary care from VA facilities.
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Figure 1. ACQUIP Study Design and Flow Chart

Figure 1. Ethnic differences in satisfaction and quality of life in veterans with ischemic heart disease.

Consistent with results from other population-based studies, the current study also found significant regional variation in results. Lee and colleagues found medical care treatment for Medicare recipients varied significantly by ethnicity and by geographic location; African-American-Caucasian disparities were largest in southern states. In contrast, Weitzman and colleagues found lower rates of invasive procedures among African Americans, but there was no significant variation by geographic location. In addition, using ACQUIP study data, Au and colleagues reported statistically significant though small regional variations in health status. In the present study, African-American-Caucasian disparities in quality of life appeared more consistently in eastern/southeastern states compared with northwestern and western states. This result may represent limited statistical power rather than an absence of true differences given that there were relatively fewer African-American patients at sites outside of the east/southeast.

Our results concerning condition-specific quality of life in patients with were at variance with those found in the literature. Bosworth and colleagues evaluated quality of life in patients with documented ischemic heart disease and found that crude and adjusted scores for health-related quality of life among African Americans were significantly higher for general health, social function, mental health and vitality compared with Caucasians. Reporting on ethnic differences in health-related attitudes toward cardiovascular procedures in patients with IHD, Kressen and colleagues found no ethnic differences in perception of disease severity, patient satisfaction with the decision-making process or satisfaction with VA physicians or of care received. We found that African-American patients had scores on the anginal frequency and stability scales of the SAQ that were comparable to those of Caucasian patients at most sites. They did have lower scores on the SAQ disease perception scale, but this disparity was no longer significant at four of six sites after adjustment for sociodemographic and other variables. However, because this is the first report of the use of the SAQ in a minority population, direct comparisons with other reports from minority populations are limited.
In unadjusted comparisons of the two SOSQ scales and the satisfaction scale of the SAQ, we found that African Americans demonstrated greater dissatisfaction with their healthcare when compared with Caucasians. However, after adjustment for sociodemographic factors and comorbidity, these disparities were no longer consistently apparent across all sites. Although these results are at odds with those of some investigators who have found lower satisfaction among African-American patients compared with Caucasian patients, the results are consistent with the findings in other studies. Among hospitalized veterans, Young et al. found that non-Caucasian veterans reported lower satisfaction for both inpatient and outpatient care than Caucasians. In a study using the Medical Outcomes Study database, Meredith and Siu found that patient satisfaction was slightly lower among African Americans than among Caucasians.

In contrast to those findings, there are several other studies that, like ours, have demonstrated similar levels of satisfaction between African-American and Caucasian patients. For example, in a large health maintenance organization, Murray-Garcia reported that African Americans were similarly satisfied when compared with Caucasians. Taira and colleagues found that overall satisfaction, trust, interpersonal treatment, organizational access, longitudinal continuity, or comprehensive scope of care did not differ significantly between African Americans and Caucasians, in a university hospital primary care group practice. In addition, Kressen and colleagues also showed that there was no variation in satisfaction between African Americans and Caucasians with IHD. The fact that these more recent studies, along with our results, fail to demonstrate systematic differences in satisfaction between African-American and Caucasian patients may indicate that a number of other factors may modify any effect of ethnicity on satisfaction. Cooper-Patrick determined that race-concordance and a participatory style between patient and physician were associated with greater satisfaction for African Americans when compared with Caucasians. Other studies have shown that in addition to ethnicity, age, marital status, socioeconomic status, health status, and type of health system where care is received all influence a patient’s satisfaction with his or her healthcare. Although limited cardiovascular disease data are available with which we can compare our data directly, our results do suggest that in a medical system where access to care is independent of ability to pay, ethnicity may not be an important determinant of satisfaction. canadian pharmacy generic viagra

Our study had several strengths, one of which includes a large sample of ethnically diverse patients. The Department of Veterans Affairs is the largest integrated health system in the United States and serves a diverse patient population. Eligibility for care is largely based on factors other than ability to pay. In addition, we used two reliable, valid, and responsive measures of health to evaluate quality of life and satisfaction in a population where quality of life has not been well-characterized.

This study, however, also had several potential limitations. First, there is the possibility of response bias. Although there were some statistically significant differences between patients who participated in the study and those who did not, most of these were relatively minor. A second limitation is that IHD and comorbid conditions were identified via a combination of self-report and information obtained from the electronic medical record. The frequency of inaccuracies based on patients’ self-report was, however, apt to have been low given that our previous research has shown that our diagnostic criteria for IHD using self-report had a specificity of 93% of patients with angina and the criteria for COPD had a specificity of 98%. Third, our patient population was composed mainly of a sample of chronically ill, elderly men, and our findings cannot be generalized to other groups. Finally, ethnic concordance between a patient and his or her provider is significantly related to satisfaction, and we did not collect information on the ethnicity of providers. buy cialis soft tabs

In summary, among patients with ischemic heart disease followed in the GIM clinics of six VA medical centers, we observed ethnic differences in reported general health and quality of life. Ethnic differences in satisfaction with the provider and medical system, and disease-specific health as measured by angina perception, satisfaction with and treatment for cardiovascular disease were not sustained at all sites after adjustment and stratification by geographic site. In this large medical system where financial barriers to care are minimal, ethnic differences in satisfaction with patients’ providers and their medical treatment were site-specific.

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