Ethnic differences in coronary artery revascularisation in New Zealand: does the inverse care law still apply?

BACKGROUND: In 2002 striking differences in cardiac revascularisation rates were reported between New Zealand Maori, Pacific and European ethnicities. This paper examines whether this inequity still exists, taking into account ethnic differences in need. METHODS: Age-standardised time trends in intervention rates for coronary artery bypass grafts (CABG), percutaneous coronary intervention (PCI) and ST elevation myocardial infarction (STEMI) were calculated by ethnicity. Ethnic-specific trends were also calculated in the ratio of observed to expected CABG and PCI interventions based on the rate of hospitalisation with a diagnosis of STEMI. RESULTS: On a per capita basis, standardised CABG intervention rates were significantly higher for Pacific (both sexes) and female Maori than Other throughout 2000-2012, and were significantly higher for Maori males than Other in 2009-12. Population based PCI rates were significantly lower for male Maori from 2000-2012, while for female Maori they were significantly lower in 2000-2004 but significantly higher in 2009-12. However, and despite some improvement since 2000-2004, Maori and Pacific intervention numbers for PCI in 2009-2012 were still 22%-32% lower than expected for the rate of STEMI hospitalisation they experience. Overall revascularisation ratios were significantly lower than expected for Maori (both sexes) and Pacific females. CONCLUSIONS: Large increases in the PCI population intervention rates in Maori and Pacific over the period 2000-2012 have not been sufficient to eliminate inequalities in relation to need, except perhaps for Pacific men.

Different needs or treated differently? Understanding ethnic inequalities in coronary revascularisation rates.

BACKGROUND: Several studies have reported major ethnic inequalities in cardiac revascularisation. This paper attempts to explain why in New Zealand, Maori and Pacific patients may be less likely to receive cardiac revascularisation interventions than Europeans. METHODS: Angiograms of 55 Maori, 45 Pacific and 100 age-sex matched European patients with ST elevation myocardial infarction were reviewed by two cardiologists blinded to the patients' ethnicity to determine ethnic differences in actual and recommended revascularisation likelihood. RESULTS: Maori and Pacific patients were 18% (95% C.I. 6%-29%) less likely to receive cardiac revascularisation procedures compared to European patients. If intervention had been based on the recommendation from blinded angiogram review they would have been 14% (2%-24%) less likely to receive revascularisation. Maori and Pacific were significantly more likely to be recommended for CABG (RR=2.9; C.I. 1.4-5.8) and less likely for PCI (RR=0.60; 0.48-0.75). Maori and Pacific were at significantly higher risk of under-treatment overall (RR=5.0; 1.1-22.8) and for CABG (RR=8.0; 1.0-64.0), but not for PCI (RR=2.0; 0.2-22.1). However these relative risks became non-significant when cases not eligible for surgery due to comorbidities were excluded. CONCLUSIONS: Maori and especially Pacific STEMI patients present with a pattern of ischaemic heart disease that is less amenable to PCI, even after allowing for differences in the number of diseased vessels and diabetes prevalence. The lower likelihood of Maori and Pacific patients receiving recommended CABG is largely explained by higher comorbidity prevalence.

Reducing ethnic disparities in the quality of trauma care: an important research gap.

OBJECTIVE: To identify interventions for reducing ethnic disparities in the quality of trauma care. BACKGROUND: Variation in the quality of health care is recognized as an important contributor to ethnic disparities in many domains of health. Although recent articles document ethnic variations in the quality of trauma care in several countries, strategies that address these disparities have received little attention. METHODS: Systematic review of intervention studies designed to reduce ethnic disparities in trauma care. RESULTS: Our systematic literature review revealed no evaluations of interventions designed to reduce ethnic disparities in trauma care. A scan of the equivalent literature in other health care settings revealed 3 types of strategies that could serve as promising interventions that warrant further investigation in the trauma care setting: (1) improving cultural competency of service providers, (2) addressing the effects of health literacy on the quality of trauma care, and (3) quality improvement strategies that recognize equity as a key dimension of quality. The trauma coordinator role may help address some aspects relating to these themes although reducing disparities is likely to require broader system-wide policies. CONCLUSIONS: The implementation and robust evaluation of strategies designed to reduce ethnic disparities in trauma care are long overdue.