Minority patients wait longer for angioplasty

Researchers say the choice of hospital is a bigger factor than differential treatment in the hospital.

Minority patients with heart attack symptoms wait longer for treatment than whites do, according to a recent study led by Harlan M. Krumholz, M.D., M.Sc., professor of medicine (cardiology), and Elizabeth H. Bradley, Ph.D. ’96, associate professor of public health (health policy and administration). But waiting time appears to have more to do with the choice of hospital than any conscious decision by health care providers to discriminate based on race or ethnicity.

For the study, published in the October 6 issue of JAMA: The Journal of the American Medical Association, researchers examined data from the National Registry of Myocardial Infarction (NRMI) to determine how much time elapsed between a patient’s arrival at the hospital and the start of either drug therapy or balloon angioplasty. Records of more than 110,000 heart attack patients treated between January 1999 and December 2002 were analyzed.

At first glance, the results showed that door-to-drug times for minority patients were significantly longer—up to seven minutes for African-Americans—than for white patients, while door-to-balloon times for this group were almost 19 minutes longer. However, once the study factored in the hospitals that were offering treatment, these differences were substantially reduced: it took about five minutes more for African-Americans to receive drugs and nine minutes more for balloon intervention. For other ethnic groups, the differences were reduced even further.

“People who get care quicker when they are having a heart attack are more likely to live, so this is an important difference to understand and address,” said Bradley. “The biggest insight from this paper was that it seems as if there were two levels of difference going on,” said Krumholz. “There’s the level where race/ethnicity differences exist, and although they’re small, they’re disturbing and need to be understood. But a bigger part of the overall difference in treatment by race and ethnicity seems to be explained by the hospitals that people are going to.”

Previously, researchers assumed that racial and ethnic disparities were due to differential treatment inside the hospital, without considering the possibility that hospitals that treat greater numbers of minority patients do not offer the same level of care as hospitals that treat fewer minority patients. “Our finding suggests that the issue is bigger than differential treatment inside the hospital. Minority patients tend to be treated at hospitals with poorer quality in this area generally,” Bradley said.

The study suggests that efforts focusing solely on racial and ethnic disparities will fall short in improving patient care. Hospitals need to examine how they’re delivering care and formulate systems that address inadequacies. “As one solution, we should really identify the characteristics and key processes that raise the quality of hospitals generally and ensure that we target these kinds of improvement efforts in hospitals that have poorer quality indicators, many of which are hospitals where minorities receive their care,” Bradley said.

—Jill Max

Camera in a pill gives an unprecedented view of the small intestine

When the White Queen assured Alice in Wonderland that she was able to believe “as many as six impossible things before breakfast,” the idea of swallowing a tiny camera first thing in the morning was probably not on her list.

But thanks to a new procedure called video capsule endoscopy, some patients with gastroenterological symptoms are doing just that. The camera, enclosed in a pill about the size of a large vitamin supplement, is swallowed early in the morning on an empty stomach; the patient drinks water two hours later and eats a light lunch two hours after that to encourage the gastric and intestinal contractions that move the video capsule along. During its eight-hour passage through the digestive tract, the camera transmits images of the small intestine to a monitoring device around the patient’s waist. The resulting pictures, downloaded into a computer, allow the clinician to see parts of the small intestine that are not visible through a regular endoscope.

According to Deborah D. Proctor, M.D., associate professor of medicine (digestive diseases), who has been using the technique since it was introduced at Yale last spring, it is helpful in diagnosing hidden gastrointestinal bleeding where upper endoscopy and colonoscopy are inconclusive. It is also useful in obtaining information about management of chronic problems such as Crohn’s disease, which depends on the degree to which the disease is located in the small intestine. “Upper endoscopy shows only about a foot of small intestine,” Proctor noted. “The enteroscope shows only about another 6 to 8 feet—a total of about one-third to one-half of the small intestine. With the camera we can see the entire small intestine in about 85 percent of patients who undergo the procedure.”

Scanning technology—using a camera at the end of a scope to transmit data, as is done with an endoscope—has been around for about 15 years, while fiber optic technology has been around for about 30 years. What is new here is the camera-inside-the-pill—a technique that originated in Israel four years ago and is currently in use at Yale and 250 other facilities around the country.

“The procedure is totally noninvasive; no radiation is involved, there is no discomfort and no need for sedation,” she said. “Once the camera and belt are in place, patients can go about their normal day.”

The only contraindication is for those patients whose GI tracts might be obstructed, preventing the capsule from moving through. For all others the capsule moves painlessly through the GI tract and is excreted.

“This is so safe that we’ve started using it with children—as long as they weigh over about 50 pounds,” Proctor said. “Being able, for instance, to see active bleeding and know exactly where it is coming from has great potential to improve GI disease diagnosis and management.”

—Rhea Hirshman

Et Cetera

Melanin can be good, or bad

It’s common knowledge that blondes and redheads need more protection from the sun to prevent skin cancer, but a Yale scientist may have discovered why. The culprit may be the melanin in the follicles of light-colored skin, Douglas E. Brash, Ph.D., professor of therapeutic radiology and genetics, reported in a study published in the Proceedings of the National Academy of Sciences in October.

Brash began his research to determine why fair-skinned but dark-haired people were less vulnerable to skin cancer than blondes or redheads. He found that among the fair-haired, melanin, the source of skin and hair color which usually protects the skin from ultraviolet (UV) rays, actually magnifies the rays’ damaging effects. For the study, he irradiated mice of various hair colors with UV rays and found pronounced cell death in yellow-haired mice.

“What this tells us is that melanin is not just good for you, it can also be bad,” Brash said. “It depends on the color of your particular melanin.”

—John Curtis

Gambling and elder health

A study by Yale researchers published in The American Journal of Psychiatry in September has found a link between good health and gambling among the elderly. Younger gamblers, however, show high rates of alcohol use and abuse, substance abuse, depression, incarceration and bankruptcy.

In a telephone survey of 2,417 adults, gamblers 65 and older were far more likely to describe their health as excellent or good, but the researchers haven’t determined why. One theory is that better health enables older people to take part in activities including gambling.

“Although the underlying reasons remain hypothetical, proposed reasons included the increased activity, socialization and cognitive stimulation that are related to engaging in gambling,” said Rani Desai, M.P.H. ’91, Ph.D. ’94, associate professor of psychiatry and public health and one of the authors of the report. “Such a mechanism would be consistent with the literature on healthy aging, which indicates that more socially and cognitively active elders are, in general, healthier.”

—J.C.


			Originally published in Yale Medicine, Spring 2005. Copyright © 2005 Yale University School of Medicine. All rights reserved.