Blacks' Higher Death Rates May Be Linked to Healthcare Barriers

In the equal-access VA healthcare system, blacks have a lower risk of death than whites, the opposite of what is seen in the general population.
In the equal-access VA healthcare system, blacks have a lower risk of death than whites, the opposite of what is seen in the general population.

Contrary to what is observed in the general U.S. population, all-cause mortality risk is lower among blacks than whites receiving care within the Veterans Health Administration (VHA) system, according to a large cohort study.

The study, led by Csaba P. Kovesdy, MD, of the Memphis VA Medical Center and the University of Tennessee Health Science Center in Memphis, included 2,525,525 white and 547,441 black patients with normal kidney function receiving care in the VHA system. Black race was associated with a significant 24% decreased risk of all-cause mortality and a 37% decreased risk of coronary heart disease compared with their white counterparts in a fully adjusted model, Dr. Kovesdy's group reported online in Circulation. Blacks and whites had similar stroke rates.

In contrast, when the researchers analyzed data from subjects with normal renal function who participated in the National Health and Nutrition Examination Survey 1999–2004, which looks at a nationwide sample of the U.S. general population, they found that blacks had a 42% increased risk of all-cause mortality compared with whites in adjusted analyses.

In an interview, Dr. Kovesdy noted that African Americans experience significantly higher mortality and worse cardiovascular outcomes compared with whites in the general U.S. population. This has been attributed in significant part to the large socioeconomic disadvantage black people face. One aspect of this otherwise extremely complex problem, he said, is access to needed healthcare, which is known to be significantly lower among African Americans.

The researchers hypothesized that the VA healthcare system offers access to healthcare to African American veterans that is not hindered by the typical barriers seen in the community, and this may alleviate the adverse outcomes experienced by blacks.

“Our findings suggest that the health disparities experienced by African American individuals in the U.S. may be alleviated by providing them with free access to needed healthcare,” Dr. Kovesdy told Renal & Urology News. “In an era when the commercialization versus socialization of healthcare is a matter of heated debate, these findings offer important insight into the potential advantages of an equal-access healthcare system.”

Dr. Kovesdy acknowledged that because their study was observational, they are unable to draw firm conclusions about the benefits of an equal-access system. Veterans enrolled in the VA healthcare system may be different from the general population in ways that could explain the study's results through different mechanisms than healthcare access alone.

In an accompanying editorial, Nakela L. Cook, MD, MPH, and George A. Mensah, MD, of the National Heart, Lung, and Blood Institute in Bethesda, Md., commented that the study by Dr. Kovesdy and colleagues “represents a significant contribution to the literature as one of the few studies that demonstrate an attenuation of cardiovascular health disparities among African Americans.”

The implications of these findings, they wrote, depend on the generalizability and ability to extrapolate the findings more broadly both within and outside the VHA healthcare system. “The report lays the foundation for future research that will more deeply probe patient characteristics and patterns of care associated with these outcomes in the VHA.”


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