Higher Risk of Death Among African-Americans with PH Linked to Insurance Status in Study

African-Americans with pulmonary hypertension and without health insurance have a two-fold increased risk of dying of this disease compared to white Americans, possibly because of delays in referral and treatment, a retrospective study reports.

The study “Health Insurance and Racial Disparities in Pulmonary Hypertension Outcomes,” published in The American Journal of Managed Care (AJMC), also found that if insurance differences — public versus private, especially — were not a factor, survival rates between these two groups were similar.

The prevalence of pulmonary hypertension is equivalent among black and white populations in the U.S. — 6.6% and 6.8%, respectively. However, blacks have a worse prognosis when compared to whites for reasons that remain poorly understood.

“We sought to investigate the association of race with survival in a population of patients referred to 2 large tertiary care centers for invasive evaluation of pulmonary hypertension,” the researchers wrote. “Additionally, given that cost may be a barrier to pulmonary arterial hypertension medications, associated equipment for intravenous/inhaled administration, and specialized care, we investigated the role of insurance status on mortality.”

Specifically, the team looked at possible links between disease characteristics, insurance status and race, compared with clinical outcomes.

In total, 250 patients with pulmonary hypertension – 82% white and 18% black – who were undergoing their first clinical evaluation at two academic referral centers, the Duke University Medical Center and Cleveland Clinic were included in the study.

The team collected data on the patients’ insurance status (Medicare, Medicaid, private, self-pay), and from exams assessing their heart and blood flow parameters.

Black patients with pulmonary hypertension were more frequently covered by Medicaid (12.5% vs. 0.7% in whites), and less likely to have private insurance coverage (50% among black patients and 61% among whites).

Results also showed that black patients were younger (mean age,  50 years) and more likely to have diabetes, a serious comorbidity. They presented more severe pulmonary vascular disease at diagnosis and, after adjusting for age and functional class, their risk of death was two-fold higher over the study’s follow-up period (a median of 2.3 years) relative to white patients.

But when additional analysis took into account patients’ insurance status, this difference in mortality risk was no longer observed.

“In a large cohort of patients with incident pulmonary hypertension, black patients had poorer right-side heart function and survival rates than white patients. However, adjustment for insurance status in our cohort removed differences in survival by race,” the team wrote.

Rather, the higher risk seen in black patients “without private insurance” may be attributed to them having been “referred later in their disease course, and presented with more difficult to treat disease.”

The study concludes: “We found that the type of insurance at the time of referral may interact with race for survival. Insurance may be a surrogate for overall socioeconomic status, and it also may have implications for ease of access to referral centers and potential pulmonary hypertension therapies.”