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Original Investigation |

Pulmonary Thromboembolism in American Indians and Alaskan Natives FREE

Paul D. Stein; Fadi Kayali; Ronald E. Olson; Creagh E. Milford
[+] Author Affiliations

From the Departments of Research, St Joseph Mercy Oakland Hospital, Pontiac (Drs Stein and Kayali and Mr Milford), Internal Medicine, Wayne State University School of Medicine, Detroit (Dr Stein), and Grants, Contracts, and Sponsored Research, Oakland University, Rochester (Dr Olson), Mich. The authors have no relevant financial interest in this article.


Arch Intern Med. 2004;164(16):1804-1806. doi:10.1001/archinte.164.16.1804.
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Background  The rate of diagnosis of deep venous thrombosis and/or pulmonary embolism (collectively, venous thromboembolism: VTE) among patients discharged from Indian Health Service hospital care from 1980 through 1996 was considerably lower than rates reported in African Americans or whites. Expansion of the national census in 1990 to include American Indians and Alaskan Natives permits a more in-depth examination of this issue.

Methods  Combined data from the National Hospital Discharge Survey (nonfederal hospitals) and the Indian Health Service (federal hospitals) from 1996 through 2001 were used to evaluate the rate of diagnosis of VTE in American Indians and Alaskan Natives.

Results  The diagnosis of VTE in American Indians and Alaskan Natives, based on combined data from the National Hospital Discharge Survey and the Indian Health Service was 71 per 100 000 per year compared with 155 per 100 000 per year in African Americans (P<.001) and 131 per 100 000 per year in whites (P<.001). The rate ratio comparing the rate of diagnosis of VTE in American Indians and Alaskan Natives with African Americans was 0.46 (95% confidence interval, 0.45-0.47) and comparing American Indians and Alaskan Natives with whites it was 0.54 (95% confidence interval, 0.53-0.55).

Conclusions  The observed relatively low incidence of VTE in American Indians and Alaskan Natives would seem to be due to as yet undetermined genetic factors. The possibility that American Indians and Alaskan Natives have different lifestyles that affect the rate of diagnosis of VTE cannot be excluded.

Figures in this Article

The rate of diagnosis of venous thromboembolism (VTE) among patients discharged from Indian Health Service hospital care from 1980 through 1996 was 33 per 100 000 per year in American Indians and Alaskan Natives based on estimates of the Indian Health Service user population.1 This rate of diagnosis is considerably lower than rates reported in African Americans or whites.2 Expansion of the national census in 1990 to include American Indians and Alaskan Natives permits a more in-depth examination of this issue.3 The National Hospital Discharge Survey (NHDS)4 is based on data from nonfederal hospitals throughout the entire United States. The Indian Health Service has data on patients treated at Indian Health Service hospitals (which are federal hospitals) from 1996 through 2001. Combining the data from the NHDS and the Indian Health Service would give a robust evaluation of the rate of diagnosis of VTE in this racial group.

DATA COLLECTION

The NHDS is based on data obtained from the face sheets of a sample of the medical records of patients discharged from a sample of nonfederal short-stay general and specialty hospitals in 50 states and the District of Columbia.4 From 1996 through 2001, 434 to 480 hospitals responded each year to the survey. The number of patient abstracts sampled yearly in the survey over this period ranged from 282 000 to 330 210. The NHDS samples about 8% of nonfederal short-stay general and specialty hospitals and about 1% of discharges from such hospitals.

Data on hospitalizations for VTE in Indian Health Service hospitals were obtained from the Department of Health and Human Services, Indian Health Service, Information Technology Support Center, Albuquerque, NM. The Indian Health Service operates 49 hospitals. These are federal hospitals. Discharge data from these and other federal hospitals were not included in the NHDS. Between 1996 and 1997, the number of hospital admissions in Indian Health Service hospitals averaged 70 000 per year.

Diagnoses from the NHDS and the Indian Health Service were based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). The ICD-9-CM codes that we used for identification of patients with pulmonary embolism (PE) were 415.1, 634.6, 635.6, 636.6, 637.6, 638.6, and 673.2. The codes used for deep venous thrombosis (DVT) were 451.1, 451.2, 451.8, 451.9, 453.2, 453.8, 453.9, 671.3, 671.4, and 671.9. Five-digit codes (eg, 451.11) were not listed separately because they were included under the corresponding 4-digit codes (eg, 451.1). Yearly population estimates by race were obtained from the US Bureau of the Census.3

STATISTICAL ANALYSIS AND METHODOLOGIC CONSIDERATIONS

Rates of diagnosis of PE, DVT, and VTE, in hospitalized patients (number of diagnoses per 100 000 population per year) were calculated by dividing the sum of the yearly number of patients hospitalized over the period of interest with a diagnosis of PE, DVT, or either by the sum of the yearly census estimates over the period of interest × 100 000. Rate ratios and 95% confidence intervals (CIs) were calculated using GraphPad InStat version 3.0 (San Diego, Calif). One-way analysis of variance was used to compare rates among races using SPSS, version 11.5 (SPSS Inc, Chicago, Ill). The t test was used for paired comparisons.

From 1996 through 2001, the rate of diagnosis of VTE (PE and/or DVT) in American Indians and Alaskan Natives, based on combined data from the NHDS and the Indian Health Service, was 71 per 100 000 per year compared with 155 per 100 000 per year in African Americans (P<.001) and 131 per 100000 per year in whites (P<.001) (Figure 1). Rates of diagnosis of DVT according to race are also shown in the Figure 1, but the number of PEs in American Indians and Alaskan Natives was too low to give an accurate estimate of the rate of diagnosis.

Place holder to copy figure label and caption

Rates of diagnosis of deep venous thrombosis (DVT) and venous thromboembolic disease (VTE) in American Indian and Alaskan Native, white, and African American populations from 1996 through 2001 based on combined data from the National Hospital Discharge Survey 4 and the Indian Health Service. Rates of diagnosis of DVT and of VTE were lower in American Indians and Alaskan Natives than in whites or African Americans (P<.001 for all differences). The rates of diagnosis in whites and African Americans were comparable.

Graphic Jump Location

The rate ratio, comparing the rate of diagnosis of VTE in American Indians and Alaskan Natives with that in African Americans, was 0.46 (95% CI, 0.45-0.47) and comparing American Indians and Alaskan Natives with whites it was 0.54 (95% CI, 0.53-0.55). The rate ratios comparing DVT in American Indians and Alaskan Natives with that in African Americans and whites were 0.44 (95% CI, 0.43-0.45) and 0.52 (95% CI, 0.51-0.53), respectively.

Only 1 patient with PE was hospitalized in Indian Health Service hospitals between 1996 and 2001. During this interval, an estimated 420 000 patients were hospitalized.

American Indians and Alaskan Natives had a lower rate of diagnosis of VTE than African Americans or whites. Indian Health Service hospitals, being federal hospitals, are not included in the NHDS. Tribally operated hospitals and hospitals that have contracted with the Indian Health Service would have been included in the NHDS. The rate of diagnosis of VTE was consistent with the rate of diagnosis estimated on the basis of the Indian Health Service user population.1

Relative values comparing rates among races are likely to be more accurate than absolute values. The rates of diagnosis of PE and DVT obtained from the NHDS and from discharge codes of patients from Indian Health Service hospitals depend on the sensitivity and specificity of diagnostic codes at discharge from the hospital. Review and reabstraction of a sample of Medicare hospitalizations from late 1984 and early 1985 showed that for pulmonary embolism, 92% of codable cases were on the abstract.5 Others showed that 93% of proven cases of PE at autopsy, if recognized ante mortem, were coded at hospital discharge.6 Regarding the robustness of discharge codes for DVT, White et al7 validated 92% of coded cases of idiopathic DVT.

We previously showed a 0.4% incidence of PE in hospitalized whites and African Americans aged 20 years or older throughout the United States, based on the NHDS use of ICD-9 codes.8 This was remarkably close to the incidence of PE in a university hospital (0.4%),6 a tertiary care center (0.5%),9 and a community teaching hospital (0.3%).10 These incidences were obtained based on retrospective review of multiple data sources, including radiographic reports and autopsies (but not including estimates of unsuspected deaths from PE when no autopsy was performed). The incidence of PE in hospitalized patients in Indian Health Service hospitals, 1 in about 420 000 patients, is orders of magnitude lower than these values.

The relatively low incidence of VTE in American Indians and Alaskan Natives would seem to be due to as yet undetermined genetic factors. A lower prevalence of factor V Leiden in American Indian and Alaskan Native populations (1.25%) compared with whites (5.3%) perhaps contributes to the lower incidence of VTE in American Indians and Alaskan Natives.11 The concept that racial groups can differ genetically and that the differences can have medical importance has recently been discussed.12 The possibility that American Indians and Alaskan Natives have different diets or lifestyles that affect the rate of diagnosis of VTE cannot be excluded.13

Correspondence: Paul D. Stein, MD, St Joseph Mercy Oakland Hospital, 44555 Woodward Ave, Suite 107, Pontiac, MI 48341-2985 (steinp@trinity-health.org).

Accepted for publication January 14, 2004.

We thank Anne E. Butman for obtaining Indian Health Service data.

Hooper  WCHolman  RCHeit  JACobb  N Venous thrombembolism hospitalizations among American Indians and Alaska Natives. Thromb Res. 2003;108273- 278
PubMed Link to Article
Stein  PDHull  RDPatel  KC  et al.  Venous thromboembolic disease: comparison of the diagnostic process in blacks and whites. Arch Intern Med. 2003;1631843- 1848
PubMed Link to Article
Bureau of the Census, Department of Commerce United States Department of Health and Human Services (US DHHS) Centers for Disease Control and Prevention (CDC)., CDC WONDER Online Database. Available at: http://wonder.cdc.gov/. Accessed May 3, 2004.
National Center for Health Statistics, National Hospital Discharge Survey Multi-Year Data File 1979-1999.  Washington, DC US Dept of Health and Human Services, Public Health ServiceAvailable at: http://www.cdc.gov/nchs/about/major/hdasd/nhds.htm. Accessed May 3, 2004.
Kniffin  WD  JrBaron  JABarrett  JBirkmeyer  JDAnderson  FA  Jr The epidemiology of diagnosed pulmonary embolism and deep venous thrombosis in the elderly. Arch Intern Med. 1994;154861- 866
PubMed Link to Article
Proctor  MCGreenfield  LJ Pulmonary embolism: diagnosis, incidence, and implications. Cardiovasc Surg. 1997;577- 81
PubMed Link to Article
White  RHZhou  HRomano  PS Incidence of idiopathic deep venous thrombosis and secondary thromboembolism among ethnic groups in California. Ann Intern Med. 1998;128737- 740
PubMed Link to Article
Stein  PDKayali  FOlson  REMilford  CE Pulmonary thromboembolism in Asian-Pacific Islanders in the United States: analysis of data from the National Hospital Discharge Survey and the United States Bureau of the Census. Am J Med. 2004;116435- 442
PubMed Link to Article
Stein  PDHenry  JW Prevalence of acute pulmonary embolism in a general hospital and at autopsy. Chest. 1995;108978- 981
PubMed Link to Article
Stein  PDPatel  KCKalra  NJ  et al.  Estimated incidence of acute pulmonary embolism in a community/teaching general hospital. Chest. 2002;121802- 805
PubMed Link to Article
Ridker  PMMiletich  JPHennekens  CHBuring  JE Ethnic distribution of Factor V Leiden in 4047 men and women: implications for venous thromboembolism screening. JAMA. 1997;2771305- 1307
PubMed Link to Article
Burchard  EGZiv  ECoyle  N  et al.  The importance of race and ethnic background in biomedical research and clinical practice. N Engl J Med. 2003;3481170- 1175
PubMed Link to Article
Cooper  RSKaufman  JSWard  R Race and genomics. N Engl J Med. 2003;3481166- 1170
PubMed Link to Article

Figures

Place holder to copy figure label and caption

Rates of diagnosis of deep venous thrombosis (DVT) and venous thromboembolic disease (VTE) in American Indian and Alaskan Native, white, and African American populations from 1996 through 2001 based on combined data from the National Hospital Discharge Survey 4 and the Indian Health Service. Rates of diagnosis of DVT and of VTE were lower in American Indians and Alaskan Natives than in whites or African Americans (P<.001 for all differences). The rates of diagnosis in whites and African Americans were comparable.

Graphic Jump Location

Tables

References

Hooper  WCHolman  RCHeit  JACobb  N Venous thrombembolism hospitalizations among American Indians and Alaska Natives. Thromb Res. 2003;108273- 278
PubMed Link to Article
Stein  PDHull  RDPatel  KC  et al.  Venous thromboembolic disease: comparison of the diagnostic process in blacks and whites. Arch Intern Med. 2003;1631843- 1848
PubMed Link to Article
Bureau of the Census, Department of Commerce United States Department of Health and Human Services (US DHHS) Centers for Disease Control and Prevention (CDC)., CDC WONDER Online Database. Available at: http://wonder.cdc.gov/. Accessed May 3, 2004.
National Center for Health Statistics, National Hospital Discharge Survey Multi-Year Data File 1979-1999.  Washington, DC US Dept of Health and Human Services, Public Health ServiceAvailable at: http://www.cdc.gov/nchs/about/major/hdasd/nhds.htm. Accessed May 3, 2004.
Kniffin  WD  JrBaron  JABarrett  JBirkmeyer  JDAnderson  FA  Jr The epidemiology of diagnosed pulmonary embolism and deep venous thrombosis in the elderly. Arch Intern Med. 1994;154861- 866
PubMed Link to Article
Proctor  MCGreenfield  LJ Pulmonary embolism: diagnosis, incidence, and implications. Cardiovasc Surg. 1997;577- 81
PubMed Link to Article
White  RHZhou  HRomano  PS Incidence of idiopathic deep venous thrombosis and secondary thromboembolism among ethnic groups in California. Ann Intern Med. 1998;128737- 740
PubMed Link to Article
Stein  PDKayali  FOlson  REMilford  CE Pulmonary thromboembolism in Asian-Pacific Islanders in the United States: analysis of data from the National Hospital Discharge Survey and the United States Bureau of the Census. Am J Med. 2004;116435- 442
PubMed Link to Article
Stein  PDHenry  JW Prevalence of acute pulmonary embolism in a general hospital and at autopsy. Chest. 1995;108978- 981
PubMed Link to Article
Stein  PDPatel  KCKalra  NJ  et al.  Estimated incidence of acute pulmonary embolism in a community/teaching general hospital. Chest. 2002;121802- 805
PubMed Link to Article
Ridker  PMMiletich  JPHennekens  CHBuring  JE Ethnic distribution of Factor V Leiden in 4047 men and women: implications for venous thromboembolism screening. JAMA. 1997;2771305- 1307
PubMed Link to Article
Burchard  EGZiv  ECoyle  N  et al.  The importance of race and ethnic background in biomedical research and clinical practice. N Engl J Med. 2003;3481170- 1175
PubMed Link to Article
Cooper  RSKaufman  JSWard  R Race and genomics. N Engl J Med. 2003;3481166- 1170
PubMed Link to Article

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