Background. Numerous studies have documented substantial differences by race and gender in the use of coronary artery bypass graft surgery and percutaneous coronary angioplasty. However, few studies have examined whether these differences reflect problems in quality of care.
Method. We selected a random sample stratified by gender, race, and income of 5026 Medicare beneficiaries aged 65 to 75 who underwent inpatient coronary angiography during 1991 to 1992 in 1 of 5 states. We compared the frequency of 2 problems in quality by race and gender: underuse or the failure to receive a clinically indicated revascularization procedure and receipt of revascularization when it was not clinically indicated. We used 2 independent sets of criteria developed by the RAND Corporation and the American College of Cardiology/American Hospital Association (ACC/AHA). We also examined survival of the cohort through March 31, 1994.
Results. Revascularization procedures were clinically indicated more frequently among whites than blacks and among men than women. Failure to receive revascularization when it was indicated was more common among blacks than among whites (40% vs. 23–24%, depending on the criteria, both P <0.001) but similar among men and women (25% vs. 22–24%, P >0.05). Racial disparities remained similar after adjusting for patient and hospital characteristics. Among patients rated inappropriate, use of procedures was greater for whites than blacks using RAND criteria (10.5% vs. 5.8%, P <0.01) and greater for men than for women (14.2% vs. 5.3% by RAND criteria, P = 0.001; 8.2% vs. 4.0%% by ACC/AHA criteria, P = 0.04). After multivariate adjustment, the disparities for race and gender remained similar and were statistically significant using RAND criteria. Mortality rates tended to validate our appropriateness criteria for underuse.
Conclusions. Racial differences in procedure use reflect higher rates of clinical appropriateness among whites, greater underuse among blacks, and more frequent revascularization when it was not clinically indicated among whites. Underuse is associated with higher mortality. In contrast, men had higher rates of clinical appropriateness and were more likely to receive revascularization when it was not clinically indicated. There was no evidence of greater underuse among women.
More than one million persons in this country undergo coronary artery bypass graft surgery (CABG) and percutaneous transluminal coronary angioplasty (PTCA) annually. Slightly more than half of these procedures are performed for patients greater than 65 years old. 1 Previous research has documented large and persistent differences in the use of these procedures among patients classified by race 2–13 and gender. 14–22
The failure to close racial and gender gaps in access to revascularization could reflect clinical skepticism about the causes of these “inequities.”23 Lower rates of use do not necessarily indicate lower quality of care. The critical questions are whether blacks and/or women are as likely as whites and men to receive surgical intervention when it would produce a superior clinical outcome compared with medical therapy, and whether whites or men are more likely to receive surgical intervention when it is not beneficial.
In this study, we identified more than 5000 patients who underwent coronary angiography in 5 states and used 2 different approaches to determine whether subsequent coronary revascularization (either PTCA or CABG) was indicated. We examined 5 aspects of care: 1) utilization by race and gender; 2) clinical appropriateness by race and gender; 3) the proportion of patients for whom revascularization was clinically indicated but who failed to receive it; 4) the proportion of patients for whom revascularization was not clinically indicated but who nonetheless received it; and 5) mortality rates among those who received coronary revascularization versus medical therapy.
From the *Division of General Medicine (Section on Health Services and Policy Research), Brigham and Women’s Hospital, Boston, Massachusetts.
From the †Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts.
From the ‡Institute for Health Policy, Massachusetts General Hospital, Boston, Massachusetts.
From the §Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee.
From the ∥Center for Statistical Sciences, Brown University, Providence, Rhode Island.
From the ¶Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.
Supported by grant #5 RO HS07098-02S1 from the Agency for Health Care Policy and Research, now called the Agency for Healthcare Research and Quality.
Address correspondence and reprint requests to: Arnold M. Epstein, MD, MA, Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Ave., Boston, MA 02115. Email: firstname.lastname@example.org.