Special Article

Racial Differences in the Use of Invasive Cardiovascular Procedures in the Department of Veterans Affairs Medical System

Jeff Whittle, Joseph Conigliaro, C.B. Good, and Richard P. Lofgren

N Engl J Med 1993; 329:621-627August 26, 1993

Abstract

Background

Previous studies have found racial differences in the use of invasive cardiovascular procedures, which may be due in part to the greater financial incentives to perform such procedures in white patients. In Department of Veterans Affairs hospitals, direct financial incentives affecting use of the procedures are minimized for both patients and physicians.

Full Text of Background...

Methods

We analyzed retrospectively the use of cardiovascular procedures among black and white male veterans discharged from Veterans Affairs hospitals with primary diagnoses of cardiovascular disease or chest pain during fiscal years 1987 through 1991. We used coded discharge data to determine whether cardiac catheterization, percutaneous transluminal coronary angioplasty, or coronary artery bypass grafting was performed during or immediately after such admissions. We used logistic-regression analysis to adjust for the primary discharge diagnosis, the presence of coexisting conditions, age, marital status, type of eligibility to receive care at Veterans Affairs hospitals, geographic region, and whether the hospital was equipped to perform bypass surgery. We classified the primary diagnosis as myocardial infarction, unstable angina, angina, chronic ischemia, chest pain, or “other” cardiovascular diagnosis.

Full Text of Methods...

Results

After we adjusted for all the potential confounders, we found that white veterans were more likely than black veterans to undergo cardiac catheterization (odds ratio, 1.38; 95 percent confidence interval, 1.34 to 1.42), angioplasty (odds ratio, 1.50; 95 percent confidence interval, 1.38 to 1.64), and coronary artery bypass surgery (odds ratio, 2.22; 95 percent confidence interval, 2.09 to 2.36).

Full Text of Results...

Conclusions

Even when financial incentives are absent, whites are more likely than blacks to undergo invasive cardiac procedures. These findings suggest that social or clinical factors affect the use of these procedures differently in blacks and whites.

Full Text of Discussion...

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Media in This Article

Table 1Characteristics of Black and White Veterans Admitted with Cardiovascular Diagnoses or Chest Pain, Fiscal Years 1987 through 1991.

Table 2Relation of Race to the Use of Invasive Cardiovascular Procedures in 1987 through 1991, According to Potential Confounding Variables.

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Article

Access to technologically advanced care for certain segments of society is an important health care issue in the United States1. Previous studies have found racial differences in the use of invasive procedures in the management of cardiac disease2-8. These studies have shown that white patients are more likely than black patients to undergo various invasive cardiac procedures, such as cardiac catheterization, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass grafting (CABG). These differences persist despite adjustment for potential confounding variables such as age, sex, clinical factors, socioeconomic status, and insurance status2,5.

Existing studies of racial differences in the use of invasive cardiac procedures have several limitations. Some studies have been restricted to a single clinical center or geographic region. It is also possible that the differences detected may have reflected differences in practice patterns between hospitals serving large numbers of blacks and those serving primarily whites. Finally, most investigators have been unable to control adequately for the potentially confounding influence of economic factors. For example, all patients with Medicare might be grouped together, regardless of whether they had supplemental insurance, because only information about the primary insurer was available.

The Department of Veteran Affairs (VA) hospital system offers distinct advantages for the study of racial differences in the use of invasive procedures to manage cardiac disease. Treatment within the VA system does not depend on patients' ability to pay. Financial incentives for physicians to perform procedures are minimized, because physicians receive a salary. Relatively few VA medical centers perform coronary artery bypass surgery (42 from 1987 through 1991), but most perform a substantial number of invasive cardiovascular procedures each year; thus, it is possible to analyze variation within individual hospitals as well as throughout the VA system. Finally, since VA medical centers are distributed nationwide, the results are more likely to be generalizable than those of studies based on data from a single hospital or from hospitals in one state.

We conducted a retrospective study using the VA administrative data base, the Patient Treatment File, to examine the use of cardiac catheterization, PTCA, and CABG among white and black male veterans treated at VA hospitals.

Methods

Data Base

We used records of hospitalizations in VA hospitals from the Patient Treatment File for fiscal years 1987 through 1991. For each discharge from a VA hospital, up to 10 diagnoses, 5 operating room procedures, and 32 non-operating room procedures are coded according to the coding system of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)9. Each record also contains demographic and administrative characteristics, such as the veteran's sex, race, age, and marital status, data on the patient's eligibility for care at a VA center (eligibility status), and an identifier for the discharging hospital.

Patient Population

We used the coded discharge data to identify all male veterans over 30 years of age who were discharged with a primary diagnosis of cardiovascular disease (ICD-9-CM codes 390 through 459) or chest pain (786.50 through 786.59) during the five-year study period. We considered each veteran's first such discharge to be his index admission. We included the discharge records in the Patient Treatment File for all admissions during the study period for each veteran.

Definition of Variables

We used the primary diagnosis (the diagnosis responsible for the major part of the patient's hospitalization) to determine the main reason for the index hospitalization. The primary diagnosis was categorized as myocardial infarction, unstable angina, chronic ischemia, angina, chest pain, or another cardiovascular diagnosis.

We measured coexisting morbidity in two ways. First, we categorized the number of secondary diagnoses during the index hospitalization (used by other investigators as a measure of coexisting morbidity2) as 0 through 3, 4 through 6, or 7 through 9. Second, we used all discharge records up to and including the index admission to determine whether the veteran had any of the following coexisting conditions, which we believed would make aggressive management of coronary artery disease less likely: human immunodeficiency virus infection; cancer, except nonmelanoma skin cancer; end-stage renal disease; cirrhosis; dementia; psychiatric illness; abuse of alcohol or other drugs, excluding tobacco abuse; diabetes mellitus; or chronic lung disease. The precise ICD-9-CM codes used to define these conditions are listed in the Appendix. In univariate analyses, each of these conditions except diabetes mellitus decreased the likelihood that an invasive cardiovascular procedure would be performed. Therefore, we considered a coexisting condition to be present if the patient had any of these conditions, except diabetes mellitus.

We categorized race as white or black. We excluded veterans whose race was not coded as white or black. Age was classified as 31 through 40, 41 through 50, 51 through 60, 61 through 70, 71 through 80, and 81 years or older. Marital status was categorized as divorced, married, never married, separated, widowed, or unknown. Eligibility for hospitalization in a VA medical center was categorized as category A, service connected (the veteran was eligible because a medical condition was incurred or aggravated while he was on active duty); category A, not service connected (the veteran had a condition not incurred or aggravated during active service but was eligible because of low income); or other (see the Appendix). The location of the hospital was categorized as Northeast, Southeast, Midwest, or West, following the Department of Veterans Affairs' present regional organization. Hospitals were categorized as CABG centers (i.e., as centers equipped to perform CABG) for fiscal years in which at least 10 CABG procedures were performed there.

For each veteran, we determined whether cardiac catheterization or PTCA was performed in a VA hospital during or within 60 days after the index admission, and whether CABG was performed within 90 days after the index admission.

Thus, our final data set included all male black or white veterans over 30 years of age who were hospitalized in VA medical centers primarily for a cardiovascular disease or chest pain during the study period. For each such person, we had information on race, age, coexisting conditions, marital status, eligibility status, the treatment capabilities of the center, the geographic location of the hospital to which he was first admitted, and whether CABG, PTCA, or cardiac catheterization was performed at the VA hospital.

Statistical Analysis

In our primary analysis we examined the use of procedures during or within 60 or 90 days after the index admission for each veteran. We performed identical analyses for each of three outcome variables -- cardiac catheterization within 60 days, PTCA within 60 days, and CABG within 90 days. Because of the size of our population, we knew that even trivial associations could be significant. Therefore, we identified potentially confounding variables on the basis of clinical judgment and evidence of their importance in previous studies. We then included these potential confounders in our final models, regardless of the degree of statistical significance.

Univariate analysis with simple chi-square tests of significance was used to evaluate the overall association of race with the use of procedures10. We then used a stratified chi-square analysis to control separately for diagnosis, region, age, coexisting morbidity, marital status, year of diagnosis, VA eligibility status, and whether CABG was performed at the hospital where the initial diagnosis was made10. To control for all these variables simultaneously, we used a multiple logistic-regression model11. In addition, we examined the interactions between each potential confounder and race.

To study potential confounding by variation in the use of procedures among hospitals, we used the subgroup of veterans whose index admissions were to hospitals that frequently performed CABG (CABG centers). We first calculated the relative risk of undergoing each procedure for whites as compared with blacks in each of these hospitals. We then used logistic-regression analyses to determine the independent influence of race on the use of procedures, controlling for coexisting morbidity, primary diagnosis, age, and hospital.

Since the categories “other cardiovascular disease” and “chest pain” include a heterogeneous set of clinical entities, we performed logistic-regression analyses both including and excluding veterans with these primary diagnoses. To facilitate comparison with the results of previous studies, however, we present our univariate and stratified results with these patients included.

To eliminate potential confounding by income, we repeated the logistic-regression analyses in the subgroup of category A patients with non-service-connected conditions (maximal household income, $18,844 for a veteran without dependents in 1992).

We used Statistical Analysis System software for all statistical analyses12,13. All P values are two-sided.

Results

We identified 882,508 admissions of veterans with a primary diagnosis of cardiovascular disease or chest pain during the study period. We excluded 6.8 percent because the patients did not meet the study criteria for race (4.7 percent), sex (1.5 percent), VA eligibility status (0.4 percent), or age (0.4 percent). The remaining 822,930 admissions occurred among the 428,300 black or white male veterans over 30 years old who constituted the study population. Table 1Table 1Characteristics of Black and White Veterans Admitted with Cardiovascular Diagnoses or Chest Pain, Fiscal Years 1987 through 1991. displays the characteristics of the study population. Given the large sample, each of the small differences between the races is statistically significant. However, the proportion of veterans with at least one important coexisting condition and the distribution of the number of secondary diagnoses were similar between the black and white veterans. Black veterans more often resided in the Southeast, had non-service-connected category A eligibility, and had a primary diagnosis of “other cardiovascular disease.”

Cardiac catheterization was performed during or within 60 days of the index admission in 77,168 (18.0 percent) of these veterans. The rate was 19.3 percent among whites and 11.8 percent among blacks (relative risk of undergoing the procedure for a white as compared with a black veteran, 1.64; 95 percent confidence interval, 1.61 to 1.68). For PTCA the corresponding number was 6819 veterans (1.6 percent). The rate was higher among whites (1.8 percent) than among blacks (0.8 percent; relative risk, 2.18; 95 percent confidence interval, 2.01 to 2.37). Similarly, 18,912 veterans (4.4 percent) underwent CABG within 90 days of the index admission -- 5.0 percent of whites and 1.6 percent of blacks (relative risk, 3.17; 95 percent confidence interval, 2.99 to 3.37).

Many independent variables other than race were associated with the use of invasive cardiovascular procedures, including age, marital status, VA eligibility status, fiscal year, the presence of clinically important coexisting conditions, the number of secondary diagnoses, the primary diagnosis, the region, and whether the index admission was to a hospital that was equipped to perform CABG (CABG center). The relative risks for the procedures, stratified according to potential confounders, are displayed in Table 2Table 2Relation of Race to the Use of Invasive Cardiovascular Procedures in 1987 through 1991, According to Potential Confounding Variables.. Whites underwent each of the procedures more frequently than blacks in all diagnostic categories. The differences were statistically significant in most of the subgroups we examined. Summary relative risks are not reported, since the white-black differences within strata for several of the independent variables were heterogeneous according to the Breslow-Day test10.

Finally, we used a multiple logistic-regression model to examine the independent contribution of race to the use of each of the three cardiovascular procedures, adjusting for the other independent variables (Table 3Table 3Odds Ratio for the Use of Procedures among Whites as Compared with Blacks with Cardiovascular Diagnoses, Adjusted for Potential Confounders.). White race was a statistically significant predictor of the use of each of the procedures, regardless of which independent variables were included. This model included primary diagnosis, race, age, coexisting morbidity, year of the index hospitalization, marital status, region, and whether the index hospitalization was in a CABG center (Table 3). After adjustment for all these variables, the odds ratios for undergoing a cardiovascular procedure for a white as compared with a black veteran were as follows: cardiac catheterization, 1.38 (95 percent confidence interval, 1.34 to 1.42); angioplasty, 1.50 (95 percent confidence interval, 1.38 to 1.64); and CABG, 2.22 (95 percent confidence interval, 2.09 to 2.36). The inclusion of interaction terms did not significantly alter our conclusions, although a number of the associations were statistically significant, as suggested by the stratified analysis.

The results of this analysis did not change when we restricted our analysis to clearly ischemic diagnoses (that is, when we excluded the nonspecific categories of “other cardiovascular diagnoses” and “chest pain”) (Table 3). When we further restricted the analysis to veterans with limited income (those with non-service-connected category A eligibility), the white-black odds ratios remained essentially unchanged (Table 3).

In our analysis of rates of procedure use among veterans admitted to CABG centers, the rates varied greatly among veterans admitted to different hospitals. For example, the rates of CABG within 90 days of discharge varied from 2.6 percent to 13.4 percent, depending on the site of the index hospitalization. However, in a logistic-regression analysis in which we controlled for site, coexisting morbidity, age, and primary diagnosis, whites remained significantly more likely to undergo cardiac catheterization (odds ratio, 1.53; 95 percent confidence interval, 1.48 to 1.59), PTCA (odds ratio, 1.47; 95 percent confidence interval, 1.32 to 1.64), and CABG (odds ratio, 2.15; 95 percent confidence interval, 1.99 to 2.33).

Discussion

We found that white patients consistently underwent invasive cardiac procedures more often than black patients. These findings were evident for cardiac catheterization, PTCA, and CABG during or after the index admissions for each diagnostic category (Table 2). Adjusting for coexisting morbidity, demographic characteristics, and the treating hospital did not alter our findings. Our data, coupled with the results of previous studies,2-7 suggest the existence of race-related inequities in our health care system.

Our results substantially strengthen previous observations in non-VA hospitals, for several reasons. First, the financial incentives that operate in fee-for-service systems are minimized in VA medical centers. VA physicians are usually salaried, so patients' finances and insurance do not affect physicians' income from procedures. In VA hospitals, unlike private-sector hospitals, patients' ability to pay does not affect the income of the center, which is determined by global budgeting. Thus, there are no financial incentives for providers to use procedures preferentially in whites. Since eligible veterans are not billed for admissions to VA hospitals, patients' fears about incurring large debts for the use of expensive procedures are also minimized. Our analysis of a subgroup of veterans with more homogeneous incomes (those with non-service-connected category A eligibility) yielded results similar to those of the analysis of our entire study population, further suggesting that differences in personal income do not underlie racial differences in the use of procedures.

We were also able to refute the suggestion that racial differences are due to lower rates of use of procedures in hospitals that treat more black patients. Although we found marked variations in the use of procedures among hospitals, these three procedures were used more often in white than in black patients in every one of the hospitals that performed a substantial number of the procedures. Controlling for the initial treatment site did not affect the differences for any of these procedures.

Additional strengths of this study include the facts that our data base was national, that it included five years of data, and that we were able to follow patients over time. Thus, we were able to determine whether patients admitted to hospitals without the capability of performing certain procedures underwent those procedures elsewhere after discharge. In addition, we were able to identify coexisting conditions that were present during hospitalizations that preceded the index admission.

Our study has important limitations that are common in analyses of administrative data sets. First, the accuracy of coding is a constant cause for concern when such data bases are used. The rate of error in diagnostic coding is known to be substantial in both VA and non-VA discharge data in general14-17 and in the coding for myocardial infarction in particular18. However, it is unlikely that coding errors would entail systematic bias toward one racial group or another.

Second, adjusting for the severity of disease and coexisting morbidity on the basis of administrative data sets has been shown to be problematic19,20. Thus, unmeasured differences in the presence and severity of coexisting conditions may explain some of the observed racial difference in the use of procedures. Further examination of this issue would require access to individual patients' records.

Third, the use of discharge data does not permit the study of decisions regarding admission. It is possible that systematic differences in admission practices affected our results. Existing data suggest that blacks are more likely than whites to forgo or delay medical care for symptoms of ischemic heart disease21-23. It is not clear how this factor would affect the use of procedures among patients who are admitted.

A factor peculiar to this study of VA data is that veterans obtain some of their care outside the VA system24. Inasmuch as whites are more likely than blacks to undergo these procedures in non-VA hospitals,2-8 our results may tend to underestimate the difference in the use of procedures between whites and blacks.

Our study is comparable to studies by Wenneker and Epstein2 and Hannan et al.,5 who analyzed administrative data on hospitalizations in nonfederal hospitals in Massachusetts and New York, respectively. The white-black odds ratios for each procedure in our overall logistic-regression model were remarkably similar to those obtained in these studies (Table 4Table 4Adjusted Odds Ratio for the Use of Procedures among Whites as Compared with Blacks from Studies Examining the Relation between Race and the Use of Invasive Cardiovascular Procedures.). This similarity suggests that the causes of the differences between whites and blacks are not specific to a given delivery system or geographic area.

Why do disparities in the rates of cardiovascular procedures between white and black patients persist? Possible explanations include differences in the severity of coronary artery disease, unmeasured differences in the presence or severity of coexisting conditions, cultural differences in attitudes toward procedures or medical care in general, differences in access to care, and systematic racial bias. More than one, and perhaps all, of these factors may be at work.

Our finding that the white-black difference in the use of procedures was smallest for cardiac catheterization, greatest for CABG, and intermediate for PTCA is consistent with the results of previous studies2,5. It is also consistent with several explanations for the disparity.

If blacks have less severe coronary artery disease than whites admitted with similar diagnoses, lower rates of PTCA and CABG among black patients would be appropriate. Indeed, two studies of angiographic results found that blacks who underwent catheterization were more likely than whites to have minimal disease or none, and less likely to have three-vessel disease. This difference persisted after adjustment for potential confounders4,25. Both studies included relatively few blacks and examined selected populations, thus limiting their generalizability. The results must be considered in the light of other data suggesting that blacks have higher rates of morbidity and mortality due to cardiovascular disease26.

Similarly, if blacks are less likely than whites to accept recommendations that they undergo invasive procedures, this reluctance might be greater for CABG and PTCA than for cardiac catheterization. Alternatively, whites may be more likely to expect that these procedures will be part of their care. Oberman and Cutter found that whites with two-vessel or three-vessel coronary artery disease were more likely to undergo CABG than blacks with similar disease, though the reason for the discrepancy was not explained4. Blacks for whom surgery was recommended in the nonrandomized portion of the Coronary Artery Surgery Study were less likely to undergo surgery than whites27.

Finally, any subtle bias against the use of invasive procedures in the treatment of black patients might be most evident when decision making is less clearly dictated by the clinical situation. Expert physicians participating in the Rand study of the appropriateness of care were more likely to disagree on the appropriateness of CABG than on the appropriateness of cardiac catheterization28. Thus, there may be more room for clinical judgment in the use of CABG than in the use of cardiac catheterization. It is interesting that the black-white disparity in the use of procedures seemed smallest for patients with acute myocardial infarction. A similar trend was seen in the report by Wenneker and Epstein2. It may be that the decision to use cardiac catheterization is least subjective in such circumstances.

The extent to which subtle or overt racism underlies racial differences in the use of cardiac procedures is unclear29,30. We believe that inadequate health education, differences in patients' preferences for invasive management, delivery systems that are unfriendly to members of certain cultures, and overt racism may all play a part. Allocating responsibility more precisely will require studies that control for angiographic data and directly examine interactions between patients and medical professionals. Debating how much “blame” should be allocated to which factor should not delay efforts to clarify and remedy each of these deficiencies in our medical care system.

Supported in part by a Health Services Research Developmental Grant (DEV 92-006) from the Department of Veterans Affairs (to Dr. Lofgren).

We are indebted to David S. Macpherson, M.D., for his helpful comments on an earlier version of this manuscript and to Mark Wenneker, M.D., M.P.H., who provided us with precise codes used in his study2.

Source Information

From the Section of General Internal Medicine, Pittsburgh Veterans Affairs Medical Center, and the Section of General Internal Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh.

Address reprint requests to Dr. Whittle at the Pittsburgh VA Medical Center (11A), University Drive C, Pittsburgh, PA 15240.

Appendix

The VA eligibility categories and diagnostic and procedural codes used in this study were as follows:

Category A eligibility. This category included veterans for whom free hospital care was federally mandated. All veterans with service-connected conditions (those incurred or aggravated during active duty) were in category A. Veterans with non-service-connected conditions were in category A if they were not dishonorably discharged and met income criteria. The maximal incomes in 1992 were as follows: no dependents, $18,844; one dependent, $22,613; two dependents, $24,277; three dependents, $25,490; four dependents, $26,703; and five or more dependents, $27,916.

Service-connected condition. A medical condition was considered service connected if it was incurred or aggravated while the serviceman was on active duty. This category included both chronic illnesses first diagnosed while the serviceman was in the military (e.g., diabetes) and conditions caused by military service (e.g., gunshot wounds).

Special categories. In the present analysis, veterans with guaranteed eligibility for hospital care because of special considerations -- for example, former prisoners of war -- are grouped with veterans with service-connected conditions.

Other categories. Categories B and C included veterans who were not dishonorably discharged who had incomes that exceeded the limits for category A. These veterans could be treated in VA facilities if the particular facility had resources available after providing care to all category A veterans who requested care, but they were billed for the services provided.

Primary diagnosis. The ICD-9-CM codes used for primary diagnosis were as follows: acute myocardial infarction, 410 through 410.92; angina, 413 through 413.9; chronic ischemic heart disease, 414.0, 414.8, and 414.9; chest pain, 786.50 through 786.59; unstable angina, 411.1 through 411.89; and other cardiovascular disease, 390 through 459.99 but none of the above.

Coexisting conditions. The codes used to identify coexisting conditions likely to decrease the likelihood that an invasive cardiovascular procedure would be used were as follows: human immunodeficiency virus infection, 042 through 044.99, 136.3, and 795.8; cancer, except nonmelanoma skin cancer, 140 through 172.9, 175 through 175.9, and 185 through 208.99; chronic lung disease, 294 through 294.9, 491 through 496, and 500 through 505; dementia, 290 through 290.99 and 294 through 294.9; diabetes mellitus, 250 through 250.99; drug or alcohol abuse, 291 through 291.92, 303 through 305.99, 425.5, 535.3, 571.0 through 571.3, 577.0, 577.1 and V11.3; end-stage renal disease, V45.1, V56.0, and V56.8; cirrhosis, 456.0 through 456.21, 568.82, 571.2, 571.5, 571.6, 572.2, 572.3, and 572.4; and psychiatric illness, 295 through 298.91.

Procedures. The codes used to identify the procedures performed were as follows: cardiac catheterization, 37.21 through 37.23 and 88.55 through 88.57; PTCA, 36.00 through 36.03 and 36.05 through 36.09; and CABG, 36.10 through 36.19.

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    Arnold M. Epstein, Joel S. Weissman, Eric C. Schneider, Constantine Gatsonis, Lucian L. Leape, Robert N. Piana. (2003) Race and Gender Disparities in Rates of Cardiac Revascularization. Medical Care 41:11, 1240-1255
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    Michele Heisler, Dylan M. Smith, Rodney A. Hayward, Sarah L. Krein, Eve A. Kerr. (2003) Racial Disparities in Diabetes Care Processes, Outcomes, and Treatment Intensity. Medical Care 41:11, 1221-1232
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    Laura A. Petersen, Sharon-Lise T. Normand, Benjamin G. Druss, Robert A. Rosenheck. (2003) Process of Care and Outcome after Acute Myocardial Infarction for Patients with Mental Illness in the VA Health Care System: Are There Disparities?. Health Services Research 38:1p1, 41-63
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    Tracie C Collins, Nancy J Petersen, Terri J Menke, Julianne Souchek, Wednesday Foster, Carol M Ashton. (2003) Short-term, intermediate-term, and long-term mortality in patients hospitalized for stroke. Journal of Clinical Epidemiology 56:1, 81-87
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    Eugene Z. Oddone, Laura A. Petersen, Morris Weinberger, Jay Freedman, Nancy R. Kressin. (2002) Contribution of the Veterans Health Administration in Understanding Racial Disparities in Access and Utilization of Health Care. Medical Care 40:Supplement, I-3-I-13
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    Vicki T. Lampley-Dallas. (2002) Research Issues for Minority Dementia Patients and Their Caregivers: What Are the Gaps in Our Knowledge Base?. Alzheimer Disease & Associated Disorders 16, S46-S49
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    Joseph Conigliaro, Jeff Whittle, Chester B. Good, Melissa Skanderson, Mary Kelley, Kenneth Goldberg. (2002) Delay in Presentation for Cardiac Care by Race, Age, and Site of Care. Medical Care 40:Supplement, I-97-I-105
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    Jodi B. Segal, Eliseo Guallar, Neil R. Powe. (2001) Autologous blood transfusion in the United States: clinical and nonclinical determinants of use. Transfusion 41:12, 1539-1547
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    Stephen Crystal, Usha Sambamoorthi, Patrick J. Moynihan, Elizabeth McSpiritt. (2001) Initiation and Continuation of Newer Antiretroviral Treatments among Medicaid Recipients with AIDS. Journal of General Internal Medicine 16:12, 850-859
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    Robert L. Williams, Susan A. Flocke, Kurt C. Stange. (2001) Race and Preventive Services Delivery Among Black Patients and White Patients Seen in Primary Care. Medical Care 39:11, 1260-1267
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    David L. Zack, John K. DiBaise, Eamonn M.M. Quigley, Hemant K. Roy. (2001) Colorectal cancer screening compliance by medicine residents: perceived and actual. The American Journal of Gastroenterology 96:10, 3004-3008
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    Sande Okelo, Anne L Taylor, Jackson T Wright, Nahida Gordon, Geetha Mohan, Edward Lesnefsky. (2001) Race and the decision to refer for coronary revascularization. Journal of the American College of Cardiology 38:3, 698-704
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    Alfredo J. Selim, Graeme Fincke, Xinhua S. Ren, Richard A. Deyo, Austin Lee, Katherine Skinner, Lewis Kazis. (2001) Racial Differences in the Use of Lumbar Spine Radiographs. Spine 26:12, 1364-1369
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    Chen, Jersey, Rathore, Saif S., Radford, Martha J., Wang, Yun, Krumholz, Harlan M., . (2001) Racial Differences in the Use of Cardiac Catheterization after Acute Myocardial Infarction. New England Journal of Medicine 344:19, 1443-1449
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    Joshua J. Spooner, Kate L. Lapane, Anne L. Hume, Vincent Mor, Giovanni Gambassi. (2001) Pharmacologic treatment of diabetes in long-term care. Journal of Clinical Epidemiology 54:5, 525-530
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    Jennifer Elston Lafata, Christine Cole Johnson, Tamir Ben-Menachem, Robert J. Morlock. (2001) Sociodemographic Differences in the Receipt of Colorectal Cancer Surveillance Care Following Treatment With Curative Intent. Medical Care 39:4, 361-372
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    Carol M. Mangione, Eileen Reynolds. (2001) Disparities in Health and Healthcare: Moving from Describing the Problem to a Call for Action. Journal of General Internal Medicine 16:4, 276-280
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     Ralph E. Watson, Aryeh D. Stein, Francesca C. Dwamena, Jill Kroll, Raj Mitra, Barbara A. McIntosh, Peter Vasilenko, Margaret M. Holmes-Rovner, Qin Chen, Joel Kupersmith, . (2001) Do Race and Gender Influence the Use of Invasive Procedures?. Journal of General Internal Medicine 16:4, 227-234
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     Vence L. Bonham. (2001) Race, Ethnicity, and Pain Treatment: Striving to Understand the Causes and Solutions to the Disparities in Pain Treatment. The Journal of Law, Medicine & Ethics 28:s4, 52-68
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     (2001) Policy statements adopted by the Governing Council of the American Public Health Association, November 15, 2000. American Journal of Public Health 91:3, 476-521
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     (2001) Expanded family and medical leave. American Journal of Public Health 91:3, 477-478
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     (2001) Reducing the incidence of blindness, lower extremity amputation, and oral health complications in minority populations due to diabetes. American Journal of Public Health 91:3, 478-479
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     (2001) Preserving consumer choice in an era of religious/secular health industry mergers (position paper). American Journal of Public Health 91:3, 479-482
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     (2001) Supporting access to midwifery services in the United States (position paper). American Journal of Public Health 91:3, 482-485
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     (2001) Effective interventions for reducing racial and ethnic disparities in health. American Journal of Public Health 91:3, 485-486
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     (2001) Making medicines affordable: the price factor (position paper). American Journal of Public Health 91:3, 486-490
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     (2001) Support for a new campaign for universal health care. American Journal of Public Health 91:3, 490-491
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     (2001) Affirming the importance of regulating pesticide exposures to protect public health. American Journal of Public Health 91:3, 491-492
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     (2001) Support for international action to eliminate persistent organic pollutants. American Journal of Public Health 91:3, 492-494
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     (2001) Creating healthier school facilities. American Journal of Public Health 91:3, 494-495
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     (2001) The precautionary principle and children's health. American Journal of Public Health 91:3, 495-496
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     (2001) Reducing the rising rates of asthma. American Journal of Public Health 91:3, 496-497
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     (2001) Maximizing public health protection with integrated vector control. American Journal of Public Health 91:3, 497-498
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     (2001) Protecting OSHA's jurisdiction over home workplaces. American Journal of Public Health 91:3, 498-499
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     (2001) Drinking water quality and public health (position paper). American Journal of Public Health 91:3, 499-500
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     (2001) Effective public health assessment, prevention, response, and training for emerging and re-emerging infectious diseases, including bioterrorism. American Journal of Public Health 91:3, 500-501
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     (2001) Confirming need for protective national health-based air quality standards. American Journal of Public Health 91:3, 501-502
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     (2001) Public health impacts of job stress. American Journal of Public Health 91:3, 502-503
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     (2001) Public health role of the National Fire Protection Association in setting codes and standards for the built environment. American Journal of Public Health 91:3, 503-504
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     (2001) Raising income to protect health. American Journal of Public Health 91:3, 504-505
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     (2001) Eliminating access barriers in public health meetings. American Journal of Public Health 91:3, 507-508
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     (2001) Ensuring optimal vision performance in visually at risk drivers. American Journal of Public Health 91:3, 510-511
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     (2001) The need for mental health and substance abuse services for the incarcerated mentally ill. American Journal of Public Health 91:3, 511-512
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     (2001) Preventing genocide. American Journal of Public Health 91:3, 512-513
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     (2001) Criteria for assessing the quality of health information on the Internet. American Journal of Public Health 91:3, 513-514
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     (2001) Discontinuation of the use of the island-municipality of Vieques, P.R., for the US Navy's training exercises. American Journal of Public Health 91:3, 514-515
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     (2001) Research and intervention on racism as a fundamental cause of ethnic disparities in health. American Journal of Public Health 91:3, 515-516
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     (2001) Opposition to the CRACK campaign. American Journal of Public Health 91:3, 516-517
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     (2001) Restoration of nutrition and health benefits eligibility to documented immigrants. American Journal of Public Health 91:3, 517-518
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     (2001) Establishment of a Medicare prescription drug benefit. American Journal of Public Health 91:3, 519-519
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133. 133

     (2001) Condemnation of pharmaceutical manufacturers' retaliatory tactics. American Journal of Public Health 91:3, 521-521
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     Enola K. Proctor, Nancy Morrow-Howell, Letha Chadiha, Alan C. Braverman, Osei Darkwa, Peter Dore. (1997) Physical and Cognitive Functioning Among Chronically Ill African-American and White Elderly in Home Care Following Hospital Discharge. Medical Care 35:8, 782-791
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     David E. Wennberg, John D. Dickens, Ab, Lois Biener, Floyd J. Fowler, David N. Soule, Ab, Robert B. Keller. (1997) Do Physicians Do What They Say? The Inclination to Test and Its Association with Coronary Angiography Rates. Journal of General Internal Medicine 12:3, 172-176
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