Correspondence

Racial Variation in the Use of Coronary-Revascularization Procedures

N Engl J Med 1997; 337:131-132July 10, 1997

Article

To the Editor:

In the past decade several reports have suggested that there are sexual or racial disparities in the use of invasive cardiac procedures.1-3 Peterson et al. (Feb. 13 issue)4 report that in their study, racial differences persisted after they had controlled for the severity of disease and the presence or absence of coexisting conditions associated with the use of coronary-artery bypass surgery. This article is among the first to assess the possible outcomes of not undergoing revascularization, as well as to report that the most striking racial disparities were found among the group of patients most likely to benefit from bypass surgery: those with three-vessel disease or left main coronary artery disease. These findings suggest that extracardiac or nonclinical factors require further investigation.

We have been examining such nonclinical factors, as well as ascertaining at what point in the process of care these differences are first manifested. Racial differences may exist before coronary revascularization — that is, in the actual recommendations made by physicians after coronary angiography has been performed. We analyzed data for the multiethnic, multiracial population of 827 patients undergoing initial angiography for the evaluation of ischemic heart disease between 1990 and 1993 at our institution and found racial and ethnic differences in recommendations for coronary revascularization after angiography in the group of patients with severe disease, such as left main coronary artery disease or three-vessel disease.5 African Americans were twice as likely and Hispanics almost three times as likely as whites with the same level of disease to have medical therapy recommended rather than revascularization (coronary bypass surgery or angioplasty).

J. Marie Barnhart, M.D.
Sylvia Wassertheil-Smoller, Ph.D.
Albert Einstein College of Medicine, Bronx, NY 10461

5 References

1
Tobin JN, Wassertheil-Smoller S, Wexler JP, et al. Sex bias in considering coronary bypass surgery. Ann Intern Med 1987;107:19-25
Web of Science | Medline

2
Ayanian JZ, Epstein AM. Differences in the use of procedures between women and men hospitalized for coronary heart disease. N Engl J Med 1991;325:221-225
Full Text | Web of Science | Medline

3
Carlisle DM, Leake BD, Shapiro MF. Racial and ethnic differences in the use of invasive cardiac procedures among cardiac patients in Los Angeles County, 1986 through 1988. Am J Public Health 1995;85:352-356
CrossRef | Web of Science | Medline

4
Peterson ED, Shaw LK, DeLong ER, Pryor DB, Califf RM, Mark DB. Racial variation in the use of coronary-revascularization procedures -- are the differences real? Do they matter? N Engl J Med 1997;336:480-486
Full Text | Web of Science | Medline

5
Barnhart JM, Wassertheil-Smoller S, Monrad SE, Ginsberg M. Recommendation patterns for coronary revascularization: evidence of racial differences. J Gen Intern Med 1995;10:60-60 abstract.

To the Editor:

What could be causing these racial differences in the use of revascularization procedures? One question is whether the authors controlled adequately for socioeconomic factors. If African Americans are less likely to have private medical insurance and more likely to be admitted to a county or state hospital, does it follow that they will be less likely to be offered an expensive procedure such as bypass surgery? Whether there is a substantial difference in the availability of coronary-artery bypass surgery between private hospitals and county or state hospitals needs to be considered.

The authors hinted that the differences may be due, at least in part, to African Americans' refusal of revascularization procedures because of their mistrust of medical personnel. This is an important point. Many African Americans are wary and skeptical of physicians, most of whom are male and culturally dissimilar. African-American patients may doubt that cardiologists are acting in their best interests or have genuine concern for their welfare in suggesting revascularization. This doubt could make them less likely to agree to such an invasive procedure.

Also, bias on the part of physicians could play a part. The possibility that cardiologists may be biased against recommending bypass surgery for African Americans because of beliefs that are contrary to scientific data and based on long-standing discriminatory attitudes should be thoroughly investigated. How treatment options are presented to a patient (or whether they are presented at all) will obviously affect the treatment choices made by the patient.

Whether the reasons for racial difference involve economic factors, bias on the part of physicians, mistrust on the part of patients, or some combination of these factors, steps must be taken to counter the trend toward underuse of revascularization in African Americans. All patients with coronary artery disease deserve an equal opportunity to improve the quality of their lives.

Cynthia Fowler, M.D.
University of California, San Francisco, San Francisco, CA 94143

Author/Editor Response

The authors reply:

To the Editor: Drs. Barnhart and Wassertheil-Smoller and their colleagues also found racial differences in the use of revascularization procedures at their institution.1 Their study, however, indicated that racial differences in coronary intervention extended back to the physicians' recommendations for treatment. Although this finding appears to indicate bias on the part of physicians, it is not clear that the study investigators fully controlled for clinical factors (such as coexisting illness) or eligibility for intervention (e.g., surgery is not an option for patients with diffuse or distal coronary lesions). A blinded review of the patients' cardiac-catheterization films would help clarify this issue.

Dr. Fowler expresses the concern that our study may not have adequately controlled for socioeconomic factors. Although we agree that it is difficult to adjust for socioeconomic differences completely, our study was limited to patients who underwent cardiac catheterization (and thus had access to a cardiology consultant) and was limited to a single type of institution. In addition, our analysis adjusted for insurance status and the type of unit the patient was admitted to (general medicine or cardiology).

Dr. Fowler also states that mistrust on the part of patients or bias on the part of physicians may partly explain our findings. We agree. As we pointed out, our study helps establish that racial differences in cardiac care are not explained by clinical factors and appear to lead to worse long-term outcomes in African Americans. We hope that these findings will motivate others to clarify the complex reasons for racial differences in care and, more important, determine how to overcome them.

Eric D. Peterson, M.D., M.P.H.
Linda K. Shaw, B.S.
Elizabeth R. DeLong, Ph.D.
Duke University Medical Center, Durham, NC 27710

1 References

1
Barnhart JM, Wassertheil-Smoller S, Monrad SE, Ginsberg M. Recommendation patterns for coronary revascularization: evidence of racial differences. J Gen Intern Med 1995;10:60-60 abstract.

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