Correspondence

Racial Differences in the Use of Cardiac Catheterization

N Engl J Med 2001; 345:839-840September 13, 2001

Article

To the Editor:

I am concerned that in their study of rates of cardiac catheterization among black patients and white patients, Chen et al. (May 10 issue)1 may have used an invalid assumption. If so, their conclusions and those of Epstein and Ayanian2 in their accompanying editorial may need to be reexamined.

Chen et al. assume that the race of the admitting physician is the appropriate variable to use in assessing racial differences in the use of catheterization. I question this assumption. I believe it is the cardiologist to whom the patient is referred who makes the definitive recommendation for or against catheterization.

Black patients admitted by a black physician were least likely to have been admitted by a cardiologist (Table 1Table 1Percentage of Patients Admitted to the Hospital by a Cardiologist, According to the Race of the Patient and the Race of the Physician.). Yet a separate analysis of the same data set used by Chen et al. showed that over 70 percent of patients were seen by a cardiologist at some time during the initial hospitalization.3

In 1996, according to the American Medical Association, there were only 316 black cardiologists in the United States, of a total of 19,237.4 (The American Medical Association did not know the race of 36.3 percent of the physicians listed in its data files.) I believe it is fair to assume that among black patients who were admitted by a black noncardiologist and were subsequently seen by a cardiologist, substantially more were seen by a white cardiologist than by a black cardiologist. If this is true, we can say very little on the basis of this study about how the race of the admitting physician is related to the differential rates of cardiac catheterization among black patients and white patients.

Donald A. Barr, M.D., Ph.D.
Stanford University, Stanford, CA 94305-2160
barr@stanford.edu

4 References

1. 1

   Chen J, Rathore SS, Radford MJ, Wang Y, Krumholz HM. Racial difference in the use of cardiac catheterization after acute myocardial infarction. N Engl J Med 2001;344:1443-1449
   Full Text | Web of Science | Medline

2. 2

   Epstein AM, Ayanian JZ. Racial disparities in medical care. N Engl J Med 2001;344:1471-1473
   Full Text | Web of Science | Medline

3. 3

   Frances CD, Shlipak MG, Noguchi H, Heidenreich PA, McClellan M. Does physician specialty affect the survival of elderly patients with myocardial infarction? Health Serv Res 2000;35:1093-1116
   Web of Science | Medline

4. 4

   Randolph L. Physician characteristics and distribution in the US: 1997-1998 edition. Chicago: American Medical Association, 1997.
   

To the Editor:

In their editorial, Drs. Epstein and Ayanian state that the study by Chen and colleagues suggests “that overt racial prejudice did not account for racial differences in the rates of cardiac catheterization.” They base this conclusion on the fact that the disparities between the rates of cardiac catheterization among black patients and the rates among white patients did not differ significantly according to whether the physician was black or white and the implied assumption that black physicians cannot be racially prejudiced. Racial prejudice, however, does not depend on the color of the perpetrator's skin. Medical training is not neutral with respect to race, and black doctors go through the same training and acculturation and face the same pressures to conform as do white doctors. Could it be that these black physicians were just practicing what they were taught? Alternatively, could it be that these physicians were not racially biased but that the institutions in which they practiced were? Institutional racism, defined as “customs, and practices which systematically reflect and produce racial inequalities in American society . . . whether or not the individuals maintaining those practices have racist intentions,”1 may also explain the findings reported by Chen and colleagues.

I would also like to believe that racial prejudice does not have a role in how we treat our patients, but we do our “minority” patients a disservice to let ourselves off the hook so easily. We need to continue to explore how racial bias, whether conscious or unconscious, might play a part in the way in which individual health care providers and health care institutions treat their patients.

Elizabeth A. Jacobs, M.D., M.P.P.
Cook County Hospital, Chicago, IL 60612
ejacobs@rush.edu

1 References

1. 1

   Jones JM. Prejudice and racism. Reading, Mass.: Addison–Wesley, 1972.
   

Author/Editor Response

The authors reply:

To the Editor: Dr. Barr misunderstood our methods. We evaluated the race of the attending physician, not the admitting physician. The attending physician is “the clinician who is primarily and largely responsible for the care of the patient from the beginning of the hospital episode.”1 The cardiologist to whom the patient is referred may make a recommendation about whether a patient should undergo cardiac catheterization after myocardial infarction, but the attending physician has the ultimate responsibility for this decision. Thus, we believe that our study design was appropriate. If we accept Dr. Barr's contention that white cardiologists exhibited racial bias in their referrals for cardiac catheterization among patients of black attending physicians, then it follows that black attending physicians concurred with and supported these racially biased decisions. We consider this unlikely. A test of racial differences in the use of cardiac catheterization among patients treated by black cardiologists as compared with those treated by white cardiologists would eliminate concern about the effects introduced by a cardiology consultation. However, we did not conduct this test, because of the small number of patients treated by black cardiologists (223 of the 39,715 patients).

Dr. Jacobs raises the concern that physicians or institutions may contribute to racial disparities in cardiac catheterization. We were careful in our article to conclude only that the racial differences in use of the procedure did not differ according to the race of the attending physician. We did not infer that discrimination does not exist within the health care system. Nonetheless, we believe, as Epstein and Ayanian stated in their accompanying editorial, that our findings suggest that overt discrimination by white physicians against black patients probably does not contribute to racial differences in the use of cardiac catheterization. Many questions remain about why these differences exist, whether they are inappropriate, and what we should do about them. Further efforts are needed to identify and eliminate inappropriate racial variations in the delivery of care.

Jersey Chen, M.D., M.P.H.
Saif S. Rathore, M.P.H.
Harlan M. Krumholz, M.D.
Yale University, New Haven, CT 06520-8025
harlan.krumholz@yale.edu

1 References

1. 1

   Iezzoni LI. Data sources and implications: administrative data bases. In: Iezzoni LI, ed. Risk adjustment for measuring health care outcomes. Ann Arbor, Mich.: Health Administration Press, 1994:119-75.
   

Author/Editor Response

The editorialists reply:

To the Editor: The decision-making process that leads from myocardial infarction to coronary angiography is complex,1 and depending on the clinical and institutional setting, the patient, members of his or her family, and multiple physicians may provide input. In most instances, the attending physician probably has a critical role, referring the patient to an angiographer directly or to a cardiologist who evaluates the patient's suitability for angiography.2 Although a consulting cardiologist may provide important input in the decision about whether to perform angiography, as Dr. Barr suggests, we believe the initial referral is a paramount factor in predicting the use of a procedure. More refined studies of the referral process may elucidate the relative effect of different types of physicians on racial differences in the use of a procedure.

We are sympathetic to the concern expressed by Dr. Jacobs. In our editorial, we noted evidence of physicians' subtle biases based on social factors that may underlie their judgments about patients' suitability for procedures. Previous research has documented difficulties in communication between physicians and patients of lower socioeconomic status, and physicians have more negative perceptions of such patients than of those with higher socioeconomic status. Because black patients are disproportionately represented in disadvantaged socioeconomic groups, they may face both racial and socioeconomic barriers to care. Institutional racism could be an important factor in explaining the patterns of procedural use reported by Chen and colleagues. Their study was not designed to examine this topic, but we agree with Dr. Jacobs that it is an important area to explore.

Arnold M. Epstein, M.D.
Harvard School of Public Health, Boston, MA 02115
aepstein@hsph.harvard.edu

John Z. Ayanian, M.D., M.P.P.
Harvard Medical School, Boston, MA 02115

2 References

1. 1

   Einbinder LC, Schulman KA. The effect of race on the referral process for invasive cardiac procedures. Med Care Res Rev 2000;57:Suppl 1:162-180
   Web of Science | Medline

2. 2

   Ayanian JZ, Guadagnoli E, McNeil BJ, Cleary PD. Treatment and outcomes of acute myocardial infarction among patients of cardiologists and generalist physicians. Arch Intern Med 1997;157:2570-2576
   CrossRef | Web of Science | Medline