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Clinical and nonclinical correlates of racial and ethnic differences in recommendation patterns for coronary
J M Barnhart1, S Wassertheil-Smoller, E S Monrad
1Department of Epidemiology, Albert Einstein College of Medicine, Bronx, New York, USA.
Insights
Racial disparities exist in coronary revascularization recommendations. Hispanics with severe coronary artery disease were less likely to be recommended for procedures like angioplasty or bypass surgery.
Area of Science:
- Cardiology
- Health Disparities
- Medical Outcomes
Background:
- Investigated potential gender and racial differences in coronary revascularization recommendations.
- Focused on a multiracial patient cohort undergoing initial coronary angiography for coronary artery disease (CAD) evaluation.
- Study period: 1990-1993 at an academic institution.
Purpose of the Study:
- To determine if race or gender influences recommendations for coronary revascularization.
- Hypothesized no racial differences in revascularization recommendations for patients with significant CAD.
Main Methods:
- Analyzed recommendations for percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft (CABG) in 590 patients with significant CAD.
- Primary analysis focused on 180 patients with severe CAD (triple-vessel or left main disease).
- Controlled for age, gender, ejection fraction, angina, diabetes, hypertension, and peripheral vascular disease; race categorized as Hispanic, black, and white.
Main Results:
- Hispanics with severe CAD were significantly less likely than whites to be recommended for PTCA/CABG (OR=0.39).
- Black patients showed a trend towards lower recommendation rates compared to whites (OR=0.67).
- Medical record review of patients not recommended for revascularization revealed reasons including subsequent ischemic events, disease severity precluding intervention, or patient preference for medical therapy.
Conclusions:
- Racial differences were observed in revascularization recommendations following coronary angiography.
- These disparities may be attributed to unmeasured clinical and nonclinical factors.
Background:
We sought to determine whether gender or racial differences exist in recommendations for coronary revascularization in a multiracial patient population undergoing their first coronary angiography at an academic institution from 1990-1993 for the evaluation of coronary artery disease (CAD).
Hypothesis:
For patients with clinically significant CAD, no racial differences exist in the recommendation to revascularization following coronary angiography.
Methods:
The main outcome measure was a recommendation for coronary revascularization such as percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft (CABG) for patients with clinically significant CAD (n = 590). The primary multiple logistic regression analysis focused on only those patients with angiographically severe disease, defined as triple-vessel or left main CAD (n = 180). Race was trichotomized into Hispanic, black, and white to ascertain whether any differential effects of race/ethnicity existed while controlling for age, gender, ejection fraction, angina, diabetes, hypertension, and peripheral vascular disease. A medical record review for all patients with severe CAD, who were given a recommendation for medical therapy, was conducted to ascertain whether previously unmeasured clinical factors or nonclinical factors may have precluded a PTCA/CABG recommendation.
Results:
Hispanics with severe disease were significantly less likely than whites to be given a recommendation for PTCA/CABG following angiography [odds ratio (OR) = 0.39; 95% confidence interval (CI) (0.17, 0.92)]. Blacks were 67% as likely as whites to be given such a recommendation [OR = 0.67; 95% CI (0.17, 2.71)]. Medical records, reviewed for 35 of 40 of these patients given a recommendation for medical therapy, revealed that 6 patients eventually had PTCA/CABG within 6 months due to precipitating ischemic events; 9 had such severe or diffuse disease that revascularization did not appear to be an alternative, and 2 patients opted for medical therapy.
Conclusions:
Racial differences were manifested in the recommendations made following angiography and may be explained by previously unmeasured clinical as well as nonclinical factors.
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