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Racial differences in cardiac revascularization rates: does "overuse" explain higher rates among white patients?
E C Schneider1, L L Leape, J S Weissman
1Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115.
Insights
White patients, particularly men, underwent more inappropriate percutaneous transluminal coronary angioplasty (PTCA) than African-American patients. However, this overuse did not fully explain racial disparities in cardiac revascularization rates.
Area of Science:
- Cardiovascular Medicine
- Health Services Research
- Health Disparities
Background:
- Coronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty (PTCA) are standard treatments for symptomatic coronary artery disease.
- Existing research indicates racial disparities in the utilization of these cardiac revascularization procedures.
- Concerns exist regarding the overuse of these interventions, meaning they are performed for clinically inappropriate reasons.
Purpose of the Study:
- To investigate whether higher rates of cardiac revascularization among white patients are linked to increased overuse compared to African-American patients.
- To analyze racial differences in the prevalence of clinically inappropriate indications for revascularization procedures.
Main Methods:
- An observational cohort study utilizing Medicare claims data and medical record reviews.
- Data collected from 173 hospitals across five U.S. states between 1991 and 1992.
- Analysis of a weighted random sample of 3960 Medicare beneficiaries undergoing coronary angiography, with a focus on 1711 revascularization procedures within 90 days.
Main Results:
- White patients showed higher rates of both PTCA (23% vs. 19%) and CABG surgery (29% vs. 17%) compared to African-American patients.
- Overall inappropriate PTCA and CABG rates were 14% and 10%, respectively, with significant geographic variation.
- White men were more likely than African-American men to receive inappropriate PTCA (20% vs. 8%), but inappropriate CABG rates did not differ by race.
Conclusions:
- Overuse of PTCA was more prevalent in white men compared to other racial groups, but this did not entirely explain overall racial disparities in revascularization.
- Significant regional variations in the overuse of cardiac revascularization procedures were observed.
- The findings highlight complex factors contributing to racial differences in cardiovascular intervention rates.
Background:
Coronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty (PTCA) are well-established treatments for symptomatic coronary artery disease. Previous studies have documented racial differences in rates of use of these cardiac revascularization procedures. Other studies suggest that these procedures are overused: that is, they are done for patients with clinically inappropriate indications.
Objective:
To test the hypothesis that the higher rate of cardiac revascularization among white patients is associated with a higher prevalence of overuse (revascularization for clinically inappropriate indications) among white patients than among African-American patients.
Design:
Observational cohort study using Medicare claims and medical record review.
Setting:
173 hospitals in five U.S. states.
Participants:
A stratified, weighted, random sample of 3960 Medicare beneficiaries who underwent coronary angiography during 1991 and 1992; 1692 of these patients underwent 1711 revascularization procedures within 90 days.
Measurements:
The proportion of CABG and PTCA procedures rated appropriate, uncertain, and inappropriate according to RAND criteria, and the multivariate odds of undergoing inappropriate revascularization among African-American patients and white patients.
Results:
After angiography, rates of PTCA (23% vs. 19%) and CABG surgery (29% vs. 17%) were significantly higher among white patients than among African-American patients. The respective rates of inappropriate PTCA and CABG surgery were 14% and 10%. Among the study states, rates of inappropriate use ranged from 4% to 24% for PTCA and 0% to 14% for CABG surgery. White patients were more likely than African-American patients to receive inappropriate PTCA (15% vs. 9%; difference, 6 percentage points [95% CI, -0.4 to 12.7 percentage points]), and difference by race was statistically significant among men (20% vs. 8%; difference, 12 percentage points [CI, 1.2 to 21.7 percentage points]). Rates of inappropriate CABG surgery did not differ by race (10% in both groups).
Conclusions:
Among a large and diverse sample of Medicare beneficiaries in five U.S. states, overuse of PTCA was greater among white men than among other groups, but this difference did not fully account for racial disparities in revascularization. Overuse of cardiac revascularization varied significantly by geographic region.
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