Physician discretion and racial variation in the use of surgical procedures

Racial variation in the use of surgical procedures raises concern about equitable access. The goal of our study was to examine racial differences in utilization across a broad range of procedures in Massachusetts and to assess whether racial variation is related to physician discretion.

We obtained fiscal year 1988 hospital discharge data for all Massachusetts residents, identified 10 clinically important surgical procedures, and calculated age- and sex-adjusted rate ratios for white and black patients. Level of discretion was determined by using a modified Delphi technique.

Whites had higher rates for eight procedures (abdominal aortic aneurysm repair, appendectomy, cardiac valve replacement, carotid endarterectomy, cholecystectomy, lumbar disk procedures, open reduction/internal fixation of the femur, and tonsillectomy) and lower rates for two procedures, hysterectomy and prostatectomy. Of the eight procedures for which utilization was higher among whites, four were ranked as moderate- or high-discretion procedures and four were ranked as low-discretion procedures. Hysterectomy, the only procedure for which utilization was substantially higher among blacks (white:black rate ratio < 0.90), was ranked as a high-discretion procedure.

With the exception of hysterectomy and prostatectomy, procedure rates for whites were greater than those for blacks for a wide range of surgical procedures. Racial variation exists for low-discretion procedures as well as for those associated with moderate and high discretion. Variation among low-discretion procedures that is not explained by medical need suggests the possibility of race-related differences in access to care or in the way patients and physicians make clinical decisions.