Background Previous studies have found racial differences inthe use of invasive cardiovascular procedures, which may bedue in part to the greater financial incentives to perform suchprocedures in white patients. In Department of Veterans Affairshospitals, direct financial incentives affecting use of theprocedures are minimized for both patients and physicians.
Methods We analyzed retrospectively the use of cardiovascularprocedures among black and white male veterans discharged fromVeterans Affairs hospitals with primary diagnoses of cardiovasculardisease or chest pain during fiscal years 1987 through 1991.We used coded discharge data to determine whether cardiac catheterization,percutaneous transluminal coronary angioplasty, or coronaryartery bypass grafting was performed during or immediately aftersuch admissions. We used logistic-regression analysis to adjustfor the primary discharge diagnosis, the presence of coexistingconditions, age, marital status, type of eligibility to receivecare at Veterans Affairs hospitals, geographic region, and whetherthe hospital was equipped to perform bypass surgery. We classifiedthe primary diagnosis as myocardial infarction, unstable angina,angina, chronic ischemia, chest pain, or "other" cardiovasculardiagnosis.
Results After we adjusted for all the potential confounders,we found that white veterans were more likely than black veteransto undergo cardiac catheterization (odds ratio, 1.38; 95 percentconfidence interval, 1.34 to 1.42), angioplasty (odds ratio,1.50; 95 percent confidence interval, 1.38 to 1.64), and coronaryartery bypass surgery (odds ratio, 2.22; 95 percent confidenceinterval, 2.09 to 2.36).
Conclusions Even when financial incentives are absent, whitesare more likely than blacks to undergo invasive cardiac procedures.These findings suggest that social or clinical factors affectthe use of these procedures differently in blacks and whites.
Access to technologically advanced care for certain segmentsof society is an important health care issue in the United States1.Previous studies have found racial differences in the use ofinvasive procedures in the management of cardiac disease2,3,4,5,6,7,8.These studies have shown that white patients are more likelythan black patients to undergo various invasive cardiac procedures,such as cardiac catheterization, percutaneous transluminal coronaryangioplasty (PTCA), and coronary artery bypass grafting (CABG).These differences persist despite adjustment for potential confoundingvariables such as age, sex, clinical factors, socioeconomicstatus, and insurance status2,5.
Existing studies of racial differences in the use of invasivecardiac procedures have several limitations. Some studies havebeen restricted to a single clinical center or geographic region.It is also possible that the differences detected may have reflecteddifferences in practice patterns between hospitals serving largenumbers of blacks and those serving primarily whites. Finally,most investigators have been unable to control adequately forthe potentially confounding influence of economic factors. Forexample, all patients with Medicare might be grouped together,regardless of whether they had supplemental insurance, becauseonly information about the primary insurer was available.
The Department of Veteran Affairs (VA) hospital system offersdistinct advantages for the study of racial differences in theuse of invasive procedures to manage cardiac disease. Treatmentwithin the VA system does not depend on patients' ability topay. Financial incentives for physicians to perform proceduresare minimized, because physicians receive a salary. Relativelyfew VA medical centers perform coronary artery bypass surgery(42 from 1987 through 1991), but most perform a substantialnumber of invasive cardiovascular procedures each year; thus,it is possible to analyze variation within individual hospitalsas well as throughout the VA system. Finally, since VA medicalcenters are distributed nationwide, the results are more likelyto be generalizable than those of studies based on data froma single hospital or from hospitals in one state.
We conducted a retrospective study using the VA administrativedata base, the Patient Treatment File, to examine the use ofcardiac catheterization, PTCA, and CABG among white and blackmale veterans treated at VA hospitals.
Methods
Data Base
We used records of hospitalizations in VA hospitals from thePatient Treatment File for fiscal years 1987 through 1991. Foreach discharge from a VA hospital, up to 10 diagnoses, 5 operatingroom procedures, and 32 non-operating room procedures are codedaccording to the coding system of the International Classificationof Diseases, 9th Revision, Clinical Modification (ICD-9-CM)9.Each record also contains demographic and administrative characteristics,such as the veteran's sex, race, age, and marital status, dataon the patient's eligibility for care at a VA center (eligibilitystatus), and an identifier for the discharging hospital.
Patient Population
We used the coded discharge data to identify all male veteransover 30 years of age who were discharged with a primary diagnosisof cardiovascular disease (ICD-9-CM codes 390 through 459) orchest pain (786.50 through 786.59) during the five-year studyperiod. We considered each veteran's first such discharge tobe his index admission. We included the discharge records inthe Patient Treatment File for all admissions during the studyperiod for each veteran.
Definition of Variables
We used the primary diagnosis (the diagnosis responsible forthe major part of the patient's hospitalization) to determinethe main reason for the index hospitalization. The primary diagnosiswas categorized as myocardial infarction, unstable angina, chronicischemia, angina, chest pain, or another cardiovascular diagnosis.
We measured coexisting morbidity in two ways. First, we categorizedthe number of secondary diagnoses during the index hospitalization(used by other investigators as a measure of coexisting morbidity2)as 0 through 3, 4 through 6, or 7 through 9. Second, we usedall discharge records up to and including the index admissionto determine whether the veteran had any of the following coexistingconditions, which we believed would make aggressive managementof coronary artery disease less likely: human immunodeficiencyvirus infection; cancer, except nonmelanoma skin cancer; end-stagerenal disease; cirrhosis; dementia; psychiatric illness; abuseof alcohol or other drugs, excluding tobacco abuse; diabetesmellitus; or chronic lung disease. The precise ICD-9-CM codesused to define these conditions are listed in the Appendix.In univariate analyses, each of these conditions except diabetesmellitus decreased the likelihood that an invasive cardiovascularprocedure would be performed. Therefore, we considered a coexistingcondition to be present if the patient had any of these conditions,except diabetes mellitus.
We categorized race as white or black. We excluded veteranswhose race was not coded as white or black. Age was classifiedas 31 through 40, 41 through 50, 51 through 60, 61 through 70,71 through 80, and 81 years or older. Marital status was categorizedas divorced, married, never married, separated, widowed, orunknown. Eligibility for hospitalization in a VA medical centerwas categorized as category A, service connected (the veteranwas eligible because a medical condition was incurred or aggravatedwhile he was on active duty); category A, not service connected(the veteran had a condition not incurred or aggravated duringactive service but was eligible because of low income); or other(see the Appendix). The location of the hospital was categorizedas Northeast, Southeast, Midwest, or West, following the Departmentof Veterans Affairs' present regional organization. Hospitalswere categorized as CABG centers (i.e., as centers equippedto perform CABG) for fiscal years in which at least 10 CABGprocedures were performed there.
For each veteran, we determined whether cardiac catheterizationor PTCA was performed in a VA hospital during or within 60 daysafter the index admission, and whether CABG was performed within90 days after the index admission.
Thus, our final data set included all male black or white veteransover 30 years of age who were hospitalized in VA medical centersprimarily for a cardiovascular disease or chest pain duringthe study period. For each such person, we had information onrace, age, coexisting conditions, marital status, eligibilitystatus, the treatment capabilities of the center, the geographiclocation of the hospital to which he was first admitted, andwhether CABG, PTCA, or cardiac catheterization was performedat the VA hospital.
Statistical Analysis
In our primary analysis we examined the use of procedures duringor within 60 or 90 days after the index admission for each veteran.We performed identical analyses for each of three outcome variables-- cardiac catheterization within 60 days, PTCA within 60 days,and CABG within 90 days. Because of the size of our population,we knew that even trivial associations could be significant.Therefore, we identified potentially confounding variables onthe basis of clinical judgment and evidence of their importancein previous studies. We then included these potential confoundersin our final models, regardless of the degree of statisticalsignificance.
Univariate analysis with simple chi-square tests of significancewas used to evaluate the overall association of race with theuse of procedures10. We then used a stratified chi-square analysisto control separately for diagnosis, region, age, coexistingmorbidity, marital status, year of diagnosis, VA eligibilitystatus, and whether CABG was performed at the hospital wherethe initial diagnosis was made10. To control for all these variablessimultaneously, we used a multiple logistic-regression model11.In addition, we examined the interactions between each potentialconfounder and race.
To study potential confounding by variation in the use of proceduresamong hospitals, we used the subgroup of veterans whose indexadmissions were to hospitals that frequently performed CABG(CABG centers). We first calculated the relative risk of undergoingeach procedure for whites as compared with blacks in each ofthese hospitals. We then used logistic-regression analyses todetermine the independent influence of race on the use of procedures,controlling for coexisting morbidity, primary diagnosis, age,and hospital.
Since the categories "other cardiovascular disease" and "chestpain" include a heterogeneous set of clinical entities, we performedlogistic-regression analyses both including and excluding veteranswith these primary diagnoses. To facilitate comparison withthe results of previous studies, however, we present our univariateand stratified results with these patients included.
To eliminate potential confounding by income, we repeated thelogistic-regression analyses in the subgroup of category A patientswith non-service-connected conditions (maximal household income,$18,844 for a veteran without dependents in 1992).
We used Statistical Analysis System software for all statisticalanalyses12,13. All P values are two-sided.
Results
We identified 882,508 admissions of veterans with a primarydiagnosis of cardiovascular disease or chest pain during thestudy period. We excluded 6.8 percent because the patients didnot meet the study criteria for race (4.7 percent), sex (1.5percent), VA eligibility status (0.4 percent), or age (0.4 percent).The remaining 822,930 admissions occurred among the 428,300black or white male veterans over 30 years old who constitutedthe study population. Table 1 displays the characteristics ofthe study population. Given the large sample, each of the smalldifferences between the races is statistically significant.However, the proportion of veterans with at least one importantcoexisting condition and the distribution of the number of secondarydiagnoses were similar between the black and white veterans.Black veterans more often resided in the Southeast, had non-service-connectedcategory A eligibility, and had a primary diagnosis of "othercardiovascular disease."
Table 1. Characteristics of Black and White Veterans Admitted with Cardiovascular Diagnoses or Chest Pain, Fiscal Years 1987 through 1991.
Cardiac catheterization was performed during or within 60 daysof the index admission in 77,168 (18.0 percent) of these veterans.The rate was 19.3 percent among whites and 11.8 percent amongblacks (relative risk of undergoing the procedure for a whiteas compared with a black veteran, 1.64; 95 percent confidenceinterval, 1.61 to 1.68). For PTCA the corresponding number was6819 veterans (1.6 percent). The rate was higher among whites(1.8 percent) than among blacks (0.8 percent; relative risk,2.18; 95 percent confidence interval, 2.01 to 2.37). Similarly,18,912 veterans (4.4 percent) underwent CABG within 90 daysof the index admission -- 5.0 percent of whites and 1.6 percentof blacks (relative risk, 3.17; 95 percent confidence interval,2.99 to 3.37).
Many independent variables other than race were associated withthe use of invasive cardiovascular procedures, including age,marital status, VA eligibility status, fiscal year, the presenceof clinically important coexisting conditions, the number ofsecondary diagnoses, the primary diagnosis, the region, andwhether the index admission was to a hospital that was equippedto perform CABG (CABG center). The relative risks for the procedures,stratified according to potential confounders, are displayedin Table 2. Whites underwent each of the procedures more frequentlythan blacks in all diagnostic categories. The differences werestatistically significant in most of the subgroups we examined.Summary relative risks are not reported, since the white-blackdifferences within strata for several of the independent variableswere heterogeneous according to the Breslow-Day test10.
Table 2. Relation of Race to the Use of Invasive Cardiovascular Procedures in 1987 through 1991, According to Potential Confounding Variables.
Finally, we used a multiple logistic-regression model to examinethe independent contribution of race to the use of each of thethree cardiovascular procedures, adjusting for the other independentvariables (Table 3). White race was a statistically significantpredictor of the use of each of the procedures, regardless ofwhich independent variables were included. This model includedprimary diagnosis, race, age, coexisting morbidity, year ofthe index hospitalization, marital status, region, and whetherthe index hospitalization was in a CABG center (Table 3). Afteradjustment for all these variables, the odds ratios for undergoinga cardiovascular procedure for a white as compared with a blackveteran were as follows: cardiac catheterization, 1.38 (95 percentconfidence interval, 1.34 to 1.42); angioplasty, 1.50 (95 percentconfidence interval, 1.38 to 1.64); and CABG, 2.22 (95 percentconfidence interval, 2.09 to 2.36). The inclusion of interactionterms did not significantly alter our conclusions, althougha number of the associations were statistically significant,as suggested by the stratified analysis.
Table 3. Odds Ratio for the Use of Procedures among Whites as Compared with Blacks with Cardiovascular Diagnoses, Adjusted for Potential Confounders.
The results of this analysis did not change when we restrictedour analysis to clearly ischemic diagnoses (that is, when weexcluded the nonspecific categories of "other cardiovasculardiagnoses" and "chest pain") (Table 3). When we further restrictedthe analysis to veterans with limited income (those with non-service-connectedcategory A eligibility), the white-black odds ratios remainedessentially unchanged (Table 3).
In our analysis of rates of procedure use among veterans admittedto CABG centers, the rates varied greatly among veterans admittedto different hospitals. For example, the rates of CABG within90 days of discharge varied from 2.6 percent to 13.4 percent,depending on the site of the index hospitalization. However,in a logistic-regression analysis in which we controlled forsite, coexisting morbidity, age, and primary diagnosis, whitesremained significantly more likely to undergo cardiac catheterization(odds ratio, 1.53; 95 percent confidence interval, 1.48 to 1.59),PTCA (odds ratio, 1.47; 95 percent confidence interval, 1.32to 1.64), and CABG (odds ratio, 2.15; 95 percent confidenceinterval, 1.99 to 2.33).
Discussion
We found that white patients consistently underwent invasivecardiac procedures more often than black patients. These findingswere evident for cardiac catheterization, PTCA, and CABG duringor after the index admissions for each diagnostic category (Table 2).Adjusting for coexisting morbidity, demographic characteristics,and the treating hospital did not alter our findings. Our data,coupled with the results of previous studies,2,3,4,5,6,7 suggestthe existence of race-related inequities in our health caresystem.
Our results substantially strengthen previous observations innon-VA hospitals, for several reasons. First, the financialincentives that operate in fee-for-service systems are minimizedin VA medical centers. VA physicians are usually salaried, sopatients' finances and insurance do not affect physicians' incomefrom procedures. In VA hospitals, unlike private-sector hospitals,patients' ability to pay does not affect the income of the center,which is determined by global budgeting. Thus, there are nofinancial incentives for providers to use procedures preferentiallyin whites. Since eligible veterans are not billed for admissionsto VA hospitals, patients' fears about incurring large debtsfor the use of expensive procedures are also minimized. Ouranalysis of a subgroup of veterans with more homogeneous incomes(those with non-service-connected category A eligibility) yieldedresults similar to those of the analysis of our entire studypopulation, further suggesting that differences in personalincome do not underlie racial differences in the use of procedures.
We were also able to refute the suggestion that racial differencesare due to lower rates of use of procedures in hospitals thattreat more black patients. Although we found marked variationsin the use of procedures among hospitals, these three procedureswere used more often in white than in black patients in everyone of the hospitals that performed a substantial number ofthe procedures. Controlling for the initial treatment site didnot affect the differences for any of these procedures.
Additional strengths of this study include the facts that ourdata base was national, that it included five years of data,and that we were able to follow patients over time. Thus, wewere able to determine whether patients admitted to hospitalswithout the capability of performing certain procedures underwentthose procedures elsewhere after discharge. In addition, wewere able to identify coexisting conditions that were presentduring hospitalizations that preceded the index admission.
Our study has important limitations that are common in analysesof administrative data sets. First, the accuracy of coding isa constant cause for concern when such data bases are used.The rate of error in diagnostic coding is known to be substantialin both VA and non-VA discharge data in general14,15,16,17 andin the coding for myocardial infarction in particular18. However,it is unlikely that coding errors would entail systematic biastoward one racial group or another.
Second, adjusting for the severity of disease and coexistingmorbidity on the basis of administrative data sets has beenshown to be problematic19,20. Thus, unmeasured differences inthe presence and severity of coexisting conditions may explainsome of the observed racial difference in the use of procedures.Further examination of this issue would require access to individualpatients' records.
Third, the use of discharge data does not permit the study ofdecisions regarding admission. It is possible that systematicdifferences in admission practices affected our results. Existingdata suggest that blacks are more likely than whites to forgoor delay medical care for symptoms of ischemic heart disease21,22,23.It is not clear how this factor would affect the use of proceduresamong patients who are admitted.
A factor peculiar to this study of VA data is that veteransobtain some of their care outside the VA system24. Inasmuchas whites are more likely than blacks to undergo these proceduresin non-VA hospitals,2,3,4,5,6,7,8 our results may tend to underestimatethe difference in the use of procedures between whites and blacks.
Our study is comparable to studies by Wenneker and Epstein2and Hannan et al.,5 who analyzed administrative data on hospitalizationsin nonfederal hospitals in Massachusetts and New York, respectively.The white-black odds ratios for each procedure in our overalllogistic-regression model were remarkably similar to those obtainedin these studies (Table 4). This similarity suggests that thecauses of the differences between whites and blacks are notspecific to a given delivery system or geographic area.
Table 4. Adjusted Odds Ratio for the Use of Procedures among Whites as Compared with Blacks from Studies Examining the Relation between Race and the Use of Invasive Cardiovascular Procedures.
Why do disparities in the rates of cardiovascular proceduresbetween white and black patients persist? Possible explanationsinclude differences in the severity of coronary artery disease,unmeasured differences in the presence or severity of coexistingconditions, cultural differences in attitudes toward proceduresor medical care in general, differences in access to care, andsystematic racial bias. More than one, and perhaps all, of thesefactors may be at work.
Our finding that the white-black difference in the use of procedureswas smallest for cardiac catheterization, greatest for CABG,and intermediate for PTCA is consistent with the results ofprevious studies2,5. It is also consistent with several explanationsfor the disparity.
If blacks have less severe coronary artery disease than whitesadmitted with similar diagnoses, lower rates of PTCA and CABGamong black patients would be appropriate. Indeed, two studiesof angiographic results found that blacks who underwent catheterizationwere more likely than whites to have minimal disease or none,and less likely to have three-vessel disease. This differencepersisted after adjustment for potential confounders4,25. Bothstudies included relatively few blacks and examined selectedpopulations, thus limiting their generalizability. The resultsmust be considered in the light of other data suggesting thatblacks have higher rates of morbidity and mortality due to cardiovasculardisease26.
Similarly, if blacks are less likely than whites to accept recommendationsthat they undergo invasive procedures, this reluctance mightbe greater for CABG and PTCA than for cardiac catheterization.Alternatively, whites may be more likely to expect that theseprocedures will be part of their care. Oberman and Cutter foundthat whites with two-vessel or three-vessel coronary arterydisease were more likely to undergo CABG than blacks with similardisease, though the reason for the discrepancy was not explained4.Blacks for whom surgery was recommended in the nonrandomizedportion of the Coronary Artery Surgery Study were less likelyto undergo surgery than whites27.
Finally, any subtle bias against the use of invasive proceduresin the treatment of black patients might be most evident whendecision making is less clearly dictated by the clinical situation.Expert physicians participating in the Rand study of the appropriatenessof care were more likely to disagree on the appropriatenessof CABG than on the appropriateness of cardiac catheterization28.Thus, there may be more room for clinical judgment in the useof CABG than in the use of cardiac catheterization. It is interestingthat the black-white disparity in the use of procedures seemedsmallest for patients with acute myocardial infarction. A similartrend was seen in the report by Wenneker and Epstein2. It maybe that the decision to use cardiac catheterization is leastsubjective in such circumstances.
The extent to which subtle or overt racism underlies racialdifferences in the use of cardiac procedures is unclear29,30.We believe that inadequate health education, differences inpatients' preferences for invasive management, delivery systemsthat are unfriendly to members of certain cultures, and overtracism may all play a part. Allocating responsibility more preciselywill require studies that control for angiographic data anddirectly examine interactions between patients and medical professionals.Debating how much "blame" should be allocated to which factorshould not delay efforts to clarify and remedy each of thesedeficiencies in our medical care system.
Supported in part by a Health Services Research DevelopmentalGrant (DEV 92-006) from the Department of Veterans Affairs (toDr. Lofgren).
We are indebted to David S. Macpherson, M.D., for his helpfulcomments on an earlier version of this manuscript and to MarkWenneker, M.D., M.P.H., who provided us with precise codes usedin his study2.
Source Information
From the Section of General Internal Medicine, Pittsburgh Veterans Affairs Medical Center, and the Section of General Internal Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh.
Address reprint requests to Dr. Whittle at the Pittsburgh VA Medical Center (11A), University Drive C, Pittsburgh, PA 15240.
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Appendix
The VA eligibility categories and diagnostic and proceduralcodes used in this study were as follows:
Category A eligibility. This category included veterans forwhom free hospital care was federally mandated. All veteranswith service-connected conditions (those incurred or aggravatedduring active duty) were in category A. Veterans with non-service-connectedconditions were in category A if they were not dishonorablydischarged and met income criteria. The maximal incomes in 1992were as follows: no dependents, $18,844; one dependent, $22,613;two dependents, $24,277; three dependents, $25,490; four dependents,$26,703; and five or more dependents, $27,916.
Service-connected condition. A medical condition was consideredservice connected if it was incurred or aggravated while theserviceman was on active duty. This category included both chronicillnesses first diagnosed while the serviceman was in the military(e.g., diabetes) and conditions caused by military service (e.g.,gunshot wounds).
Special categories. In the present analysis, veterans with guaranteedeligibility for hospital care because of special considerations-- for example, former prisoners of war -- are grouped withveterans with service-connected conditions.
Other categories. Categories B and C included veterans who werenot dishonorably discharged who had incomes that exceeded thelimits for category A. These veterans could be treated in VAfacilities if the particular facility had resources availableafter providing care to all category A veterans who requestedcare, but they were billed for the services provided.
Primary diagnosis. The ICD-9-CM codes used for primary diagnosiswere as follows: acute myocardial infarction, 410 through 410.92;angina, 413 through 413.9; chronic ischemic heart disease, 414.0,414.8, and 414.9; chest pain, 786.50 through 786.59; unstableangina, 411.1 through 411.89; and other cardiovascular disease,390 through 459.99 but none of the above.
Coexisting conditions. The codes used to identify coexistingconditions likely to decrease the likelihood that an invasivecardiovascular procedure would be used were as follows: humanimmunodeficiency virus infection, 042 through 044.99, 136.3,and 795.8; cancer, except nonmelanoma skin cancer, 140 through172.9, 175 through 175.9, and 185 through 208.99; chronic lungdisease, 294 through 294.9, 491 through 496, and 500 through505; dementia, 290 through 290.99 and 294 through 294.9; diabetesmellitus, 250 through 250.99; drug or alcohol abuse, 291 through291.92, 303 through 305.99, 425.5, 535.3, 571.0 through 571.3,577.0, 577.1 and V11.3; end-stage renal disease, V45.1, V56.0,and V56.8; cirrhosis, 456.0 through 456.21, 568.82, 571.2, 571.5,571.6, 572.2, 572.3, and 572.4; and psychiatric illness, 295through 298.91.
Procedures. The codes used to identify the procedures performedwere as follows: cardiac catheterization, 37.21 through 37.23and 88.55 through 88.57; PTCA, 36.00 through 36.03 and 36.05through 36.09; and CABG, 36.10 through 36.19.
Heart Disease and Race
Lai S., Page J. B., Rodney E., Vasavada B. C., Sacchi T. J., Platt F. W., Becker L. B., Meyer P. M., Whittle J., Conigliaro J., Good C.B.
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N Engl J Med 1994;
330:216-218, Jan 20, 1994.
Correspondence
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