The Effect of Race and Sex on Physicians' Recommendations for Cardiac Catheterization
Kevin A. Schulman, M.D., Jesse A. Berlin, Sc.D., William Harless, Ph.D., Jon F. Kerner, Ph.D., Shyrl Sistrunk, M.D., Bernard J. Gersh, M.B., Ch.B., D.Phil., Ross Dubé, Christopher K. Taleghani, M.D., Jennifer E. Burke, M.A., M.S., Sankey Williams, M.D., John M. Eisenberg, M.D., José J. Escarce, M.D., Ph.D., and William Ayers, M.D.
Background Epidemiologic studies have reported differences inthe use of cardiovascular procedures according to the race andsex of the patient. Whether the differences stem from differencesin the recommendations of physicians remains uncertain.
Methods We developed a computerized survey instrument to assessphysicians' recommendations for managing chest pain. Actorsportrayed patients with particular characteristics in scriptedinterviews about their symptoms. A total of 720 physicians attwo national meetings of organizations of primary care physiciansparticipated in the survey. Each physician viewed a recordedinterview and was given other data about a hypothetical patient.He or she then made recommendations about that patient's care.We used multivariate logistic-regression analysis to assessthe effects of the race and sex of the patients on treatmentrecommendations, while controlling for the physicians' assessmentof the probability of coronary artery disease as well as forthe age of the patient, the level of coronary risk, the typeof chest pain, and the results of an exercise stress test.
Results The physicians' mean (±SD) estimates of the probabilityof coronary artery disease were lower for women (probability,64.1±19.3 percent, vs. 69.2±18.2 percent for men;P<0.001), younger patients (63.8±19.5 percent forpatients who were 55 years old, vs. 69.5±17.9 percentfor patients who were 70 years old; P<0.001), and patientswith nonanginal pain (58.3±19.0 percent, vs. 64.4±18.3percent for patients with possible angina and 77.1±14.0percent for those with definite angina; P<0.001). Logistic-regressionanalysis indicated that women (odds ratio, 0.60; 95 percentconfidence interval, 0.4 to 0.9; P=0.02) and blacks (odds ratio,0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) wereless likely to be referred for cardiac catheterization thanmen and whites, respectively. Analysis of race–sex interactionsshowed that black women were significantly less likely to bereferred for catheterization than white men (odds ratio, 0.4;95 percent confidence interval, 0.2 to 0.7; P=0.004).
Conclusions Our findings suggest that the race and sex of apatient independently influence how physicians manage chestpain.
Epidemiologic studies have identified differences accordingto race and sex in the treatment of patients with cardiovasculardisease in the United States.1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18Some studies have found that blacks and women are less likelythan whites and men, respectively, to undergo cardiac catheterizationor coronary-artery bypass graft surgery when they are admittedto the hospital for treatment of chest pain or myocardial infarction.1,2,3,4,5,7,8,10,11,13,14In contrast, other studies were unable to confirm that invasiveprocedures are underused in women.15,16
Racial differences in the treatment of cardiovascular diseasemay be explained by financial and organizational barriers,13clinical differences among patients,17 preferences of the patients,7,8,10,12and the amount of contact the patients have with the healthcare system or hospitals that offer invasive cardiovascularservices.18 Most studies that have controlled for the insurancestatus of patients1,5,7,9,10,11,12,13 or have assessed patientsalready within the health care system1,2,3,5,7,8,9,10,11,12,13,14still found significant effects of race. However, one studyhas reported that there were no effects of race among patientswith private insurance.13
Sex differences in the treatment of cardiovascular disease areless well established. Sex differences persist despite the poorerprognosis for women after myocardial infarction19,20 and thehigher likelihood that they will have had greater functionaldisability due to angina before myocardial infarction.4 Differencesin treatment may be related to a lack of research on cardiovasculardisease in women,21 differences in physicians' interpretationsof women's and men's symptoms,6 time of presentation for treatmentwith respect to the progression of disease,22 or the recommendationsof physicians.23
One question that has not been addressed directly by previousstudies is the extent to which physicians are responsible forthe differences in treatment recommendations with respect torace and sex. The goal of this study was to assess, in a controlledexperiment, physicians' treatment recommendations for patientspresenting with various types of chest pain. We hypothesizedthat the race and sex of the patients would influence the physicians'recommendations regarding cardiac catheterization.
Methods
Survey Instrument
We developed a computerized survey instrument, incorporatingvideo recorded interviews and text, to present descriptionsof patients with chest pain to clinicians and to assess clinicians'decisions about how to manage such symptoms. We constructed144 descriptions using all possible combinations of six experimentalfactors: race (black or white), sex, age (55 or 70 years), levelof coronary risk (low or high), type of chest pain (definiteangina, possible angina, or nonanginal pain), and the resultsof an exercise stress test with thallium (moderate inferolateralischemia, moderate anterolateral ischemia, or multiple severeischemic defects). In addition, each description included thesame results of electrocardiography (nonspecific T-wave changes).
The survey was administered by means of a multimedia computerprogram developed for this study. The instrument included avideo recorded interview of a patient with chest pain and wasdesigned to assess the physicians' management recommendationsand judgment of the characteristics of the patient, and to recordthe demographic characteristics of the physicians.
The recorded component consisted of a scripted interview witha patient. Three scripts were developed, one for each type ofchest pain. Each script contained information on the presentingsymptom, associated cardiac symptoms, relief of symptoms, andduration of symptoms. The scripts were reviewed by four cardiologists,who independently used established criteria to classify thefeatures of the pain described in each interview as definiteangina, possible angina, or nonanginal chest pain.24 The rateof agreement among the classifications made by the cardiologistson the basis of the scripts was greater than 75 percent.
Eight actors representing each of the possible combinationsof race, sex, and age were recruited to portray the patientsin the interviews (Figure 1A, Figure 1B, Figure 1C, Figure 1D,Figure 1E, Figure 1F, Figure 1G, and Figure 1H). Actors wereused because they were considered better able than patientsto express a consistent range of emotions and to read the scriptsverbatim for recording. The interviews were recorded at a singlestudio, with the actors following a particular set of directionsfor each script. The hand motions used by the actors were identicalfor each script, the actors were dressed in identical gowns,and the camera position was the same for all interviews. Thevideo recordings were produced by a company with experiencein the production of educational medical video products (InteractiveDrama, Bethesda, Md.).
Figure 1. Patients as Portrayed by Actors in the Video Component of the Survey.
Panel A shows a 55-year-old black woman, Panel B a 55-year-old black man, Panel C a 70-year-old black woman, Panel D a 70-year-old black man, Panel E a 55-year-old white woman, Panel F a 55-year-old white man, Panel G a 70-year-old white woman, and Panel H a 70-year-old white man.
The video segment was introduced by a screen that listed thepatient's type of insurance (Blue Cross–Blue Shield indemnityinsurance for the 55-year-old patients and Medicare and BlueCross–Blue Shield supplemental insurance for the 70-year-oldpatients) and occupation (assembly supervisor for the 55-year-oldpatients, retired assembly supervisor for the 70-year-old patients).The patients were considered to be at low risk or at high riskfor coronary disease on the basis of blood pressure (low risk,133/81 mm Hg; high risk, 145/86 mm Hg), blood cholesterol concentrations(low risk: low-density lipoprotein [LDL], 146 mg per deciliter[3.8 mmol per liter] and high-density lipoprotein [HDL], 59mg per deciliter [1.5 mmol per liter]; high risk: LDL, 158 mgper deciliter [4.1 mmol per liter] and HDL, 46 mg per deciliter[1.2 mmol per liter]), and smoking history (low risk, no smoking;high risk, smoking one pack of cigarettes a day for 30 years).None of the patients had diabetes, and all had a father whohad had a myocardial infarction at the age of 75 years. Thesecharacteristics were based on those of the subjects in the 20thto 30th percentiles for the risk of coronary artery disease(low risk) and those in the 70th to 80th percentiles (high risk)in the Framingham Study.25
To assess their decisions about management, the physicians wereasked to characterize the type of chest pain described by thepatient and to estimate the probability that he or she had clinicallysignificant coronary disease (defined as 70 percent narrowingof an epicardial coronary artery). The physicians were thenasked if they wished to order further cardiac evaluations forthe patient and were given four options: no stress test, regularstress test, stress test with thallium, and other types of functionalcardiac assessment (e.g., stress echocardiography). The physicianswere then shown the results of one of three stress tests withthallium, asked to estimate the probability of coronary diseaseon the basis of the results of the stress test, and asked whetherthey wished to refer the patient for cardiac catheterization.
The section on patient assessment included a two-part surveyto be completed by the physician, modified from the instrumentdeveloped by van Ryn (van Ryn M: personal communication). Thefirst component of the survey was a 10-item scale, which includeditems assessing the physicians' judgments of the emotional,intellectual, and communication characteristics of patients;these factors are believed to be predictive of patient complianceand treatment outcomes. The personal characteristics of thepatients were evaluated by the physicians on a seven-point Likertscale that rated the strength and direction of the attributeswithin the domain, with scores ranging from –3 (negativeattributes) to 3 (positive attributes). The second componentof the instrument included six individual assessment items evaluatedon a five-point Likert scale, with 1 representing "very unlikely"and 5 representing "very likely." The physicians were askedto predict the likelihood that the patient seen in the interviewhad overreported his or her symptoms, the likelihood that thepatient would miss follow-up appointments, the likelihood thatthe patient would participate in treatment, the likelihood thatthe patient would sue for malpractice, the likelihood that thepatient would comply with therapy, and the likelihood that thepatient would benefit from a revascularization procedure (coronaryangioplasty or coronary-artery bypass surgery). Finally, thesurvey asked the physicians to report their age, race or ethnicgroup, sex, specialty and subspecialty, and year of graduationfrom medical school.
The software program required that all the components of the10-minute survey instrument be presented to each physician andthat the physician see the entire interview before answeringquestions. The interactive programs were developed with theuse of Combersim, a proprietary software program designed byInteractive Drama for the creation of standardized multimediapatients on a personal computer for training purposes.
Study Subjects and Data Collection
Physicians who were in full-time clinical practice and who attendedthe 1997 annual meeting of the American College of Physicians(ACP) or the 1996 annual meeting of the American Academy ofFamily Practice (AAFP) were eligible to participate in the survey.Physicians who registered for the meetings in advance were maileda postcard inviting them to participate in the survey, withthe incentive of an offer of a food gift. The physicians weretold they were participating in a study of clinical decisionmaking but were not told that the primary purpose of the studywas to assess the effects of patients' race and sex on decisionmaking. The surveys were administered in a booth located inthe main exhibit hall of each meeting with six individual computerstations. The computer stations were designed to offer privacyto the physicians and to prevent them from viewing other participantswhile they were completing the survey.
The physicians were randomly assigned to view 1 of 144 possiblecases according to the full-factorial experimental design (i.e.,all the possible combinations of race, sex, age, risk level,type of chest pain, and stress-test results). After each replicationof the study design was completed, the randomized scheme beganagain for a new replicate of 144 cases. Sample-size calculationsrequired a minimum of two replicates (288 subjects) from eachmeeting for the study to achieve 80 percent power to detecta 15 percent difference in referral decisions at a level ofsignificance of 0.05. We collected data for three replicatesat the AAFP meeting (432 subjects) and for two replicates atthe ACP meeting (288 subjects).
Statistical Analysis
We performed univariate analyses to assess differences in thephysicians' responses when different values of the experimentalfactors were used to construct the case descriptions. Differencesin the means of continuous variables were evaluated with t-testsor analysis of variance, and differences in proportions wereevaluated with chi-square tests.
In addition, we used multivariable logistic-regression analysesto assess the effect of the race and sex of the patient on thedecisions of physicians regarding referral for cardiac catheterization,with adjustment for the other experimental variables and additionalpotential confounding variables. We included the race and sexof the patient in the regression models, using two approaches:analyzing the main effects of race and sex only, and analyzingthe main effects of race and sex plus a race–sex interaction.The second approach enabled us to assess treatment recommendationsfor four combinations of race and sex (white man, black man,white woman, and black woman).
In our main analyses, the covariates in the regression modelswere the age of the patient, the level of risk, the type ofchest pain (as classified by the study cardiologists), the resultsof the exercise stress test with thallium, and the physician'sestimate of the probability of coronary disease after the stresstest. We also assessed whether the results remained robust afterthe following changes were made to the models: replacing thetype of chest pain as classified by the study cardiologistswith the type of chest pain as classified by the physicians;replacing the probability of disease after the results of thestress test were known with the probability before they wereknown; omitting estimates of the probability of disease altogether;adding the responses of the physicians regarding the personalcharacteristics of the patients to the covariates in the model;adding the physicians' responses to the individual assessmentitems to the covariates in the model; and adding the characteristicsof the physicians, including race and sex, to the model.
Preliminary analyses showed no difference in survey responsesbetween the physicians at the AAFP meeting and those at theACP meeting and similar effects of the race and sex of the patientat the two meetings. Consequently, we pooled the data from bothmeetings in all subsequent analyses. We converted logistic-regressioncoefficients to odds ratios and calculated 95 percent confidenceintervals, using standard methods.
Results
The only characteristic of the 720 physicians that differedwith respect to the race and sex of the patient was the sexof the physician, with more female physicians assigned to blackfemale patients (P=0.02) (Table 1).
Table 1. Characteristics of the Physicians According to the Race and Sex of the Patient.
The physicians' estimates of the probability of coronary arterydisease before the results of the stress test were known differedaccording to the sex, age, level of risk, and type of chestpain of the patient (Table 2). The patterns of the differenceswere consistent with the known prevalence of coronary diseasein various groups of patients (e.g., older patients have higherrates of coronary disease than younger patients). As expected,these estimates of probability did not differ according to theresults of the stress test, which were unknown to the physiciansat the time the assessments were made.
Table 2. Physicians' Estimates of the Probability of Coronary Artery Disease According to Experimental Factors.
For all categories of all experimental factors, the probabilitiesof disease assigned after the results of the stress test wereknown were consistently greater than those assigned before theresults were known (Table 2). This finding was expected, becauseall the patients had a positive stress test. The probabilitiesassigned after the results of the stress test were known differedaccording to age, the type of chest pain, and the results ofthe exercise stress test.
Overall, the physicians classified 30.6 percent of the patientsas having definite angina, 65.0 percent as having possible angina,and 4.4 percent as having nonanginal chest pain. There wereno differences in the assessments of chest pain according tothe combined race and sex of the patient (P=0.20). The overallrate of agreement with the expert classification was 51 percentand varied from 48 percent to 55 percent for the various combinationsof race and sex. Stress tests were recommended for 93.3 percentof white men and white women and for 97.8 percent of black menand black women (P=0.04).
The physicians' perceptions of the personal characteristicsof the patients differed significantly in 7 of the categoriesmeasured on the 10-item scale according to the combined raceand sex of the patient (P<0.05). However, in no categorywas the difference greater than 0.87 point on the 7-point Likertscale (Table 3). In addition, the responses with respect tothe individual assessment of the predicted behavior of the patientsdiffered significantly for three of the six categories accordingto the combined race and sex of the patient (P<0.02); inno category was the difference greater than 0.27 point on a5-point Likert scale (Table 3).
Table 3. Physicians' Assessments of the Characteristics of the Patients According to Category of Race and Sex.
In univariate analyses, the race and sex of the patient weresignificantly associated with the physicians' decisions aboutwhether to make referrals for cardiac catheterization, withmen and whites more likely to be referred than women and blacks,respectively (Table 4). For the other experimental factors,only the type of chest pain was a significant predictor of whetherthe patient would be referred for cardiac catheterization.
Table 4. Referral for Cardiac Catheterization According to Experimental Factors.
Table 5 shows the results of the multivariable logistic-regressionanalyses. In the model that included only the main effects ofrace and sex, we found that both variables were significantpredictors of rates of referral for cardiac catheterization.Men and whites were significantly more likely to be referredthan women and blacks. These results indicate that the differenceswith respect to race and sex were not simply due to the differencesin the probabilities of disease assigned by the physicians.We then examined the interaction of race and sex in terms ofreferral for cardiac catheterization (P=0.06 for the interaction).Black women were the only patients who were significantly lesslikely to be referred for cardiac catheterization than whitemen, who served as the reference category. In addition, ageand the type of chest pain were significant predictors of referralfor cardiac catheterization, with the odds ratios for all factorssimilar to those in the univariate results. Sensitivity analyses(alternative model specifications) did not change the resultsof the main analyses.
Table 5. Predictors of Referral for Cardiac Catheterization.
Discussion
We found that the race and sex of the patient affected the physicians'decisions about whether to refer patients with chest pain forcardiac catheterization, even after we adjusted for symptoms,the physicians' estimates of the probability of coronary disease,and clinical characteristics. Our findings are most strikingfor black women. Epidemiologic studies have reported differencesin treatment according to race and sex,1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18but they could not assess whether these differences were dueto differences in the clinical presentation of the patients.This study directly addressed this issue by using actors torepresent patients with identical histories and controllingfor characteristics reflective of their personalities. Our findingsare consistent with the results of epidemiologic studies inwhich the lowest rates of cardiovascular procedures were amongnonwhite women.5,9
The physicians' recommendations for cardiac catheterizationcould have reflected their perceptions of the personalitiesrather than the race or sex of the patients. To assess thispossibility, we collected detailed information on the physicians'perceptions of the patients' personalities and other attributeswith the use of a 10-item scale and six individual assessmentquestions. Incorporating this information into the analysisdid not change the main results. Also, because we used a balanced,randomized design, the statistical tests of the experimentalfactors, including the race and sex of the patient, remain valideven if the patients' personality traits and attributes wereimperfectly captured by our methods.26
Our findings suggest that a patient's race and sex may influencea physician's recommendation with respect to cardiac catheterizationregardless of the patient's clinical characteristics. Alternatively,these findings may be the result of other factors not includedin the information we presented to the physicians. For example,data on bypass surgery and angioplasty suggest that women mayhave worse outcomes than men,27,28,29,30 although these effectsmay be due to differences in other confounding variables ratherthan to the sex of the patient.28,30 Why these clinical effectswould influence recommendations for black women and not whitewomen is unclear. We did not find lower rates of referrals forstress tests among women or blacks.
Our study design has several strengths. By having actors poseas patients, clothed in an identical manner and having identicalinsurance and occupations, we removed the effects of differingsocioeconomic status and insurance from our experiment. By providingthe actors with identical scripts, by having them present inhospital gowns under identical direction, and by creating theprogram in a fixed format, we removed the effects of differencesin the presentation of clinical symptoms by patients from ourassessment. Finally, by asking the physicians for their estimatesof the probability of coronary artery disease, we were ableto control for differences in their perceptions of the prevalenceof disease according to the race and sex of the patients. Althoughthe physicians' estimates of the probability of disease beforethe results of the stress test were known were higher than thevalues for nonanginal pain reported in the literature,31,32these estimates are most relevant in the analysis of the treatmentrecommendations. Physicians' tendency to overestimate the probabilityof coronary artery disease in patients from groups with a lowprevalence of disease has been documented previously.33
Our finding that the race and sex of the patient influence therecommendations of physicians independently of other factorsmay suggest bias on the part of the physicians. However, ourstudy could not assess the form of bias. Bias may representovert prejudice on the part of physicians or, more likely, couldbe the result of subconscious perceptions rather than deliberateactions or thoughts.34,35 Subconscious bias occurs when a patient'smembership in a target group automatically activates a culturalstereotype in the physician's memory regardless of the levelof prejudice the physician has.35
Our study has two main limitations. First, we assessed the managementdecisions of physicians using video recordings of actors portrayingpatients and a computerized survey instrument. Several reportssupport the use of case vignettes to assess clinical decisionmaking by physicians.36,37,38,39,40 In two studies of the externalvalidity of case vignettes, assessments made on the basis ofwritten case descriptions correlated highly with those madeon the basis of examinations of patients with equivalent symptomsseen in person.37,38 Video recordings rather than written casepresentations may increase the accuracy of the probability estimatesmade by physicians.40
Second, the recruitment of physicians at national meetings ofmajor professional organizations may have resulted in nonrepresentativesamples. Physicians who attend professional meetings may bebetter informed than those who do not attend. Also, the physicianswho volunteered for this project may have had a greater interestthan others in coronary heart disease.
Our findings indicate that the race and sex of patients independentlyinfluence physicians' recommendations for the management ofchest pain. They suggest that decision making by physiciansmay be an important factor in explaining differences in thetreatment of cardiovascular disease with respect to race andsex.
Supported by a grant (HS07315) from the Agency for Health CarePolicy and Research.
We are indebted to Damon Seils for his assistance in the preparationof the manuscript and to Henry Glick, M.A., for providing therisk profiles from the Framingham Study for use in this study.
Source Information
From the Clinical Economics Research Unit (K.A.S., C.K.T.), the Lombardi Cancer Center (J.F.K.), the Division of General Internal Medicine (S.S.), the Division of Cardiology (B.J.G.), and the Department of Medicine (J.M.E.), Georgetown University Medical Center, Washington, D.C.; the Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology (J.A.B.), and the Division of General Internal Medicine (S.W.), University of Pennsylvania School of Medicine, Philadelphia; Interactive Drama, Bethesda, Md. (W.H., R.D.); and the RAND Health Program, Santa Monica, Calif. (J.E.B., J.J.E.). William Ayers, M.D., Georgetown University Medical Center, Washington, D.C., was also an author.
Address reprint requests to Dr. Schulman at the Clinical Economics Research Unit, Georgetown University Medical Center, 2233 Wisconsin Ave., NW, Suite 440, Washington, DC 20007.
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Missed Diagnoses of Acute Cardiac Ischemia
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66: 436-455
[Abstract]
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(2009). Health Care Disparities and Diabetes Care: Practical Considerations for Primary Care Providers. Clin. Diabetes
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(2009). A Randomized Study of Scleroderma Health State Values: A Picture Is Worth a Thousand Words, and Quite a Few Utilities. Med Decis Making
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Epstein, S. A., Hooper, L. M., Weinfurt, K. P., DePuy, V., Cooper, L. A., Harless, W. G., Tracy, C. M.
(2008). Primary Care Physicians' Evaluation and Treatment of Depression: Results of an Experimental Study Using Video Vignettes. Med Care Res Rev
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(2008). Trends in Racial Disparities Among the Elderly for Selected Procedures. Med Care Res Rev
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(2008). Perceived Medical Discrimination and Cancer Screening Behaviors of Racial and Ethnic Minority Adults. Cancer Epidemiol. Biomarkers Prev.
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(2008). Potentially Avoidable Pediatric Hospitalizations as Defined by the Agency for Healthcare Research and Quality: What Do They Tell Us About Disparities in Child Health?. CLIN PEDIATR
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Lee, C. H., Tan, M., Yan, A. T., Yan, R. T., Fitchett, D., Grima, E. A., Langer, A., Goodman, S. G., for the Canadian Acute Coronary Syndromes (ACS) Re,
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(2007). Disparities in Orthopaedic Surgical Intervention. J Am Acad Orthop Surg
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(2006). Racial Differences in Prevalence of Coronary Obstructions Among Men With Positive Nuclear Imaging Studies. J Am Coll Cardiol
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Pearson, S.-A., Soumerai, S., Mah, C., Zhang, F., Simoni-Wastila, L., Salzman, C., Cosler, L. E., Fanning, T., Gallagher, P., Ross-Degnan, D.
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Daly, C., Clemens, F., Lopez Sendon, J. L., Tavazzi, L., Boersma, E., Danchin, N., Delahaye, F., Gitt, A., Julian, D., Mulcahy, D., Ruzyllo, W., Thygesen, K., Verheugt, F., Fox, K. M., on behalf of the Euro Heart Survey Investigators,
(2006). Gender Differences in the Management and Clinical Outcome of Stable Angina. Circulation
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Blackstock, A. W., Herndon, J. E. II, Paskett, E. D., Miller, A. A., Lathan, C., Niell, H. B., Socinski, M. A., Vokes, E. E., Green, M. R.
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Ostermann, J., Sloan, F. A., Herndon, L., Lee, P. P.
(2005). Racial Differences in Glaucoma Care: The Longitudinal Pattern of Care. Arch Ophthalmol
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Iribarren, C., Tolstykh, I., Somkin, C. P., Ackerson, L. M., Brown, T. T., Scheffler, R., Syme, L., Kawachi, I.
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Smith, M. A., Lisabeth, L. D., Brown, D. L., Morgenstern, L. B.
(2005). Gender comparisons of diagnostic evaluation for ischemic stroke patients. Neurology
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Grossman, S. A., Shapiro, N. I., Van Epp, S., Kohen, R., Arnold, R., Moore, R., Lee, L., Wolfe, R. E., Lipsitz, L. A.
(2005). Sex Differences in the Emergency Department Evaluation of Elderly Patients With Syncope. Journals of Gerontology Series A: Biological Sciences and Medical Sciences
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Lanting, L. C., Joung, I. M.A., Mackenbach, J. P., Lamberts, S. W.J., Bootsma, A. H.
(2005). Ethnic Differences in Mortality, End-Stage Complications, and Quality of Care Among Diabetic Patients: A review. Diabetes Care
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Vaccarino, V., Rathore, S. S., Wenger, N. K., Frederick, P. D., Abramson, J. L., Barron, H. V., Manhapra, A., Mallik, S., Krumholz, H. M., the National Registry of Myocardial Infarction Inv,
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Kales, H. C., Neighbors, H. W., Blow, F. C., Taylor, K. K. K., Gillon, L., Welsh, D. E., Maixner, S. M., Mellow, A. M.
(2005). Race, Gender, and Psychiatrists' Diagnosis and Treatment of Major Depression Among Elderly Patients. Psychiatr. Serv.
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Smink, D. S., Fishman, S. J., Kleinman, K., Finkelstein, J. A.
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Sabatine, M. S., Blake, G. J., Drazner, M. H., Morrow, D. A., Scirica, B. M., Murphy, S. A., McCabe, C. H., Weintraub, W. S., Gibson, C. M., Cannon, C. P.
(2005). Influence of Race on Death and Ischemic Complications in Patients With Non-ST-Elevation Acute Coronary Syndromes Despite Modern, Protocol-Guided Treatment. Circulation
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Sonel, A. F., Good, C. B., Mulgund, J., Roe, M. T., Gibler, W. B., Smith, S. C. Jr, Cohen, M. G., Pollack, C. V. Jr, Ohman, E. M., Peterson, E. D., for the CRUSADE Investigators,
(2005). Racial Variations in Treatment and Outcomes of Black and White Patients With High-Risk Non-ST-Elevation Acute Coronary Syndromes: Insights From CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines?). Circulation
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Werner, R. M., Asch, D. A., Polsky, D.
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Wexler, D. J., Grant, R. W., Meigs, J. B., Nathan, D. M., Cagliero, E.
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Lansky, A. J., Hochman, J. S., Ward, P. A., Mintz, G. S., Fabunmi, R., Berger, P. B., New, G., Grines, C. L., Pietras, C. G., Kern, M. J., Ferrell, M., Leon, M. B., Mehran, R., White, C., Mieres, J. H., Moses, J. W., Stone, G. W., Jacobs, A. K., Endorsed by the American College of Cardiology Fou,
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Mosca, L., Linfante, A. H., Benjamin, E. J., Berra, K., Hayes, S. N., Walsh, B. W., Fabunmi, R. P., Kwan, J., Mills, T., Simpson, S. L.
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Steyerberg, E. W., Earle, C. C., Neville, B. A., Weeks, J. C.
(2005). Racial Differences in Surgical Evaluation, Treatment, and Outcome of Locoregional Esophageal Cancer: A Population-Based Analysis of Elderly Patients. JCO
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Bhatt, D. L., Roe, M. T., Peterson, E. D., Li, Y., Chen, A. Y., Harrington, R. A., Greenbaum, A. B., Berger, P. B., Cannon, C. P., Cohen, D. J., Gibson, C. M., Saucedo, J. F., Kleiman, N. S., Hochman, J. S., Boden, W. E., Brindis, R. G., Peacock, W. F., Smith,, S. C. Jr, Pollack,, C. V. Jr, Gibler, W. B., Ohman, E. M., for the CRUSADE Investigators,
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Tamayo-Sarver, J. H., Hinze, S. W., Cydulka, R. K., Baker, D. W.
(2003). Racial and Ethnic Disparities in Emergency Department Analgesic Prescription. AJPH
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A correction has been published: N Engl J Med 1999;340(14):1130.
70 percent narrowing of an epicardial coronary artery). The physicians were then asked if they wished to order further cardiac evaluations for the patient and were given four options: no stress test, regular stress test, stress test with thallium, and other types of functional cardiac assessment (e.g., stress echocardiography). The physicians were then shown the results of one of three stress tests with thallium, asked to estimate the probability of coronary disease on the basis of the results of the stress test, and asked whether they wished to refer the patient for cardiac catheterization. 
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