The effect of race and gender on invasive treatment for cardiovascular disease

Journal of Cultural Diversity, Fall, 2004 by James Gerard Caillier, Sandra C. Brown, Sharon Parsons, Phillip J. Ardoin, Peter Cruise

Abstract: The purpose of this study was to investigate racial and gender differences in the utilization of invasive procedures for cardiovascular treatment. Medical records data of 3,015 patients were abstracted from a Medical System Database from 1999 to 2001. Logit models were used to estimate the adjusted odds in the utilization, referral, and acceptance of invasive procedures, while controlling for confounders (age, race, sex, comorbidity, disease severity, payer type, marital status and family history) simultaneously.

When considering utilization of invasive procedures, the adjusted odds were lower for African-Americans compared to Caucasians. There was a statistically significant difference (p<.05) in Coronary Artery Bypass Graft (CABG) utilization between African Americans and Caucasians. African Americans were less likely than Caucasians to receive a CABG. Although not statistically significant, African-Americans were less likely than Caucasians to receive a cardiac catheterization and Percutaneous Transluminal Coronary Angioplasty (PTCA). Findings failed to yield a statistical significance for gender disparities regarding invasive procedure utilizations.

Key Words: Race, Gender, Invasive Treatment

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Cardiovascular disease (CVD) is the leading cause of death among every racial and ethnic group in the United States. An individual's ability to access and use modern cardiac therapy and procedures may have profound implications for improving diagnostic precision, relieving symptoms, and reducing premature mortality from heart-related conditions. Research to investigate underlying causes, subsequent outcomes and effective interventions is crucial for reducing racial/gender disparities in medical care. Although invasive cardiac procedures have been documented to reduce symptoms and prolong life for those with severe CVD, numerous studies over the past two decades have reported that African Americans are less likely than Caucasians to utilize invasive procedures (Brown, 2002; Ford, Cooper, Castner, Simmons, & Mar, 1989; Giles, Anda, Casper, Escobedo, & Taylor, 1995; Goldberg, Hartz, & Jacobsen, 1992; Hannan, Van Ryn, & Burke, 1999; Kressin & Peterson, 2001; Maynard, Fischer, Passamani, & Pullum, 1986; Watson et al., 2001; Wenneker & Epstein, 1989). Additionally, previous studies have shown that when stratifying by race and sex, African American females are less likely to utilize invasive procedures compared to Caucasians (Ayanian, Udvarhelyi, Constantine, Chris, & Arnold, 1993).

Research has shown that disparities regarding use of invasive treatments remain even after controlling for clinical and socioeconomic factors. There is concern in the medical community that the race and gender of a patient could be prompting differences in physician behavior. Therefore, the purpose of this study was to explore the effect of race and gender on the use of invasive treatment for cardiovascular disease. Accordingly, this study proposed to test the following hypothesis: African-Americans and females will be less likely to receive invasive treatment for cardiovascular disease compared to Caucasians and males, respectively.

METHOD

Design

A retrospective longitudinal review of hospital patient information was conducted using statewide patient data obtained from a Medical System shared by three urban public health hospitals in the state of Louisiana. The use of statewide patient data provided a unique opportunity to examine treatment in the only state in the United States that provides a state system of acute care for its citizens. The vast majority of the persons served by this system are indigent or Medicaid recipients. Data used in the analysis were from July 1998 to July 2000.

Data was obtained from three public health teaching hospitals, which encompass professional schools in medicine, nursing, and dentistry, as well as allied health vocations. The three hospitals (Hospital A, B, &C) are located in metropolitan areas and serve both rural and urban patients in the southeastern part of the state. Only non-invasive cardiac procedures such as treadmills, echocardiograms, holter monitors, electrocardiograms, stress echograms, and pacemaker insertions are performed at Hospitals A and C. Both non-invasive and invasive cardiac procedures such as cardiac catheterization, (CC), coronary artery bypass grafts (CABG), and percutaneous transluminal coronary angioplasties (PTCA) are performed at Hospital B. Since both hospitals are in the same public health system and are responsible for taking care of the indigent, Hospitals A and C refer all invasive procedures to Hospital B.

Sample

The data set from the three hospitals contained a total of 3,015 CVD patients whose principal diagnoses indicated diseases of the circulatory system (ICD-9-CM codes 390-459) and chest pain (ICD-9-CM codes 786.50 through 786.52). These diagnoses included myocardial infarction, unstable angina, chronic ischemic heart disease, angina pectoris, and chest pain. Patients excluded from the study included those with comorbid diagnoses of stroke, cancer, renal failure, psychiatric illnesses, abuse of drugs and alcohol, Human Immunodeficiency Virus (HIV), cirrhosis, dementia, lung disease, and congestive heart failure (CHF) because these conditions may influence treatment outcomes, thus reducing the likelihood of these patients being referred for an invasive procedure. Figure 1 displays the selected patient population from the database.