More than 1 million people in the United States undergo coronary revascularization with coronary artery bypass graft (CABG) surgery or percutaneous transluminal coronary angioplasty (PTCA) each year, and slightly more than half of these procedures are performed in elderly patients. Many studies have documented large and persistent differences in use of these procedures by race and sex.
A new study supported by the Agency for Healthcare Research and Quality went a step further to determine whether these discrepancies are clinically appropriate. The findings show that elderly whites and men are more likely to receive a revascularization procedure that is not needed, and that elderly blacks are less likely to undergo needed revascularization.
A second AHRQ-supported study (HS11612) of New York City residents found that lack of hospitals that perform revascularization procedures in disadvantaged neighborhoods further reduces revascularization (beyond race and socioeconomic factors) among residents of these neighborhoods. Both studies are summarized here.
Epstein, A.M., Weissman, J.S., Schneider, E.C., and others (2003). "Race and gender disparities in rates of cardiac revascularization: Do they reflect appropriate use of procedures or problems in quality of care?" (AHRQ grant HS07098). Medical Care 41(11), pp. 1240-1255.
Among patients who receive angiography, a procedure used to diagnose the extent of heart damage, blacks and women are less likely than other patients to be rated necessary for revascularization procedures (CABG or PTCA) to repair the damage, according to this five-State study of 5,026 elderly Medicare patients who underwent coronary angiography during 1991 and 1992. Study investigators compared the frequency of two problems in quality of care by race and sex: underuse or the failure to receive a clinically indicated revascularization procedure (based on criteria developed by RAND and the American College of Cardiology/American Hospital Association, ACC/AHA) and receipt of revascularization when it is not clinically indicated (overuse).
The researchers found that revascularization procedures were rated as clinically indicated more often among whites than blacks and among men than women. Failure to receive revascularization when indicated was more common among blacks than among whites (40 vs. 23-24 percent, depending on the criteria) but similar among men and women (25 vs. 22-24 percent). Racial disparities remained even after adjusting for patient and hospital characteristics.
Among patients for whom revascularization was rated inappropriate, use of procedures was greater for whites than blacks using RAND criteria (10.5 vs. 5.8 percent) and greater for men than for women (14.2 vs. 5.3 percent by RAND criteria and 8.2 vs. 4 percent by ACC/AHA criteria). These findings reflect quality of care problems, since patients in this study who failed to receive clinically indicated CABG surgery or angioplasty had higher mortality rates.
Fang, J., and Alderman, M.H. (2003). "Is geography destiny for patients in New York with myocardial infarction?" (AHRQ grant HS11612). American Journal of Medicine 115, pp. 448-453.
The purpose of this study was to determine whether the ability of local hospitals to perform revascularization procedures (PTCA and CABG) influenced apparent racial disparities in revascularization and health outcomes. Using 1988-1999 data from the New York State Department of Health, the investigators determined revascularization rates among patients hospitalized with heart attack in two socioeconomically disadvantaged communities in New York City: the South Bronx, which has no hospitals that have revascularization facilities, and Harlem, which has three revascularization facilities, as well as in its most advantaged community, mid-Manhattan, which has six such facilities. The rest of New York City served as a reference.
Among patients hospitalized for heart attack, age-adjusted revascularization rates were 29.2 percent for whites, 12.5 percent for blacks, and 19.9 percent for Hispanics. Rates were 12 percent in the South Bronx, 24 percent in Harlem, 38.4 percent in mid-Manhattan, and 21.2 percent in the rest of New York City. After adjusting for other characteristics affecting revascularization such as age, race, sex, insurance status, and clinical factors, South Bronx patients were about 20 percent less likely to undergo bypass surgery or angioplasty than those in the rest of New York City.
Patients living in Harlem were twice as likely to receive such treatment as residents in the rest of New York City. However, among patients admitted to hospitals with cardiac revascularization facilities, after adjusting for patient characteristics, Harlem residents were significantly less likely to undergo CABG surgery or PTCA than those from the rest of New York City.
Editor's Note: Another AHRQ-supported study on revascularization shows that use of a new procedure, transmyocardial revascularization, is expanding in community practice; so far its benefits are unclear. For more details see Peterson, E.D., Kaul, P., Kaczmarek, R.G., and others (2003). "From controlled trials to clinical practice: Monitoring transmyocardial revascularization use and outcomes. (AHRQ grant HS10548). Journal of the American College of Cardiology 42(9), pp. 1611-1616.