Crawford SL, McGraw SA, Smith KW, McKinlay JB, Pierson JE.
Do blacks and whites differ in their use of health care for symptoms of coronary disease?
Am J Public Health 1994;84(6):957-64.

The purpose of this study was to examine patterns of coronary heart disease-related care in a community-based random sample of black and white adults with similar SES and geographic access to cases. The authors emphasize the need to compare racial patterns in health and health care using population-based data in order to avoid the biases that might be caused using hospital-based data which exclude persons who are not in the medical care system. Data were collected from a random-digit-dialed telephone survey in three inner-city Boston neighborhoods. Persons who were black or white and aged 44 to 75 years were eligible for the study, which included a twenty-minute telephone interview. Interviews were conducted from September 1988 to December 1989.

The sample consisted of 39.8% whites and 60.2% blacks. Of the respondents who reported ever experiencing at least one coronary health disease symptom, 47.0% were white and 51.3% were black. Among this group, there were several demographic and clinical differences between blacks and whites: blacks were more likely to be female, younger, and have a lower SES. They were also more likely to be diabetic, hypertensive, and have a higher average Body Mass Index (BMI). However, they were less likely to have a family history of coronary heart disease. There were no racial differences in the frequency of specific symptoms.

With regard to access and satisfaction related to treatment, blacks were more likely to report having to travel more than 30 minutes to receive care (18.9% of the blacks had to travel a long distance versus 10.0% of the whites, p<=0.001) and were more likely to report they did not receive the care they needed (21.7% of blacks were dissatisfied versus 14.8% of the whites, p<=0.01). There were no differences in other satisfaction measures. Blacks had a higher propensity to seek care (65.7% of blacks would seek care for symptoms versus 47.6% of whites, p<=0.001), whereas whites’ knowledge of myocardial infarction symptoms was slightly higher (mean number of symptoms known for blacks was 2.5 versus 3.0 for whites, p<=0.001).

There were no differences in seeking care for chest pain or shortness of breath. The adjusted (for the above listed factors) racial differences in seeking care were smaller than the unadjusted differences. Lower odds of help seeking were associated with not having insurance and inability to pay for basic needs. Symptom severity was positively associated with help-seeking, as was satisfaction with care, higher propensity to seek care, and greater knowledge about myocardial infarction symptoms. Smokers were less likely to seek care; white hypertensives were more likely to seek care.

Among those who sought help, the mean delay in seeking care for shortness of breath was longer for whites than for blacks (336.0 hours versus 96.0 hours, p<=0.05). The adjusted racial differences in delay in seeking care were similar to the unadjusted racial differences; the only significant effect was that black women had a shorter delay than white women. Delay time was negatively associated with severity of illness, difficulty in reaching care, and general propensity to seek care. Persons with elevated cholesterol and who were currently employed had longer delays in seeking care for chest pain.

With regard to recommendations for electrocardiograms, treadmill tests, and echocardiograms, the rates were similar among black and white men and women. However, recommended invasive procedures varied among these four groups, with white men having the highest rate (31.1%), white women having the lowest rate (14.1%), and black men and women falling in between these two rates and being nearly equal (20.3% and 16.9%). A similar pattern was found for medication treatments. With regard to hospitalization, white men had the higher rate (22.5%), followed by black men (18.4%), white women (13.4%) and black women (9.8%). Referral to a cardiologist was highest among white men (40.0%), followed by white women (29.8%), black men (26.9%), and black women (19.3%). There was no race/sex pattern in receiving a diagnosis of a heart problem. The only statistically significant racial difference after adjusting for demographic and other factors (listed above) was referral to a cardiologist (adjusted OR for black versus white men=0.56, 95% confidence interval=0.31 to 0.99; adjusted OR for black versus white women=0.54, 95% confidence interval=0.33 to 0.91). Given previous reports, it is especially interesting that the adjusted odds of being recommended for invasive procedures did not differ by racial group (adjusted OR for black versus white men=0.61, 95% confidence interval=0.31 to 1.19; adjusted OR for black versus white women=1.27, 95% confidence interval=0.67 to 2.42). It is also noteworthy that symptom severity and risk factors, particularly hypertension, elevated cholesterol, and diabetes were consistently positively associated with care received.

The authors conclude that “in an urban low-SES population of blacks and whites who were similar with respect to SES and access to care, there were few racial differences in coronary heart disease-related care patterns, either in help-seeking behavior or in care received. The authors attribute the lack of racial difference in this sample to the “similarity between blacks and whites with regard to important predictors such as severity of symptoms and employment status. Exceptions were delay in seeking care (delays were shorter for blacks, particularly women) and referral to a cardiologist (rates were lower for blacks), both of which persisted after controlling for other factors.” With regard to the findings that help-seeking blacks were significantly less likely than help-seeking whites to have been referred to a cardiologist, white women had lower rates of receipt of care, and women of both races were less likely to be referred to a cardiologist than men, the authors conclude that “further study is need to determine if this difference can be explained by factors not adequately measured in this study, such as clinical data, or whether they reflect true racial and sex difference in the receipt of coronary health care.”