The objective of this study was to investigate the basis for the decision to use coronary artery bypass grafting surgery by examining the demographic and socioeconomic characteristics of patients who have received it. The authors hypothesized that the surgery rates would vary across geographic area and income levels.

Data were reviewed for all patients receiving coronary artery bypass surgery (CABG) in any of the four hospitals in Erie County of New York State from July 1, 1977 to June 30, 1978.
The hospitals were all associated with a major teaching institution (SUNY Buffalo School of Medicine). Control variables included age, sex, race, and marital status. The main outcome variables were broad geographic location, neighborhood median family income (based on census tracts associated with permanent addresses), and method of payment. The main results were only reported for males between the ages of 45 to 64 years “since (this group) received the majority of the operations in Erie County (67%).”

The majority of the patients who received CABG surgery were treated in two of the four hospitals studied (approximately 83%). One of these two hospitals failed to report racial group for its patients. Thus, although 58% of the patients included in the study who had race information available were white, 40% of the study participants were missing race data. The authors state, “Although data on racial background of the CABG patients are incomplete, analysis of the place of residence of CABG patients from (the missing) hospital shows that only five cases resided in census tracts with less than a 90% white population. The remaining cases were from census tracts with an average white population of 97%.”

The age-sex adjusted rate of CABG surgery per population at risk was highest in the suburban and rural areas compared with urban areas. (The authors note that the median income in the rural area is relatively high and that the rural townships are relatively close to the major medical centers providing tertiary care, in contrast to those areas geographically and politically typical of rural America.) Additionally, the CABG surgery rate for four quartiles of median family income increased across the first three quartiles. (The surgery rate per 1,000 for the lowest quartile was 1.70, compared with 2.98, 3.83, and 3.74 for the next three consecutive quartiles.) Finally, over 85% of patients receiving CABG surgery had private insurance, while only 4% were on Medicaid.

The authors did not have supplemental information regarding clinical characteristics of patients receiving and not receiving CABG surgery, nor regarding the base rate of coronary heart disease. Thus, they were unable to ascertain using these data whether the observed patterns represented inequities in the system with regard to access to care or differing health care needs among patients appropriate for CABG surgery.

Three main theoretical categories of the distribution of medical resources were discussed with regard to their application to these data and results. However, a final conclusion was not drawn. An egalitarian theory (medical goods are distributed purely on need, by lottery, or as it may benefit the least well off) would only be supported in this case if populations from urban areas, poorer groups, or blacks had fewer CABG needs. A principle of utility (maximize the greatest good for the greatest number) would be supported if CABG surgery were performed on those patients most able to contribute to society. The authors indicate that this latter theory might be supported by these data. Finally, a notion of liberty (resources are rightfully owned by those who possess them) could also be supported by these data. However, this last theory has limited application to the health care field since medical education and facilities are subsidized by public money.