The purpose of this study was to apply the RAND criteria to identify rates of underuse and overuse of invasive cardiac procedures among black and white patients admitted to a Veterans hospital for evaluation of cardiovascular disease.

The data were derived from inpatient records in the Department of Veterans Affairs database (the Patient Treatment File) for patients discharged during calendar year 1993. Those eligible were black or white male patients 35 years of age or greater residing in Indianapolis, with a diagnosis of cardiovascular disease or chest pain and a recent (within 90 days) invasive cardiac procedure prior to admission. Among this group, a random sample of 100 patients per race was selected. Computer record and chart audits were conducted for the patient’s first hospitalization in 1993 to identify the cardiac procedures performed. Chart abstracts were performed to collect data on demographic and clinical characteristics (risk factors for cardiac disease), comorbid conditions and disease severity, response to pharmaceutical therapies, physicians' recommendations for treatment and patients’ agreements or refusals, and results of noninvasive and invasive cardiac procedures. Blind to cardiac procedure status and race, study investigators used these data to rate each patient’s appropriateness for undergoing an invasive cardiac procedure (using RAND criteria: 1=most inappropriate to 9=most appropriate).

Overall, black patients in this cohort had less severe cardiac disease presentations compared with white patients. That is, black patients were assigned significantly more ratings of inappropriate (62% versus 43%) and fewer ratings of appropriate (6% versus 20%) compared with white patients. About one-third of both blacks (32%) and whites (37%) were assigned “uncertain appropriateness.” Accordingly, fewer blacks were offered cardiac catheterizations compared with whites (20% of blacks versus 42% of whites) and fewer blacks received this procedure (14% of blacks versus 41% of whites). More blacks refused offered cardiac catheterizations (6% of blacks versus 1% of whites).

Among patients rated as appropriate, 100% (6 out of 6) of blacks received cardiac catheterization, while 89% (18 out of 20) of white patients received this procedure (the remaining two were not offered the procedure). Among patients rated as inappropriate, only 1.6% of the black patients (1 out of 62) versus 9.3% of the white patients (4 out of 43) were offered cardiac catheterization. Finally, among patients with an uncertain appropriateness rating, 40.6% of the blacks versus 54.1% of the whites were offered cardiac catheterization. However, only 21.9% of black patients versus 51.4% of white patients actually underwent this procedure, because a larger proportion of black patients refused. The same patterns for underuse and overuse of procedures were found when the analyses were repeated using all patients undergoing cardiac catheterization as well as PTCA or CABG surgery.

The authors conclude that these data did not provide evidence of discriminatory underuse of invasive procedures among blacks, but instead indicated that the previously observed interracial differences in invasive cardiac procedure use may be due to overuse among white patients. They state that “this study provides an example of the inadequacy of an administrative database in making a quality of care assessments. In the absence of critical clinical data…blacks in our cohort could be perceived as recipients of suboptimal care compared with whites. However, when the clinical data…are considered, these interracial treatment differences are consistent with high quality care and the desire of patients for treatment.”