Peterson ED, Wright SM, Daley J, Thibault GE
Racial variation in cardiac procedure use and survival following acute myocardial infarction in the Department of Veterans Affairs.
JAMA 1994;271(15):1175-80. (Comments in: JAMA. 1994;271(15):1207-8. JAMA. 1994;272(1

The goal of this study was to examine whether blacks admitted to Veterans Affairs Medical Centers with an acute myocardial infarction (AMI) were less likely than whites to undergo cardiac catheterization or coronary revascularization procedures and to determine the impact of these differences on patient survival. The study was a retrospective observational study of inpatient discharge abstracts from the Veterans Health Administration (VHA) examining the records of 33,641 male veterans from all 158 acute hospitals in the VHA.

Adjusting for patient and hospital and characteristics, blacks with an AMI were 33% less likely than whites to undergo cardiac catheterization, 42% less likely to receive coronary angioplasty, and 54% less likely to receive coronary bypass surgery. Among patients who underwent cardiac catheterization, blacks were also less likely than whites to have a subsequent cardiac revascularization procedure. Adjusted 30-day survival for blacks was significantly greater than for whites. One- and 2-year survival rates after AMI were not significantly different between blacks and whites.

“In a health care system designed to provide equivalent availability of care to all eligible patients, blacks received substantially fewer cardiac procedures after AMI than whites. Despite undergoing fewer interventional procedures, blacks had better short-term and equivalent intermediate survival rates compared with whites.”

“…Blacks have been reported to undergo fewer cardiac catheterizations or coronary revascularization procedures compared with whites. These differences in procedure use have been noted in single institution reviews, cross-sectional surveys, within single state all payer databases, and national administrative databases.”

“These results showing lower cardiac procedure use among blacks with AMI are similar to those previously reported findings in both the private sector and in the VHA for patients with coronary artery disease and AMI.”

”Several explanations for why blacks receive fewer cardiac procedures remain. First, blacks in our study may have had differences in disease severity….Second, racial differences in patient preference for invasive cardiac procedures may exist. Blacks may decline cardiac procedures when they are offered…Finally, physicians may weigh the risks and benefits of interventional procedures differently for blacks and whites. It was previously believed that blacks had worse survival after coronary bypass surgery than whites. This belief has not been supported by multiple reviews of surgical outcomes. Weighing of benefits and risks from a procedure, however, is a multifaceted decision…Within complex physician-patient interactions, a physician’s racial and cultural biases may influence the decision-making process.”
“…Whether this improved survival (of blacks) is because of baseline differences in disease severity, different natural histories of the disease, or differences in care rendered remains unclear….Future research using detailed clinical databases is indicated to clarify the natural history of coronary disease in blacks and whites and the appropriateness and effectiveness of interventions used in its treatment.”