Data for this study were derived from the Birmingham-Black Health Seeking for Coronary Heart Disease Project, which included black and white inpatients of five hospitals in Alabama admitted during the period from 1989 to 1990 for coronary disease. Information was obtained from medical records and patient interviews.

Significant racial differences in patient reports of insurance status, clinical history, and cardiac risk factors were reported. Additionally, blacks patients were less likely to report diagnostic procedures (electrocardiogram, graded exercise test, and coronary angiography) and less likely to report treatment procedures (percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG)). For males, the differences in all but PTCA were statistically significant; for females, all but electrocardiogram and coronary angiography were statistically significant. In analyses that adjusted for demographic and risk factors, whites were significantly more likely to receive a graded exercise test (OR=1.78; 95% confidence interval=1.20-2.64) and to receive coronary artery bypass grafting (OR=2.00; 95% confidence interval=1.25-3.18). The rates of adherence to physician recommendations ranged from 92% to 100% across ethnic and sex groups; there were no statistically significant differences.

Although this study found racial differences in reported use of diagnostic and treatment procedures after controlling for various cardiac risk factors, symptoms, and knowledge of coronary heart disease (CHD) diagnosis, it could not explore potential explanations for these differences.

One important finding from this study that might rule out a potential explanation for racial differences was that there was no racial pattern in patient adherence to physician recommendations. The authors interpret this to indicate that racial differences in patient preferences about treatment are not likely to explain racial differences in receiving cardiac procedures.

The authors suggest that “subtle ethnic bias may be a result of social and cultural factors that affect communication. It may be that some patients, including African Americans, do not use the classic presentation style that physicians are taught to recognize… It may be that physicians do not communicate effectively with different ethnic groups about available diagnostic and treatment options that may aid in the management of coronary disease. There may be a lack of culturally sensitive education material so that patients can learn about their disease process and management options. Physician education programs may also be lacking in terms of effective communication strategies for different ethnic and socioeconomic groups.” The authors also argue that “however disturbing, overt ethnic bias is also a possibility that cannot be excluded as a factor that influences physicians when making clinical decisions to recommend cardiac procedures.”