Schecter AD, Goldshmidt Clermont PJ, McKee G, Hoffeld D, Myers M, Velez R, Duran J, Schulman SP, Chandra NG, Ford DE.
Influence of gender, race and education on patient preferences and receipt of cardiac catheterizations among coronary care unit patients.
Am J Cardiol 1996;78(9):996-1001.

This cohort study of 272 patients was conducted at two urban hospitals (John Hopkins Hospital and Francis Scott Key Medical Center) in Baltimore, Maryland from December 1992 to April 1993. The John Hopkins Hospital has an active cardiac surgery unit, unlike the Francis Scott Key Medical Center, which provides only cardiac catheterization service. The subjects were primarily white (n=122), male and lower middle class. One-third had less than a ninth grade education, and the sample mean age was 62 years old. The two primary questions the authors sought to examine were “(1) how do patients’ socioeconomic characteristics, clinical status, and knowledge of cardiac risk factors relate to their preferences for invasive cardiac care? and (2) how do these factors and preferences for invasive care relate to the receipt of cardiac catheterization, a prerequisite for subsequent invasive procedures?” Cardiac Care Unit (CCU) nurses blinded to the study hypothesis administered the interviews, which consisted of standardized questions, such as level of education, and open-ended questions, which ranged from asking patients to list the cardiac risk factors for heart disease to assessing how likelihood of the patient accepting their physicians’ recommendations regarding cardiac catheterization. Since this was a prospective study of hospitalized patients in the real-life situation of facing treatment choices (85% were interviewed within 24 hours of admission), the subjects’ demographic characteristics, clinical characteristics, and stated preference for or against agreement with a physician recommendation for catheterization could be examined for their predictive value–i.e., did the patient subsequently receive or refuse catheterization?

The investigators found patients with no education beyond high school (OR 2.43; 95% CI 1.08-2.46; ref: college attendance) and current smokers were more likely to disagree with a recommendation for a cardiac catheterization (OR 1.81; 95% CI 1.01-3.26). Black patients and patients who lived alone had a non-significant “tendency to state that they would disagree with such a recommendation.”

Being a patient at the referral hospital was the variable most strongly associated with receiving catheterization. In the analysis of the relationship between receiving cardiac catheterization and willingness of the patient to undergo the procedure (which was limited to the patients with unstable angina, subendocardial or transmural infarction during the CCU hospitalization), the authors found that the patient’s willingness was “also a powerful predictor of receiving cardiac catheterization (OR 4.69; 95% CI 2.1-10.4).” Even after controlling for these two factors and the severity of heart disease, patients who had attended high school and white patients were more likely to undergo catheterization.

The results of this study suggest that both patient preferences and physician practice influence variability in the rates of cardiac catheterization. Patients’ acceptance of physician recommendations was directly related to educational level even after adjusting for race, gender, age, household income and previous myocardial infarction. The study provides a possible explanation for the gender and racial discrepancies in rates of invasive procedures by demonstrating the importance of other (non-clinical) variables, such as level of education, patients’ willingness to undergo catheterization, and degree of social support. However, the data “suggest that differences in patient preferences only partially explain differences between African-American and white patients in receipt of invasive cardiac procedures, and do not rule out the explanation that physician practice may also vary between African-American and white patients.”

The authors conclude, “Hospital setting, physician’s attitudes, patient’s attitudes, and communication style between physician and patient all interact to influence how decisions about medical procedures are made. Health care providers need to be especially vigilant that they understand the preferences of and communicate appropriately with patients with low levels of education, who are in one way most dissimilar to themselves.”