Strogatz DS.
Use of medical care for chest pain: differences between blacks and whites.
Am J Pub Health 1990;80(3):290-4.

Coronary heart disease (CHD) mortality rates for black Americans exceed those of whites for persons aged 25-64 years, but population rates of CHD occurrence based on cases from hospital discharge surveys are lower for blacks than for whites. The inconsistency between the mortality and hospitalization data may be due to bias in detection and measurement but may also reflect an excess of CHD deaths among blacks before the hospital is reached. The goal of this analysis was to compare reported use of medical care by blacks and whites who experienced chest pain and to examine the degree to which demographic characteristics, access to medical care, and health status modified or accounted for black-white differences in care-seeking behavior.

Data were collected as part of the 1980 survey of a North Carolina High Blood Pressure Control Program. Households were randomly selected, and data were collected for a total of 2,029 individuals. Three hundred nineteen respondents reported having chest pain in the previous year, and of these 302 were included in this analysis (15 did not have a regular source of health care and 2 had missing data on variables of interest).

Almost half of all blacks with repeated pain near the heart never saw or discussed this with a doctor (49%), compared with 27% of whites. Only 22% of blacks with chest pain saw a doctor in the past year compared with 47% of whites.

For both blacks and whites, patients who received care were older, had worse perceived health, were more likely to have a history of myocardial infarction, and were more likely to have received treatment for high blood pressure. Psychological access (dissatisfaction with accessibility, ease in getting an appointment, and how well respondents get along with providers) did not differ between blacks who received care and blacks who did not. Among whites, persons who did not receive care were more likely to be dissatisfied with three measures of psychological access: affordability, accommodation, and acceptability of health care. Blacks who had no care had higher ratings on structural access (tangible entities, such as distance to be traveled) than blacks who received any care, while whites who received care had higher ratings on structural access. (No significance test results were provided.)

In multivariate analyses, the only statistically significant effect of race was on structural affordability (an index that combines information on income and insurance) – the racial difference in use of medical care for chest pain increased with greater structural affordability. The authors argue that interpretation of these results requires recognition that measure of SES may not have the same meaning and implications for blacks and whites. They gave several possible explanations. The black-white difference in utilization at higher levels of structural affordability may reflect differences in economic resources that are not captured by family income. It may also be that social support is directly related to economic resources in this population, and perhaps more economically advantaged blacks rely on more social support networks for advice on health. Untapped dissatisfaction with past medical visits may also explain lower utilization by those individuals with somewhat low income or insurance. Thus, as others have concluded, the elimination of racial differences in the use of medical care will require more than just modifying the ability to pay for services. Other possible explanations include differences in perceptions of the seriousness of symptoms and the potential efficacy of medical care.