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SPH study shows minorities receive fewer invasive cardiac procedures

By Brian Fitzgerald

The racial divide between whites and blacks in the delivery of medical services has long been recognized as a problem in the United States. However, a new study, led by the BU School of Public Health, shows conclusively that African-American, Hispanic, and Asian patients are disproportionately less likely to undergo invasive cardiac procedures than Caucasian patients.

	SPH Associate Professor of Health Nancy Kressin Photo by Albert L'Etoile

The study, which appears in the September 4 issue of the Annals of Internal Medicine, also suggests that future studies on this topic examine patient and physician variables in order to account for the racial differences.

"Although racial disparities in care are persistent across numerous studies, prior research has not adequately identified the reasons for such disparities," says lead author Nancy Kressin, an associate professor of health at SPH. "This limits our ability to design interventions to address these disparities -- and to thereby decrease inequalities and provide models for similar interventions in other areas of medicine."

Minorities are lagging in the care of a broad range of medical conditions, but not performing an invasive cardiac procedure when necessary causes a potentially life-threatening situation. Clogged arteries often lead to heart attacks or strokes.

The study, which includes researchers from the Bedford, Mass. Veterans Administration (VA) Medical Center, the Houston VA, and the Baylor College of Medicine, reviews more than 60 previously published studies that had examined racial differences among patients undergoing cardiac catherizations, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass grafting. The study was funded by the American Heart Association and the Department of Veterans Affairs Health Services Research and Development Service.

The cause of racial disparities in the use of interventional cardiology remains unclear, concludes the study, but the researchers found that less-educated patients and those who were not as familiar with the procedure were more likely to decline a PTCA, where the physician inserts a catheter into the patient's coronary artery and inflates a tiny balloon, opening a blockage and restoring blood flow to the heart.

Kressin, who is also a research health psychologist at the Bedford VA Medical Center, says that several promising avenues can reduce the racial disparities. "Improving a provider's cultural competence and communication skills and increasing the number of African-American physicians and other clinicians will likely improve relations between physicians and minority patients," she says. "This may increase patient satisfaction and improve health outcomes." Further, this education could be included in medical school, and in postgraduate medical training, she says, and "would enhance these skills in future physicians."

In an earlier study headed by Kressin at five VA hospitals examining white and African-American potential candidates for invasive cardiac procedures, the African-American patients had less education, were less often married, and had more coverage from Medicaid, a government insurance program for certain low-income people. The study found that fewer African-Americans had friends or family members strongly encourage them to have cardiac catherization, and had less prior personal or familial experience with cardiac or other surgical procedures. African-Americans were also less likely to believe that cardiac catherization or other surgical procedures would help their doctors diagnose their heart condition.

"These results suggest that differences in health beliefs and socioeconomic resources may help account for differences in patients' perceptions of invasive cardiac procedures," concluded the earlier study. "Less education and health insurance may place patients at a disadvantage, even in the context of accessible VA care. Health beliefs and less social support for invasive procedures may result in dispreferences for these procedures."

Kressin says that most studies on the issue by traditionally trained physician researchers failed to account for factors such as attitudes, beliefs, and communication patterns between the physician and the patient. "As a social scientist and psychologist, I saw that a lot had been left out of the equation," she says.

To read the study, visit www.annals.org/issues/v135n5.abs/200109040-00012.html.

28 September 2001
Boston University
Office of University Relations