MINORITY HEALTH: No Ethnic Disparities in Cardiac Care
The current issue of the Annals of Internal Medicine presents two studies that look at ethnic disparities in cardiac care treatment. The first study found that black and white patients are equally likely to receive cardiac catheterization, angioplasty and coronary artery bypass surgery after they become eligible for Medicare.
Sickness the Key?
Researchers at Johns Hopkins School of Public Health tracked nearly 5,000 black and white adults with end-stage renal disease (ESRD) in a seven year study based on data collected by the U.S. Renal Data System. Patients with chronic renal disease were considered good candidates for the study due to their relatively high risk for developing cardiovascular disease. At the start of the study in 1996-87, 2.8% of black patients and 9.9% of white patients underwent cardiac procedures. However, the "[d]ifferences between ethnic groups in use of cardiovascular procedures narrowed markedly once a serious illness [End Stage Renal Disease] developed and adequate insurance coverage was ensured." At the seven-year mark, the disparity had all but disappeared among ESRD patients, with 7.8% of white patients receiving a procedure, compared to 8.5% of black patients. Although the narrowed gap was associated with patients' acquisition of Medicare, the authors note that the "substantial baseline disparity between black patients and white patients ... exists in [both] the privately insured and Medicare subgroups, providing evidence against acquisition of health insurance as the only factor in narrowing the gap" (Daumit et al., Annals of Internal Medicine, 2/2 issue). Lead author Gail Daumit concluded, "The study suggests that when patients have adequate health insurance, a regular source of care, and a strong clinical indication for a cardiac procedure, equity in use of services among blacks and whites can be achieved" (Johns Hopkins release, 2/1).
Again, No Discrimination
A second study in the same issue of the Annals of Internal Medicine found that coronary artery bypass grafts and angioplasty surgeries are underused across the board, with no sex, ethnic group, or payer status differences among the recipients. In 1992, the research team enrolled 631 patients in 13 New York City hospitals who "met the RAND expert panel criteria for necessary revascularization" and tracked the patient outcomes. The researchers found that overall, 74% of those patients who met the criteria to receive either procedure actually underwent the "necessary revascularization." While the authors found no statistically significant differences in the rates of the procedures by patient sex, ethnic group or payer status, hospitals that offered the procedures on-site had higher utilization rates than hospitals that shuttled the surgery candidates to off-site facilities for the procedure. In addition, Medicare and Medicaid beneficiaries were recommended for procedures at similar rates as privately insured patients -- 91%, 75% and 82%, respectively. The researchers found that overall, 26% of candidates did not receive the procedures, and that number jumped to nearly 33% for uninsured patients at hospitals that do not perform the procedure. The authors conclude, "The disturbing result is that many patients who need these procedures fail to get them" (Leape et al., Annals of Internal Medicine, 2/2 issue).
"The real lesson to be learned" from the two studies, writes Dr. Richard Kravitz of the University of California-Davis in an accompanying editorial, "is that access, quality and equity are related. It is a mistake to consider them separately." Kravitz takes issue with the assumption that "the only kind of access that matters is the ability to obtain needed care when it is needed." He writes, "Increased use of care that is inappropriate, ill-timed, or poorly delivered will not confer benefit (Annals of Internal Medicine, 2/2 issue).