Ethnic Differences in Use of Cardiovascular Procedures: New Insights and New Challenges

• Angoplasty, transluminal, percutaneous coronary
• Coronary artery bypass
• Minority groups
• Health services accessibility
• Health services needs and demands

Although we might wish it otherwise, ethnicity in the United States still matters. Over the past few decades, inequalities between Americans of European descent and those of African descent have been documented in the Jeffersonian domains of life, liberty, and the pursuit of happiness. Compared with white Americans, the rates of mortality, incarceration, and poverty are higher among black Americans (1-3). An extensive literature documents persisting differences between black persons and white persons with respect to both access to health care and health status. Although such reports are often greeted with short-term alarm, long-term action rarely follows. Such inertia cannot always be ascribed to indifference or insensitivity. Reasonable people can and do disagree about what ethnic differences in use of health care services actually mean.

Much of the research on ethnic differences in health care has concerned cardiovascular care, for obvious reasons. Cardiovascular disease remains the leading cause of death in the United States, medical care is highly effective in preventing and treating the most prevalent forms of heart disease, and many of the most effective procedures are expensive and therefore prone to underuse among uninsured and capitated populations. In the late 1980s, studies began to show substantially lower rates of cardiovascular procedure use among black persons than white persons (4-7). The differences were generally large (up to threefold) and clinically significant. However, most of these early studies relied on administrative data and therefore could not distinguish between overuse among white persons, underuse among black persons, or some combination of the two.

New data published in the mid-1990s began to untangle these possibilities. Peterson and colleagues (8) analyzed detailed clinical data on 12 402 patients with coronary artery disease treated at Duke University. They found that after adjustment for severity of disease, angina status, and estimated …