Racial disparities in cardiac catheterization (CATH) use are well documented, but the reasons for these disparities have not been elucidated.
We sought to develop valid questionnaire items with which to assess patient health-related attitudes and beliefs, and to learn whether patient health related beliefs and attitudes, or physician attitudes about or assessments of patients, were associated with racial disparities in CATH use, after controlling for clinical indications for procedures and sociodemographic factors.
To develop valid questionnaire items, we conducted a series of focus groups with white and African American cardiac patients. We identified the most salient themes from the patients and created questionnaire items to assess these issues. Thus, we queried patients about the domains proposed to be important to treatment decision making by the Health Decision Model: sociodemographic characteristics, social interactions, health care experiences, patient preferences for care, knowledge about diseases and potential treatments, and health beliefs. After conducting analyses to examine the characteristics of the items and scales we created, we developed eight psychometrically valid scales: disease severity, patient evaluation of physician’s interpersonal style, patient evaluations of VA care, satisfaction with treatment decision making, perceived urgency of catheterization, vulnerability to catheterization, bodily impact of catheterization, and attitudes toward religion. We then interviewed 1,045 white (W) and African-American (AA; 22.6%) patients with positive nuclear imaging studies at five Department of Veterans Affairs medical centers to assess patient health beliefs. We also interviewed the ordering physician to determine their attitudes about and clinical assessments of each patient, and we reviewed every enrolled patients’ medical record to obtain information about their clinical status and whether CATH had been received.
African-American and white patients’ demographic characteristics were similar, but they differed on several clinical parameters. African-American patients were less likely to have had a prior MI (p<0.05), prior revascularization (p<0.0001), or lung disease (p<0.01), but were more likely to have hypertension (p<0.01), and to be on renal dialysis (p<0.01). African-Americans were less likely to undergo CATH (33% vs. 47%, W/AA OR=1.53, p<0.001), a difference that persisted after controlling for demographic and clinical factors (adjusted W/AA OR = 1.74, 95% CI: 1.21 – 2.50). African-Americans indicated a stronger reliance on religion than whites, less trust in people, and more racial and class discrimination. However, these few differences in patient beliefs did not account for CATH disparities (Adjusted W/AA OR=1.87, 95% CI=1.19-2.94). Physicians reported a lower pre-test probability of coronary artery disease among African-Americans than whites. In a subset analysis, differences in physician clinical assessments appeared to account for much of the racial differences in CATH (Adjusted W/AA OR=1.20, 95% CI=0.58-2.47). We examined multiple dimensions of white and African American patients’ health-related attitudes, beliefs, and experiences, finding few differences. Further, racial differences in patient health beliefs did not explain racial disparities in CATH rates. However, racial differences in physicians’ estimates of the likelihood of coronary artery disease accounted for much of the observed disparities. Future interventions to improve the accuracy of physicians’ assessments may reduce racial disparities in cardiac procedure use.
These findings indicate that there are still disparities in provided care in VA, so further research is necessary to pinpoint the exact source of the disparities. Patient beliefs, as they were measured in our study, do not account for disparities, so interventions focusing solely upon patients will probably not eliminate racial disparities in health care use. To the extent that physicians evaluate white and African American patients’ clinical presentation differently, computerized decision aids (e.g., computerized clinical reminders or decision making algorithms) provided to physicians at the point of care that provide objective and accurate estimates of the prior probability of disease, might help reduce this source of disparity. Raising physicians’ consciousness about the possibility of bias through cultural competency training may also help decrease the use of racially based clinical stereotypes.
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