Patient Preferences May Be Key to Why Blacks Receive Less Aggressive Heart Treatment Than Whites
DURHAM, N.C. -- In the most comprehensive study of its kind, Duke University Medical Center cardiologists found that in a group of 12,000 patients, blacks were much less likely to receive heart bypass surgery than whites, and the death rates of blacks were significantly higher.
"This disparity in treatment exists nationwide, and we see the study results as a call to action to improve patient-physician interactions, which are crucial in arriving at the best course of treatment," said cardiologist Dr. Eric Peterson, who led the research team. "Both patients and physicians must be highly involved in making informed decisions about what makes the most sense for individual patients."
The study, published in the Feb. 13 issue of the New England Journal of Medicine, was financed by grants from the Agency for Health Care Policy and Research, by the National Heart, Lung, and Blood Institute, and the Robert Wood Johnson Foundation. A preliminary report on the findings was presented at the annual meeting of the American College of Cardiology last March.
Peterson and five fellow researchers at Duke's Clinical Research Institute used information from the Duke Databank for Cardiovascular Disease to perform the analysis. The databank is the largest single computerized repository of extensive treatment information on heart patients. It contains data on more than 100,000 cardiac patients seen at Duke over the last 28 years.
For this study, the researchers examined in detail the clinical care given to a group of 12,402 patients, 10 percent of whom were black, treated at Duke between 1984 and 1992.
The black patients were slightly younger than the white patients, and more of them were women. They were also more likely to have diabetes and hypertension.
The researchers found that, all things being equal, blacks received slightly fewer artery-clearing angioplasties as whites, but blacks were 32 percent less likely to undergo heart bypass surgery. Peterson further concluded that "the greatest racial disparity in the use of bypass surgery was actually among the patients who stood the most to gain from it."
Peterson also found black patients had worse long-term outcomes, and, in fact, blacks were 18 percent more likely to die than whites during five years of follow-up study.
But what isn't so clear cut, according to the researchers, is why the disparity in care exists. The Duke records are some of the most detailed available, but they don't include information on what treatments physicians recommended to patients or whether the patients chose to follow those recommendations. And they also don't reflect whether a decision not to proceed to bypass surgery was made upon examination of angiograms, which are diagnostic tests that show the extent of coronary disease. Patients with diffuse or distal heart disease are not prime candidates for surgery, Peterson said.
The researchers, most of whom are physicians who see patients in clinic, believe that a major factor in the finding that blacks are not getting surgery is that many of these patients prefer a less invasive, less high-tech approach to disease treatment.
"Our findings are consistent with other institutional reviews that found blacks were less likely than whites to opt for surgery," Peterson said. "I know that among my own patients, there is a considerable difference in preferences. That may be due to a combination of religious values, cultural mores, and/or one's trust in aggressive medical approaches, which often present high risks."