Research has shown that in both the veteran and general US populations, White patients are significantly more likely to undergo coronary artery bypass (CABG) surgery than African American (AA) patients. It is unclear what is determining these differences. Understanding the reasons for this variation is important to providing high quality care to all veterans.
The overall objective of this study is to examine how health care providers (HCPs) make recommendations, and patients (PT) make decisions about non-invasive vs. invasive diagnostic testing (e.g., stress test vs. cardiac cath) and treatment procedures (i.e., medical management vs. angioplasty (PCI) and CABG). Specifically, we will: 1) describe HCP-PT interactions; 2) outline comparisons between AA and White veterans’ attitudes towards testing and treatment for CAD; 3) examine HCP views about CAD care; and 4) determine factors in the HCP-PT interaction that impact decision-making, and the role of ethnicity in these decisions.
This cohort study of 200 AA and 200 White patients, recruits participants based on a new referral to have an evaluation in cardiology for CAD. PTs with prior invasive cardiac procedures are excluded from the study. The interaction and decisions of patients and HCPs are followed from diagnostic testing through to treatment. Research assistants observe and audiotape select consultations between PTs and HCPs. Surveys are administered to both patients and physicians. PT surveys assess the PTs’ understanding of the discussions with their HCPs. Patient-specific characteristics measured include comorbid conditions, decision-making style, prior knowledge and beliefs about heart disease, religiosity, social support, trust in physicians, perceptions of current cardiac and general functional status, as well as emotional health. HCPs are assessed on how strongly they recommend diagnostic testing and treatment for their patients, and how they perceive their patients’ decision-making styles, and understanding of what was discussed. An Observer Checklist codes the communication and information-giving process between HCPs and PTs. Content is coded as occurring or not, initiated by the HCP or PT, and whether the HCP responded to a topic raised by the PT. Primary outcomes include HCP testing and treatment recommendations, and PT’s acceptance of recommendations, satisfaction with decisions, and measures of functional status.
302 patients have been recruited into the study thus far from various CAD decision making time points. Data collection is complete for 201 patients. The ethnicity of PTs recruited include 64.8 percent White, 32.4 percent AA, 0.4 percent Hispanic, 0.7 percent Native American, and 1.7 percent mixed ethnicity. The study participation rate is 92 percent. Of the patients for whom data collection is complete, 153 were referred to stress testing, and 106 were referred for cardiac cath, 22 percent refused to have stress testing done, and 12 percent refused to have cardiac cath. To date, five patients were treated with medical management after stress testing only. After cardiac cath 28 received MM, 13 received PCI, and 28 patients received CABG treatment. Five had a change in treatment after the initial recommendation.
The study will provide a description of the decision-making process of PTs as they go through the process of being evaluated and recommended for treatment for CAD. Most importantly, the study will be able to describe how the process may differ for AA and White PTs, and how it might account for differing rates of procedure use.
- Siminoff LA, Hausmann LR, Ibrahim S. Barriers to obtaining diagnostic testing for coronary artery disease among veterans. American journal of public health. 2008 Dec 1; 98(12):2207-13.