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ECV 97-022 – HSR&D Study

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ECV 97-022
Racial Variations in Cardiac Procedures: Do Health Beliefs Matter?
Nancy R. Kressin PhD
Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA
Bedford, MA
Funding Period: October 1998 - September 2001

BACKGROUND/RATIONALE:
Racial disparities in cardiac catheterization (CATH) use are well documented, but the reasons for these disparities have not been elucidated.

OBJECTIVE(S):
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.

METHODS:
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.

FINDINGS/RESULTS:
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.

IMPACT:
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.

PUBLICATIONS:

Journal Articles

  1. Whittle J, Kressin NR, Peterson ED, Orner MB, Glickman M, Mazzella M, Petersen LA. Racial differences in prevalence of coronary obstructions among men with positive nuclear imaging studies. Journal of the American College of Cardiology. 2006 May 16; 47(10):2034-41.
  2. Kressin NR. Separate but not equal: the consequences of segregated health care. Circulation. 2005 Oct 25; 112(17):2582-4.
  3. Kressin NR, Chang BH, Whittle J, Peterson ED, Clark JA, Rosen AK, Orner M, Collins TC, Alley LG, Petersen LA. Racial differences in cardiac catheterization as a function of patients' beliefs. American journal of public health. 2004 Dec 1; 94(12):2091-7.
  4. Charles H, Good CB, Hanusa BH, Chang CC, Whittle J. Racial differences in adherence to cardiac medications. Journal of the National Medical Association. 2003 Jan 1; 95(1):17-27.
  5. Petersen LA. Racial differences in trust: reaping what we have sown? Medical care. 2002 Feb 1; 40(2):81-4.
  6. Collins TC, Clark JA, Petersen LA, Kressin NR. Racial differences in how patients perceive physician communication regarding cardiac testing. Medical care. 2002 Jan 1; 40(1 Suppl):I27-34.
  7. Kressin NR, Clark JA, Whittle J, East M, Peterson ED, Chang BH, Rosen AK, Ren XS, Alley LG, Kroupa L, Collins TC, Petersen LA. Racial differences in health-related beliefs, attitudes, and experiences of VA cardiac patients: scale development and application. Medical care. 2002 Jan 1; 40(1 Suppl):I72-85.
  8. Oddone EZ, Petersen LA, Weinberger M, Freedman J, Kressin NR. Contribution of the Veterans Health Administration in understanding racial disparities in access and utilization of health care: a spirit of inquiry. Medical care. 2002 Jan 1; 40(1 Suppl):I3-13.
  9. Kressin NR, Petersen LA. Racial differences in the use of invasive cardiovascular procedures: review of the literature and prescription for future research. Annals of internal medicine. 2001 Sep 4; 135(5):352-66.
  10. Kressin NR, Meterko M, Wilson NJ. Racial disparities in participation in biomedical research. Journal of the National Medical Association. 2000 Feb 1; 92(2):62-9.
Journal Other

  1. Collins T, Petersen L, Kressin N, Clark J. How patients perceive physician communication regarding cardiac testing [abstract]. [Editorial]. Journal of general internal medicine. 2000 Jan 1; 15(supplement):160.
Conference Presentations

  1. Woodard L, Hernandez MT, Petersen LA. Racial Differences in Attitudes Regarding Cardiovascular Disease Prevention and Treatment: A Qualitative Study. Paper presented at: Society of General Internal Medicine Annual Meeting; 2002 May 1; Atlanta, GA.
  2. Kressin N, Chang B, Orner M, Clark J, Rosen A, Ren X, East M, Kroupa L, Alley L, Whittle J, Petersen L. Racial Differences in Physician Perceptions of and Communication with Cardiac Patients. Paper presented at: VA HSR&D National Meeting; 2002 Mar 1; Washington, DC.
  3. Kressin N, Chang B, Orner M, Clark J, Rosen A, Ren X, Petersen E, East M, Kroupa L, Alley L, Whittle J, Petersen L. Racial difference in physician perceptions of and communication with cardiac patients. Paper presented at: VA HSR&D National Meeting; 2002 Feb 14; Washington, DC.
  4. Kressin N, Chang B, Peterson E, Whittle J, Orner M, Clark J, Rosen A, Ren X, East M, Kroupa L, Alley L, Petersen L. Racial differences in cardiac catherization are not a function of patient beliefs, but may be related to provider attitudes about patients. Paper presented at: AcademyHealth Annual Research Meeting; 2002 Jan 15; Washington, DC.
  5. Chang B, Kressin N, Petersen LA. Religiosity, Optimism and Satisfaction with Decision Making About Invasive Cardiac Procedures. Paper presented at: American Geriatrics Society Annual Meeting; 2001 Nov 1; Chicago, IL.
  6. Kressin N, Chang B, Peterson E, Orner M, Petersen L. Are Racial Differences in Functional Status Associated with Invasive Cardiac Procedure Use. Paper presented at: Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Annual Scientific Forum; 2001 Jan 5; Washington, DC.
  7. Kressin N, Clark J, Whittle J, East M, Peterson E, Chang B, Rosen A, Ren X, Alley L, Kroupa L, Collins T, Petersen L. Racial Differences in Health Beliefs Among VA Cardiac Patients. Paper presented at: American Association for Dental Research Annual Meeting; 2001 Jan 5; Washington, DC.


DRA: none
DRE: none
Keywords: Cardiac procedures, Minority, Patient preferences
MeSH Terms: Patient Satisfaction, Cardiac Surgical Procedures

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