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Use of Cardiovascular Procedures among Black Persons and White Persons: A 7-Year Nationwide Study in Patients with Renal Disease

Gail L. Daumit, MD; Judith A. Hermann, MLA; Josef Coresh, MD, PhD; and Neil R. Powe, MD, MPH, MBA
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From Johns Hopkins University School of Medicine and Johns Hopkins University School of Hygiene and Public Health, Baltimore, Maryland.

Ann Intern Med. 1999;130(3):173-182. doi:10.7326/0003-4819-130-3-199902020-00002
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Background: Black persons historically undergo fewer invasive cardiovascular procedures than white persons.

Objective: To determine whether acquisition of Medicare health insurance and comprehensive care for severe illness reduce ethnic disparity in use of cardiovascular procedures.

Design: 7-year longitudinal analyses in a cohort from the United States Renal Data System.

Setting: Health care institutions in the United States.

Patients: Nationwide random sample of 4987 adult black and white patients with incident end-stage renal disease (ESRD) from 303 dialysis facilities in 1986 to 1987.

Measurements: Medical history and service use records, physical examination, and laboratory data. Main outcome measures were receipt of a coronary catheterization or revascularization procedure before (baseline) and after (follow-up) development of ESRD and acquisition of Medicare, adjusted for clinical and socioeconomic variables.

Results: At baseline, 9.9% of white patients and 2.8% of black patients had had a cardiac procedure; the odds were almost three times greater in white than in black patients (adjusted odds ratio, 2.92 [95% CI, 2.04 to 4.18]). During follow-up, white patients were only 1.4 times more likely than black patients to have a procedure (adjusted relative risk, 1.41 [CI, 1.13 to 1.77]); rates were 7.8% for white persons and 8.5% for black persons. In patients with Medicare coverage before development of ESRD, the initial threefold difference in procedure use was eliminated over follow-up (odds ratio, 1.05 [CI, 0.56 to 1.60]). For procedures after hospital admission for myocardial infarction or coronary disease, no difference between ethnic groups was seen during follow-up (relative risk, 1.12 [CI, 0.68 to 1.85]).

Conclusions: Differences between ethnic groups in use of cardiovascular procedures narrowed markedly once a serious illness (ESRD) developed and adequate insurance coverage was ensured; the disparity was eliminated in patients with previous Medicare insurance or a stronger indication for a procedure. These findings suggest that almost equal access to care is attainable by combining insurance with delivery of comprehensive, clinically appropriate care.


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Figure 1.
Adjusted odds ratio of receiving a cardiovascular procedure (cardiac catheterization, angioplasty, or coronary artery bypass grafting) over time among white patients and black patients.

The odds ratios are derived from a logistic regression model that included the following covariates: age, sex, health insurance status at baseline, coronary artery disease at baseline, cholesterol level, history of smoking, presence of a malignant condition, and days at risk for a procedure. The heights of the bars represent the 95% CIs for the odds ratios; the horizontal lines represent the point estimates.

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Grahic Jump Location
Figure 2.
Disparity in use of cardiovascular procedures (cardiac catheterization, angioplasty, or coronary artery bypass grafting) by type of health insurance at baseline over time among white patients and black patients.

The odds ratios are derived from a logistic regression model that included the following covariates: age, sex, presence of coronary artery disease at baseline, presence of a malignant condition, and days at risk for a procedure. The striped bars represent odds ratios (point estimates and 95% CIs) at baseline; the white bars represent odds ratios at follow-up.

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