Race and gender disparities in rates of cardiac revascularization - Do they reflect appropriate use of procedures or problems in quality of care?
Race and gender disparities in rates of cardiac revascularization - Do they reflect appropriate use of procedures or problems in quality of care?
复制标题
DOI：
10.1097/01.mlr.0000093423.38746.8c
复制
发表时间：
2003-11-01
期刊：
影响因子：
3
通讯作者：
Piana, RN
中科院分区：
文献类型：
--
作者：
Epstein, AM;Weissman, JS;Piana, RN
背景许多研究已经证明了种族和性别在冠状动脉旁路移植术和经皮冠状动脉成形术的使用方面存在实质性差异。然而，很少有研究探讨这些差异是否反映了护理质量的问题。我们选择了一个按性别、种族和收入分层的随机样本，5026名年龄在65岁至75岁之间的医疗保险受益人，他们在1991年至1992年期间在5个州中的1个州接受了住院冠状动脉造影术。我们比较了2个质量问题的频率，按种族和性别，使用不足或未能接受有临床指征的血运重建手术和接受无临床指征的血运重建。我们使用了由兰德公司和美国心脏病学会/美国医院协会（ACC/ AHA）制定的两套独立的标准。我们还检查了队列的生存率，直到1994年3月31日。血运重建手术在白人中比黑人更常见，在男性中比女性更常见。在有指征的情况下未能接受血运重建在黑人中比在白人中更常见（40%比23- 24%，取决于标准，均P < 0.001），但在男性和女性中相似（25%比22- 24%，P >0.05）。在调整患者和医院特征后，种族差异仍然相似。在被评定为不适当的患者中，使用兰德标准的白人手术率高于黑人（10.5% vs. 5.8%，P < 0.01），男性手术率高于女性（兰德标准为14.2% vs. 5.3%，P = 0.001; ACC/AHA标准为8.2% vs. 4.0%，P = 0.04）。多变量校正后，种族和性别的差异保持相似，并且使用兰德标准具有统计学显著性。死亡率倾向于验证我们的使用不足的适当性标准。手术使用的种族差异反映了白人的临床适当性较高，黑人的使用不足率较高，白人中无临床指征时的血运重建频率较高。使用不足与较高的死亡率有关。相比之下，男性的临床适用性更高，并且在没有临床指征时更有可能接受血运重建。没有证据表明妇女使用不足的情况更严重。
BACKGROUND. Numerous studies have documented substantial differences by race and gender in the use of coronary artery bypass graft surgery and percutaneous coronary angioplasty. However, few studies have examined whether these differences reflect problems in quality of care.METHOD. We selected a random sample stratified by gender, race, and income of 5026 Medicare beneficiaries aged 65 to 75 who underwent inpatient coronary angiography during 1991 to 1992 in 1 of 5 states. We compared the frequency of 2 problems in quality by race and gender underuse or the failure to receive a clinically indicated revascularization procedure and receipt of revascularization when it was not clinically indicated. We used 2 independent sets of criteria developed by the RAND Corporation and the American College of Cardiology/American Hospital Association (ACC/ AHA). We also examined survival of the cohort through March 31, 1994.RESULTS. Revascularization procedures were clinically indicated more frequently among whites than blacks and among men than women. Failure to receive revascularization when it was indicated was more common among blacks than among whites (40% vs. 23-24%, depending on the criteria, both P < 0.001) but similar among men and women (25% vs. 22-24%, P >0.05). Racial disparities remained similar after adjusting for patient and hospital characteristics. Among patients rated inappropriate, use of procedures was greater for whites than blacks using RAND criteria (10.5% vs. 5.8%, P < 0.01) and greater for men than for women (14.2% vs. 5.3% by RAND criteria, P = 0.001; 8.2% vs. 4.0%% by ACC/AHA criteria, P = 0.04). After multivariate adjustment, the disparities for race and gender remained similar and were statistically significant using RAND criteria. Mortality rates tended to validate our appropriateness criteria for underuse.CONCLUSIONS. Racial differences in procedure use reflect higher rates of clinical appropriateness among whites, greater underuse among blacks, and more frequent revascularization when it was not clinically indicated among whites. Underuse is associated with higher mortality. In contrast, men had higher rates of clinical appropriateness and were more likely to receive revascularization when it was not clinically indicated. There was no evidence of greater underuse among women.