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Ann Thorac Surg 2001;72:6-8
© 2001 The Society of Thoracic Surgeons
Address reprint requests to Dr Jones, Department of Surgery, University of Missouri, M580 Health Sciences Center, Columbia, MO 65212
e-mail: jonesjw{at}health.missouri.edu
A decade ago the American Medical Association Council on Ethical and Judicial Affairs examined available data and concluded "that even when blacks gain access to the health care system, they are less likely than whites to receive certain surgical or other therapies." Their study focused particularly on expensive therapies, including coronary bypass procedures [1]. In ensuing years, the data suggesting racial bias in availability of cardiac surgical care has grown. A retrospective review of 33,641 male ischemic heart disease patients at 158 acute-care VA hospitals found that black patients received invasive procedures significantly less often than whites with equivalent diagnoses [2]. Gornick and colleagues [3] had similar findings in reviewing 1993 Medicare administrative data for 26.3 million beneficiaries 65 years of age or older (24.2 million whites and 2.1 million blacks), and concluded that black people with the same medical characteristics received coronary bypass treatment for ischemic heart disease only 40% as often as whites. Hispanics also received percutaneous transluminal coronary angioplasty and coronary artery bypass graft operations proportionately less often than whites [4]. In other studies, even when adjustments for severity of disease were made, coronary revascularization was still underutilized in black patients [5]. Black people received surgical therapy for ischemic heart disease 22% [6] to 68% [5] as often as symptomatically similar white people, with the difference remaining significant in every published study on the subject. Blacks received a disproportionately low share of many other expensive therapies as well. Nonetheless, because coronary bypass operation was the most commonly cited disparity, our assessment will explore conclusions implying widespread unwarranted racial bias in patient selection within the specialty of thoracic surgery.
Bias is morally neutral; it depends on context for ethical status [7]. In its medical or scientific context, it is commonly defined as "a systematic error introduced into sampling or testing by selecting or encouraging one outcome or answer over others" [8]. Studies have shown a clear distinction between use of surgical revascularization in white and nonwhite patients independent of socioeconomic status [9–12]. Because nonwhite ethnicity is no longer synonymous with poverty in America, it has been concluded that the lower rate of surgical revascularization provided to minorities unmasks a specifically racial bias among cardiac surgeons [1].
The process that results in a cardiac patient being brought to the operating room or treated in another manner may or may not reflect racial prejudice by nonsurgeons, internists, and surgeons. The answer reflects upon the integrity of the medical profession and the care we provide the patients who trust us. Components of this process should be closely scrutinized before we accept or deny a conclusion of systematic racially motivated exclusion, particularly by thoracic surgeons.
Several procedural steps must always precede surgical therapy for ischemic heart disease. First, the patient develops manifestations of disease and seeks care from a primary physician or cardiologist. Next, the signs and symptoms warrant the physician’s order for a coronary angiogram. The results of that study show that the angiographic anatomy is satisfactory for surgical therapy rather than angioplasty, whereupon the patient is referred to a cardiothoracic surgeon. After reviewing the patient history and angiogram, the surgeon decides to recommend an operation, which will occur only if the patient consents. Of these essential presurgical steps, only the decisions to accept the referral and recommend operative care based on the clinical indications are within the surgeon’s discretion.
A number of factors can cause this process to fail and leave a patient without needed surgical revascularization. The affected individual might endure his or her pain without consulting a physician. The absence of medical insurance or other means to pay might similarly discourage a potential patient from seeking care. The patient might have silent ischemia and be unaware of a developing disease process. The sufferer may have insufficient insight into the consequences of remaining untreated, fear or mistrust of the medical system, be unaware of system entry points, or visit a provider who fails to diagnose the disease. Accumulated data indicates that both minorities [6] and the uninsured [13] present themselves for care with more advanced illnesses, suggesting that they procrastinate or have difficulty finding timely care. The presence of more, or more severe, comorbidity than seen in white counterparts could negatively influence the physician’s decision to operate.
Furthermore, demographic and utilization studies have shown that minority patients may obtain care from less-skilled physicians [14] or at poorly equipped community hospitals [12] closer to home, particularly for surgical therapy. Black people delayed seeking care significantly longer than whites for acute myocardial infarction, and therefore received angiograms and definitive diagnosis and treatment later [15, 16].
Minority patients appearing in emergency departments with clear evidence of acute myocardial infarction are significantly less likely than white people to receive an angiogram [4, 11, 16]. In a 1999 study of 13,690 patients admitted to New Jersey hospitals for acute myocardial infarction, angiograms were ordered significantly more often if patients presented to a hospital equipped with a catheterization laboratory [17]. Travel patterns to higher technology hospitals were revealing as well. White patients were more likely than blacks to bypass nearby community facilities and travel to tertiary care hospitals equipped to provide catheterization and invasive therapies [18]. In addition, if whites entered the health care system through a "basic facility" they were more likely than minority patients to be referred to a high-technology institution for care completion [12]. Receiving initial care in a tertiary care hospital with advanced technologic capability, including invasive cardiology and cardiac operations, improves patient access to definitive studies and thoracic surgery referral for all [19], but is crucial in uninsured minority patients.
The coronary angiograms of black patients frequently showed less anatomical suitability for bypass than those of white patients. Although differences in the distribution of invasive procedures among patients receiving catheterizations favor whites, black patients showed a significantly smaller proportion of lesions susceptible to surgical treatment [20]. Peniston and associates [20] found that angiogrammed whites with acute myocardial infarctions had more lesions, and similarly studied black patients showed a higher incidence of normal coronary anatomy despite their clinical state. Surgical therapy was recommended less often for blacks, including those with full insurance coverage, when nearly 1,500 archived angiograms were restudied by blinded reviewers in a combined cardiology-cardiac operation conference [21]. Diffuse disease with poor target vessels was regularly cited when medical therapy rather than an operation was recommended for these patients noted to have triple-vessel disease [22]. When surgical therapy was recommended, black patients were significantly more reluctant than whites to give their consent for the procedures (p = 0.0025) [21].
Leape and colleagues [19] reviewed 631 consecutive angiograms of acute myocardial infarction patients admitted to the 13 hospitals in New York City equipped with catheterization laboratories and whom a panel of cardiologists identified as surgical candidates. He found that only 74% of patients meeting the expert panel criteria for revascularization actually had procedures performed; the underutilization was concentrated in uninsured patients admitted to hospitals without onsite surgical revascularization capability. Forty eight percent of patients in this category did not receive the recommended therapy. Notably, patients with Medicare insurance were treated as recommended in 91% of cases. The investigators reported that "...no variations in rate of use by sex, ethnic group, or payer status were seen among patients treated in hospitals that provide coronary artery bypass graft surgery and interventional cardiology. However, underuse was significantly greater in hospitals that do not provide these procedures, particularly among uninsured persons."
There are significant indications that racial bias unfairly limits access to needed coronary revascularization for many patients in America. There is also compelling evidence that the appearance of an unwarranted racial component in the process of selecting patients for bypass procedures may in fact be attributable to less sinister but nonetheless flawed features in the health care system. These flaws include how we relate to one another as colleagues across specialties, how compensation affects medical decisions, how well we recognize and diagnose variations in anatomy, and how we accommodate our patients’ cultural sensitivities. The essential route of access for coronary operations is the surgical consultation request accompanied by a recent coronary angiogram. None of the studies exploring disparities in surgery rates found that thoracic surgeons turned away referrals based upon patient race. Surgical treatment rates were negatively affected by (1) delays in patient presentation, (2) primary care provided by less able physicians or at community hospitals with limited capabilities, (3) either normal anatomy or anatomically diffuse disease with poor target vessels, and (4) withheld patient consent. These limitations exist independent of actions by thoracic surgeons. Published results confirm that racial minorities are heavily represented within these areas of procedural difficulty. Minorities are also well known to be prominent among low-income population groups, whom a few practitioners in every specialty unethically avoid in the service of economic self-interest rather than conscious racial prejudice. Our specialty must remain alert to both the appearance and the potential reality of widespread prejudicial behavior. Although questions remain about the patterns of diagnosis and referrals that determine what patients reach us, there is no evidence that thoracic surgeons systematically and intentionally deny operations to minority patients coming to them for care.
References
This article has been cited by other articles:
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  R. P. Scott and K. C. Heslin Historical perspectives on the care of african americans with cardiovascular disease Ann. Thorac. Surg., October 1, 2003; 76(4): S1348 - 1355. [Full Text] [PDF]
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