June 12, 2007 -- When you roll into the ER with crushing chest pain, does your skin color determine the care you get?
A new study in this week's Journal of the American Medical Association suggests it very well might, though experts continue to be at odds over the impact of race in heart disease treatment.
Lead study author Dr. Ioana Popescu and colleagues at the University of Iowa Medical School reported on a five-year study of what happened to more than 1 million elderly black and white Medicare patients after they had heart attacks.
What Popescu found was that that black patients were less likely to receive invasive, aggressive treatments following a heart attack -- procedures like bypass surgery or receiving an artery-opening stent.
Though the study did not examine certain other factors that could influence death rates -- such as obesity and smoking -- Popescu cited consistently higher death rates for black patients between one month and one year after their episode.
The importance of the findings was echoed by other cardiologists and heart surgeons not affiliated with the study.
Dr. Carl Pepine, chief of cardiology at the University of Florida, noted, "These are very important findings that emphasize that we have much important work remaining in the battle against heart disease that is not linked simply to insurance status."
Fewer Aggressive Treatments
When dealing with a patient who has suffered heart problems, doctors have an array of options, some more aggressive than others.
A stent is a sort of scaffolding that props a clogged artery open. In a bypass surgery, a nonessential vein (like one from the leg) is cut out and used to reroute blood away from the blocked artery that caused the heart attack.
Both can be done on an emergency basis, or can be scheduled if an artery is dangerously close to closing off.
Heart patients who do not receive these treatments instead take medications, such as beta-blockers and aspirin, to prevent another heart attack.
Since not all hospitals have the facilities or the specialists needed to do these procedures, patients who need the treatments are normally transferred to centers that offer this level of care.
But Popescu showed that black patients in these hospitals were less likely to be transferred -- and were not transferred as quickly -- to a hospital that could do bypass or stent procedures. This was true even when they were compared with white patients who had similar pre-existing illnesses and were of the same socioeconomic status.
And no matter what kind of hospital they went to first, black patients still received fewer procedures.
Since all patients were Medicare patients, there was no question of discrimination based on ability to pay for the expensive procedures.
Reasons for Racial Disparities
So what could be the reason for the treatment gap?
While researchers have known for a while that black and white patients do not receive the same levels of care in many circumstances, they hotly debate why these differences exist in the current study.
On one side, some experts said that the data can be explained by patient preference.
"Blacks are twice as likely to refuse procedures as nonblacks," said Dr. Peter McCullough of William Beaumont, a teaching hospital near Detroit. "So that explains the lower transfer and revascularization rates."
Pepine acknowledged that, in his experience, some black patients did refuse more aggressive treatment.
"Some of this was related to not wanting to leave their family … not fully understanding the treatment recommended … and some was related to delaying the decision until family members could be assembled," he said.
The latter was particularly problematic in his practice, as some patients had so many family members trying to agree on a course of treatment that the patient refused. Others, he said, had to wait so long for family members to arrive that by the time they did, it was past the point when the procedure would have helped.
Commenting on the worrisome trend of higher death rates among blacks, Nancy Adler, a professor of medical psychology at the University of California at San Francisco pointed out that in many cases, black patients are "sicker to begin with."
"They have markedly higher rates of diabetes, renal failure, weight loss, dementia," she said. "The analysis of death rates [did not take] this into account."
She also noted that benchmarks of health care quality are generally poorer in the South, and more black patients may have lived in that region.
On the other side of the debate is Dr. Quinn Capers, a prominent black cardiologist who believes that the findings are partly due to racism.
"It has been suggested that African-Americans with heart disease have coronary artery anatomy that is not suitable for [stents]; are more likely to decline to have procedures and are primarily served by hospitals without the capability or access to perform high-tech procedures," he said.
"All of these [things]have ultimately been disproved."
David Williams, a Harvard faculty member who co-wrote an Institute of Medicine report on unequal patient treatment, said, "My personal view is that unconscious or unthinking discrimination based on negative stereotypes is the [simplest] explanation of this phenomenon."
Dr. Scott Shurmur, a cardiologist at the University of Nebraska, concurred that physicians' attitudes could be responsible for the difference.
"Unfortunately this only confirms previous studies citing racial differences," he said. "Consent is less frequently given for invasive procedures by blacks than whites, but much of that could be bias in the presentation of the procedure to the patient."
In other words, if black patients perceive decreased optimism or any reservations from their cardiologists about invasive procedures, they might be less likely to sign on the dotted line.
These experts' conclusions might be supported by the findings of an unusual study in 1999 in which cardiologists watched videos of white and black patients describing their symptoms and received other clinical information from, say, EKGs.
When asked to recommend treatment, cardiologists suggested invasive procedures for white men at the highest rates, even though the patients were "clinically equal." Capers said he believes this study makes a strong case for physician racial bias.
To protect themselves, patients should arm themselves with information so that they get the best possible treatment, Popescu said.
"The more informed and assertive you are, the better off you are. Patient involvement is key."