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

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 three-fold 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.