Ann Thorac Surg 2006;81:531-536
© 2006 The Society of Thoracic Surgeons
Original article: Cardiovascular
Racial and Ethnic Disparities in Care: The Perspectives of Cardiovascular Surgeons
Stephanie L. Taylor, PhD
a
,
b
,
*
,
Allen Fremont, MD, PhD
b
,
c
,
Arvind K. Jain, MS
b
,
Rebecca McLaughlin, BA
b
,
Eric Peterson, MD, MPH
d
,
T. Bruce Ferguson, Jr, MD
e
,
f
,
Nicole Lurie, MD, MSPH
b
a RAND Corp, Washington, DC
b RAND Corp, Santa Monica
c University of California Los Angeles, West Los Angeles VAMC Division of Medicine, Los Angeles, California
d Duke University, Durham, North Carolina
e American College of Cardiology, Bethesda, Maryland
f Louisiana State University, New Orleans, Louisiana; The Society of Thoracic Surgeons, Chicago, Illinois
Accepted for publication August 15, 2005.
* Address correspondence to Dr Taylor, RAND Corp, 1776 Main St, M5S, PO Box 2138, Santa Monica, CA 90407 (Email: staylor{at}rand.org).
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Abstract
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BACKGROUND: Although racial/ethnic disparities in care are well documented, particularly for cardiac care, we know little about what cardiac surgeons think about them. For educational efforts to be effective in helping physicians address disparities, they must consider providers' knowledge and beliefs about the underlying causes of the disparities.
METHODS: We conducted a survey in 2004 to assess cardiologists' and cardiac surgeons' knowledge of racial/ethnic disparities in cardiovascular care and their perceptions about the underlying causes. Respondents were recruited from the membership of four cardiovascular professional associations. This paper focuses on cardiovascular surgeons' responses (n = 208).
RESULTS: Forty-four percent of cardiovascular surgeons thought that, among patients with cardiac risk factors, black patients were not as likely as white patients to receive cardiac diagnostic tests and procedures. Additionally, 30% thought that black patients were not as likely as white patients to receive therapeutic tests and procedures. However, only 13% agreed that cardiac care disparities occur "often" or "somewhat often" based on patients' race/ethnicity, independent of their insurance and education. Only 3% thought disparities were likely to occur in their clinical setting. Respondents appeared more likely to endorse patient factors (eg, health behaviors or treatment adherence) than system or provider (eg, miscommunication or continuity of care) factors as reasons for disparities.
CONCLUSIONS: Although some surgeons acknowledge that racial/ethnic disparities in cardiac care occur, very few agree that they occur often, independent of patients' characteristics. Educational efforts tailored to local care settings, such as reviewing quality of care data on patients of different races/ethnicities within a clinic/hospital, may effectively inform all physicians of these disparities.
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Introduction
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Well over a hundred peer-reviewed studies now document the phenomenon that people of different races or ethnicities do not always receive the same clinical care [1, 2]. Several seminal reports, such as the Institute of Medicine's report entitled "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care" and the "National Healthcare Disparities Report" from the Agency for Healthcare Research and Quality have summarized these data over the last 2 decades. Although disparities appear to exist in nearly all clinical areas and settings studied, much of the evidence comes from the field of cardiovascular care. For example, the American College of Cardiology (ACC) and the Henry J. Kaiser Family Foundation's (KFF) review of the literature demonstrated strong evidence of racial/ethnic disparities in the use of a variety of diagnostic and therapeutic cardiac procedures including coronary revascularization and thrombolytic therapy [3]. The authors of this report identified 81 "methodologically strong" peer-reviewed studies in the area of cardiovascular care. To meet the definition of "methodologically strong," studies must have controlled for several variables in multivariate analyses such as: socioeconomic and insurance status, severity of disease, health status or behaviors, comorbidities, age, and gender. Of the 81 such studies reviewed, 68 found evidence of racial/ethnic disparities in care. These studies also indicate that racial/ethnic minorities were 23% to 83% as likely as white patients to receive or be offered cardiac care, and that white patients were 22% to 688% more likely than minorities to receive or be offered cardiac care. Although it is unknown whether racial/ethnic minorities are receiving too little or too much care relative to white patients, all would agree that patients should receive equal treatment, regardless of their race/ethnicity.
Understanding what physicians know about racial/ethnic disparities in cardiovascular care, what they think are the underlying causes and what can be done about them, are key to developing additional strategies—educational or otherwise—to address the disparities. In early 2004, we conducted a study of cardiovascular surgeons' and cardiologists' knowledge of racial/ethnic disparities in cardiovascular care with the intent that the findings be used to guide further efforts at reducing disparities. We included both groups of physicians in our study because they provide care at different points in cardiovascular disease trajectories. We previously reported on cardiologists' perspectives about racial/ethnic disparities [4]. This paper focuses on what cardiovascular surgeons know about racial/ethnic disparities in cardiovascular care. To our knowledge, it is the first to do so.
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Material and Methods
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Study Sample
Data for the overall study were derived from a sample of cardiovascular surgeons and cardiologists who were members of one of four professional organizations: ACC, the American Heart Association (AHA), the Association of Black Cardiologists (ABC), and the Society of Thoracic Surgeons (STS). We obtained e-mail addresses for samples of ACC and AHA members in the United States. The AHA sample was restricted to those councils with the highest proportion of practicing cardiologists. For ABC and STS, we obtained contact information from the complete membership list. Persons whose names appeared on more than one organization's list were randomly assigned to one organization for purposes of sampling, with one exception: all ABC members were assigned to that organization. Additionally, we eliminated addresses of physicians at pharmaceutical companies or device manufacturers, and persons who were not physicians.
To obtain a sample of surgeons, the focus of this paper, we randomly selected 500 members from the STS list. Of these, 107 surgeons (21%) had e-mail addresses that were returned as undeliverable, and another 12 returned the survey indicating that they did not practice medicine, resulting in a final eligible sample of 381 surgeons. The anonymous survey was accessed through a web-link included in an e-mail that asked recipients to participate. As many as five reminder e-mails were sent to e-mail addresses of respondents who did not click the link to respond to the survey. Finally, we attempted to deliver surveys by Federal Express for those nonresponders for whom we had addresses, but the response rate to these surveys was low. These survey activities were conducted between February and April 2004. Of the 381 surgeons in the final eligible sample, 3 declined to participate and 170 never accessed the survey on line. We cannot determine how many in this latter group never received our initial e-mail versus those not wishing to participate. The final sample included 208 cardiovascular surgeons, resulting in a 55% response rate. In this paper, we briefly compare the responses of cardiovascular surgeons to those of cardiologists who participated in the overall study. Additional details of that study, and the findings for cardiologists, have been previously reported [4].
Survey
The survey was based in part on a 1999 Kaiser Family Foundation survey that assessed knowledge and attitudes of a random sample of US physicians in all specialties [5]. The draft survey then was reviewed by two external researchers and by ACC, ABC, AHA, and STS leadership. The survey was subjected to a series of cognitive interviews and was pretested both in print and web-based forms. The survey items used one of the following 5- or 4-point Likert scales: (1) very often, somewhat often, neither often nor rarely, somewhat rarely, and very rarely; (2) very likely, somewhat likely, neither likely nor unlikely, somewhat unlikely, very unlikely; (3) strongly agree, agree, neither agree nor disagree, disagree, and strongly disagree, and (4) a great deal, some, a little, and none. A copy of the survey is available upon request.
Analysis
We first dichotomized responses to several items by combining those reporting to "strongly agree" or "agree" and considered the other three response options as evidence of lack of agreement. We were unable to analyze the effects of surgeons' sex or racial/ethnic status because the sample sizes for women and nonwhites was too small. We also combined three types of respondents' practice settings—solo, small group (containing 2 to 10 physicians), and free-standing clinics or offices—into one category of settings, solo or small group, because the sample sizes for each were too small to analyze separately, and they were substantively similar to each other, relative to the other setting categories. Next, we examined frequency distributions of physician responses to each item. We then performed bivariate analyses to compare physicians who did and did not respond "very often" or "somewhat often" to the item, "How often do you think clinically similar patients receive different cardiovascular care based on their race or ethnic background, regardless of the factors listed above" (having insurance, type of insurance, ability to speak English, and education level)?. For this comparison, we used 
2 or Fisher's exact tests as appropriate. Additionally, we could not perform meaningful multivariate analyses because some of the cell counts would have been too low to produce robust coefficients.
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Results
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Characteristics of the cardiovascular surgeon sample are shown in Table 1. Respondents were predominantly white and male, with nearly three quarters graduating medical school prior to 1985. Almost three quarters (72%) of respondents reported that their main practice setting was either an academic medical center or hospital. Three quarters (75%) worked in settings where minorities comprised less than a quarter of their patients.
Nearly half (48%) of surgeons reported that, among clinically similar patients, disparities in care based on patients' insurance occur "very often" or "somewhat often" in the United States health care system (Fig 1). However, only 16% of respondents reported that clinically similar patients "often" or "somewhat often" receive different care (in general) according to their racial/ethnic status, and 13% reported this of cardiac care in particular.
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Fig 1. Proportion of respondents who believe, within the US health care system in general, that patients often or somewhat often receive different care based on having insurance, insurance type, speaking English, education, or race/ethnicity (n = 206).
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Surgeons were then asked about the extent of disparities, independent of other patient characteristics such as having insurance, type of insurance, English ability, and education level, with the question "How likely do you think it is that clinically similar patients receive different cardiovascular care based on what their race or ethnic background is, regardless of the factors listed above?". Only 3% of respondents indicated that receipt of different care was "likely" or "very likely" in their own hospital or clinic, and 2% said it was likely among their own patients.
Table 2
shows the results of bivariate analyses examining the characteristics of physicians reporting that racial/ethnic disparities in cardiovascular care occur "very" or "somewhat often" among clinically similar patients. Surgeons residing in the South were more likely to believe that disparities occur often. Additionally, surgeons graduating before 1985 appeared more likely to (although, not significantly) believe racial/ethnic disparities occur often. Cardiovascular surgeons also were asked how strongly they agreed or disagreed with six statements on racial/ethnic disparities in the receipt of specific cardiac services. Forty-four percent disagreed or "strongly" disagreed with the statement that "Among people with cardiac risk factors, blacks are just as likely as whites to undergo diagnostic tests and procedures for cardiac disease." Thirty-nine percent disagreed with a similar statement about Hispanics versus whites, and 32% disagreed with a similar statement about other racial/ethnic minorities versus whites. However, when asked if racial/ethnic disparities exist in the receipt of therapeutic tests and procedures among persons with known heart disease, only 30% disagreed that blacks are just as likely as whites to get these services. Twenty-eight percent disagreed that Hispanics are just as likely as whites to get these services, and 21% disagreed that other racial/ethnic minorities are just as likely as whites to get these services.
Regarding the causes of race/ethnic disparities in cardiovascular care, respondents appeared to endorse more patient (Fig 2) than nonclinical, system factors (Fig 3) as contributing to racial/ethnic disparities in cardiovascular care in the United States. Of those thinking that any racial/ethnic disparities in the receipt of specific cardiac services exist, about half (54%) reported that patient factors such as patients' health behaviors contributed "a great deal" to these disparities. About half also thought that patients' adherence to treatment (51%) or their attitudes and beliefs about health care providers (50%) contributed to the disparities. Alternatively, only 38% thought that the continuity of care contributed "a great deal" to disparities in cardiac care, and only 26% thought this of provider-patient miscommunication. With regard to the means of overcoming racial/ethnic disparities, 55% of respondents felt that increasing patients' self-management skills would be the most effective in reducing racial/ethnic disparities in care, and 48% reported that conducting public education would be effective. In contrast, fewer than 20% of cardiovascular surgeons felt that increasing provider awareness about racial/ethnic disparities or improving the cultural competence of either the provider or the institution would be likely to be useful in addressing disparities.
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Fig 2. Percent reporting that specific patient characteristics contribute a great deal to racial/ethnic disparities in cardiovascular care in the United States, among those thinking that disparities in specific cardiac services exist (n = 95).
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Fig 3. Percent reporting that specific nonclinical factors contribute a great deal to racial/ethnic disparities in cardiovascular care in the United States, among those thinking that disparities in specific cardiac services exist (n = 92).
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We also compared the responses of cardiovascular surgeons with those of cardiologists on a few key issues. Surgeons were more than half as likely (13% versus 32%) as cardiologists to report that racial/ethnic disparities occur often or somewhat often in cardiovascular care (p < 0.001). Surgeons also were less likely than cardiologists (3% versus 12%) to report that disparities in cardiovascular care in their practice settings were likely, regardless of the four patient characteristics (p < 0.001). Additionally, they were less likely than cardiologists (35% versus 60%) to rate the evidence for racial/ethnic disparities as strong or somewhat strong (p < 0.001). Surgeons also were less likely than cardiologists to attribute each of the 12 provider or system factors to those disparities (p < 0.05) [4].
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Comment
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We assessed the perspectives of cardiovascular surgeons with regard to racial/ethnic disparities, and found that only 32% to 44% of respondents thought that racial/ethnic disparities in cardiac diagnostic tests and procedures were likely among patients with cardiac risk factors. Additionally, 21% to 30% thought disparities in patients' therapeutic tests and procedures were likely among patients with known heart disease. Furthermore, only 13% thought disparities in cardiac care in general occurred often or somewhat often, independent of four other patient characteristics (having insurance, type of insurance, ability to speak English, and education level).
There are several possible explanations for the differences between the first two questions and the third question that considers additional patient characteristics. Some cardiovascular surgeons might think that although racial/ethnic disparities occur, they might not occur that often and do not occur in their practices or among their patients. Alternatively, surgeons may attribute racial/ethnic disparities to differences in patients' education, insurance or English language skills, not directly to their racial/ethnic status. Indeed, the contributing factors to racial/ethnic disparities in care are multiple and include both patient and nonclinical, system factors. Most published studies concerning racial/ethnic disparities do indeed find that controlling for differences in patient characteristics reduces, but does not eliminate, the findings of racial/ethnic disparities. Respondents identified patient factors (treatment adherence and health beliefs) as the two major causes of disparities, whereas far fewer identified nonclinical, system factors as a cause, in spite of evidence to the contrary. For example, physicians' referral decisions were shown elsewhere to be based on their inaccurate assumptions about particular patients being uninsured [6]. Another study found that whites were more likely than African-Americans to receive a revascularization procedure for reasons consistent with appropriateness criteria, suggesting that physicians may apply different criteria in recommending procedures for whites and African-Americans [7].
Although only 13% of surgeons believed racial/ethnic disparities in cardiac care in general occur often or somewhat often, only 3 in every 100 surgeons thought they were likely in their own practice settings. This discrepancy between what exists in theory and what occurs in surgeons' own practice settings is not an uncommon phenomenon. For example, patients have been known to report dissatisfaction with care in general, but highly regard their own care [5]. One explanation for this may be that many respondents do not provide care for minority patients, and thus would not have an opportunity to consider disparate care in their practices. However, only 19% of respondents' practices had less than 10% minority patients. Alternatively, our findings may reflect the fact that cardiovascular surgeons are less involved in the referral process that influences whether and what kind of cardiovascular care patients should receive, and, as such, are less aware of the patients who are not referred to them. That also might explain why surgeons were less likely than cardiologists to report that racial/ethnic disparities were likely or occurred often.
Historical race relation issues may explain why surgeons residing in the South were more likely than those residing elsewhere to think that racial/ethnic disparities in cardiac care occur often or somewhat often. That might also explain why surgeons graduating before 1985 were more likely to report this; they were adults when much attention was given to racial prejudice in the 1960s and 1970s.
This study has several important limitations. Although disparities are well documented, the day-to-day frequency with which they occur in individual settings cannot be precisely established. Thus, while it would be ideal to compare surgeons' responses of how often they think disparities occur to some established benchmark, this is not possible. Nevertheless, given the number of well publicized studies documenting the existence of racial/ethnic disparities in cardiac care, it is safe to say that these disparities are not uncommon. Another potential limitation is that physicians have rarely been surveyed about their perceptions of disparities, so there is no "control" group against which we can compare cardiovascular surgeons, other than cardiologists. Also, the response rate was lower than we would have liked. However, response rates to surveys of providers have declined significantly over the past decade given the increased demand on providers' time, and a 55% response rate is consistent with other recent studies, and higher than many web-based surveys [8–11]. Additionally, there was ultimately little that could have been done to increase the response rate for this web-based survey, as we did not have access to all respondents' mailing addresses or telephone numbers nor did we have the resources to contact all by Federal Express. We attempted to reach some by Federal Express but the yield was low, and we determined that it was not worth the investment.
Also, we were able to sample only those members that had provided e-mail addresses to the STS. We do not know how STS members differ from the population of cardiovascular surgeons. However, we do know they closely resemble the 1,328 members of the STS and the American Association for Thoracic Surgery who completed a membership survey in 2003. Those data indicated that 98% were male and the mean year of medical school graduation was 1973 [12]. Additionally, the relatively small sample size prevented us from examining multivariate relationships and the lack of variation in two provider characteristics, sex and race/ethnicity, prevented us from examining bivariate relationships with provider attitudes.
Despite these limitations, this paper serves to highlight the degree to which cardiovascular surgeons think racial/ethnic disparities in cardiac care exist, how often they occur, and the potential underlying reasons for those disparities. One step in eliminating any racial/ethnic disparities in cardiac care may be provider education, so that all, not only a few, are aware of the existence of disparities in care and about the possibility that such disparities could be present in their practices. In the case of cardiologists, the professional associations representing cardiologists (AHA, ACC, and ABC) took responsibility for increasing awareness among their members [3].
Professional associations representing cardiovascular surgeons could do something similar. Once aware of the possibility of these disparities in their practices, providers can address the situation by tackling the factors over which they have control, such as communication with patients. An additional approach may be to encourage practice settings to collect data on their own patients' race/ethnicities and to produce reports on quality of care stratified by race/ethnicity. Some plans and hospitals have had experience with collecting such data, at least on a limited basis [13]. Additionally, some data suggest that improving quality of care through the use of practice guidelines can play an important role in addressing racial and ethnic disparities [14]. Both the ACC and AHA are already active in promoting such programs, and in some cases, their data bases and registries provide additional useful information about disparities on a national scale, although it is not yet clear how much they will contribute to disparity reduction. The Robert Wood Johnson Foundation recently launched a new quality improvement initiative, focused directly on the provision of cardiovascular care [15]. Through this initiative, participating hospitals will receive support to assess their local cardiovascular care market and environment (including an examination of their own practice patterns), develop strategies to improve inpatient cardiovascular care, and form partnerships with providers to address disparities in the outpatient setting.
Although surgeons may feel they have little to do with racial/ethnic disparities in cardiac care because they receive their patients through referrals, we are unaware of evidence to inform this perspective. One step toward reducing these disparities would be for all health care providers, not only those who more directly prescribe treatment or diagnostic procedures, to be aware of the existence of these disparities. Ultimately, reducing and eliminating racial/ethnic disparities may require the combination of increasing awareness, improving quality, and increasing patient demand for and participation in high quality care. No single intervention is likely to contribute significantly to this important societal health issue. The effort to reduce or eliminate disparities in cardiovascular care will require the collaboration of multiple stakeholders. Cardiovascular physicians and surgeons are in a unique position to lead this effort across the care system and within their professions and practice settings.
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Acknowledgments
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This study was supported by the Robert Wood Johnson Foundation. We appreciate the help of American College of Cardiology, American Heart Association, and the Association of Black Cardiologists, and The Society of Thoracic Surgeons in developing the survey and in providing e-mail lists of a sample of their members. We also appreciate the helpful comments of Augustus Grant and Marsha Lillie-Blanton in reviewing the survey as well as the help of Suma Thomas at the American College of Cardiology.
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References
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- Agency for Healthcare Research and Quality. National healthcare disparities report, 2004. Available at: http://www.qualitytools.ahrq.gov/disparitiesreport. Accessed July 25, 2005..
- Kaiser Family Foundation. Racial/ethnic differences in cardiac care: the weight of the evidence. Menlo Park, CA: Kaiser Family Foundation, 2002. Available at: http://www.kff.org/uninsured/20021009c-index.cfm. Accessed July 25, 2005..
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Abstract
Introduction
