Ann Thorac Surg 2008;85:93. doi:10.1016/j.athoracsur.2007.08.067
© 2008 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Invited commentary
Charles R. Bridges, MD, ScD
Division of Cardiothoracic Surgery, University of Pennsylvania Medical Center, The Farm Journal Building, 230 W Washington Square, 3rd Floor, Philadelphia, PA 19106
(Email: cbridges{at}pahosp.com).
This report by DiGiorgi and colleagues [1] is only the most recent in a series of reports documenting significant racial disparities both in healthcare delivery and outcomes in this country. Although the present study was not powered to make this determination, other studies have consistently demonstrated that even when other covariates, such as socioeconomic status, education, and healthcare insurance are considered, race inevitably and inexorably emerges as a significant predictor of how healthcare is administered. Specifically, African Americans are less likely to undergo cardiac catheterization, percutaneous coronary intervention, coronary artery bypass graft surgery, knee and hip replacement, renal transplantation, or curative surgery for esophageal or lung cancer than their otherwise comparable white counterparts. Because each of the studies from which these conclusions are based is retrospective by definition, one can never completely rule out the idea that covariates that are unmeasured or immeasurable are actually responsible for the differences that appear to be attributable to race. In the healthcare disparity debate, this study by DiGiorgi and colleagues [1] does provide us with some new and interesting fodder for reflection. Any reservations to the contrary notwithstanding, this report and the aggregate weight of many others overwhelmingly support the conclusion that race is indeed a significant issue in how patients get treated.
The most striking new and unanticipated finding in this report is that African Americans are significantly less likely than whites to undergo mitral valve repair, and that this difference is most pronounced among those with degenerative disease. Coupled with their and our earlier observation that African American patients present at a younger age for mitral valve surgery than whites, at least two hypotheses become immediately apparent. Either African Americans with reparable valves with the same group of surgeons (and therefore, the same surgical expertise) are less likely to have their valves repaired due to unrecognized racial bias, or alternatively, African Americans with degenerative disease have more severe disease and are therefore less often candidates for repair than white patients. Thus, as with most important studies in science and medicine, this report allows us to ask questions that are arguably more interesting than the questions it answers for us. Regardless of which hypothesis is correct, we need to look carefully at how African American patients are treated and lobby to improve their access to primary care (ie, the second hypothesis) and insist on even handedness and equality in the administration of care (ie, the first hypothesis) for all of the patients we treat regardless of race.
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References
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- DiGiorgi PL, Baumann FG, O’Leary AM, et al. Mitral valve disease presentation and surgical outcome in African-American patients compared with white patients Ann Thorac Surg 2008;85:89-93.[Abstract/Free Full Text]
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Mitral Valve Disease Presentation and Surgical Outcome in African-American Patients Compared With White Patients
- Paul L. DiGiorgi, F. Gregory Baumann, Anne M. O’Leary, Charles F. Schwartz, Eugene A. Grossi, Greg H. Ribakove, Stephen B. Colvin, Aubrey C. Galloway, and Juan B. Grau
Ann. Thorac. Surg. 2008 85: 89-93.
[Abstract]
[Full Text]
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