In this survey of more than 350 black and white patients, we found that whites were more likely to say they would undergo revascularization if recommended by their physician, and to say they would elect CABG if they were in a situation in which it would be likely to improve symptoms and long-term survival. This finding is consistent with previous work that has found that among patients offered CABG, blacks are less likely to actually undergo the procedure.10
Unlike these previous findings, which may have reflected differences in clinical characteristics among blacks and whites offered CABG, our study design controls for different clinical scenarios by providing all patients with identical situations. In addition, we were able to show that much of the black-white difference in patient preferences seemed to be explained by questions that addressed familiarity with the procedures in different ways. When these questions are included in multivariate models, race is a significant predictor of only one of four measures of attitudes. Finally, although these findings are based on small numbers of patients, it is also interesting that these differences were smaller when the interviewer was also black.
We have been unable to identify analogous studies of patient preferences for procedure use in the literature. However, several studies have found that blacks are more likely to delay seeking care for chest pain than whites, although at least one suggested this may reflect primarily socioeconomic differences.13–15
Several authors have suggested that this may be because black patients are less familiar with signs and symptoms of coronary heart disease.16,17
Lack of knowledge concerning heart disease symptoms might lead to different responses to symptoms of chest pain, but it is not clear how this would result in different attitudes toward revascularization among black patients.16,18
Another possibility is that blacks are more averse to using the medical system in general, perhaps reflecting previous negative experiences with it.19,20
Our survey did not address this possibility.
Other factors that may be important for understanding racial differences in the decision to accept or elect revascularization procedures are identified in the Health Belief Model.11
This model suggests that decision making is affected by a number of factors including beliefs about individual vulnerability to disease and the seriousness of disease and confidence in treatment efficacy, balanced against perceived barriers to care.21
Our finding that familiarity with the procedure was associated with procedure use would seem consistent with this model.
We should note that the grouping of our questions measuring familiarity is based on our theoretical perception that these questions would all measure the same construct in different ways. Our inability to group these with factor analysis, despite their having significant collinearity, suggests that more than one construct is being measured by these questions. More detailed studies using larger numbers of patients and different formulations of these questions may clarify the constructs that are truly important to the decision making process.
The consistent trend for black patients to be more likely to say they would choose revascularization when surveyed by a black RA as opposed to a white RA is also consistent with earlier reports. Brooks reported that 24% of black patients are dissatisfied with clinic visits, and attributed this to communication barriers, use of medical jargon, lack of warmth and friendliness by physicians, and perhaps a distrust of whites.22
As blacks make up 12% of the U.S. population but comprise only 3% of physicians,23
and even fewer subspecialists, most black patients facing an invasive cardiac procedure will be counseled by a physician who is not black. Thus, it is plausible that racial incongruity between patient and physician may contribute to the lower revascularization rates among blacks. One should consider that this analysis was not a part of our original study design. It also should be noted that the RAs, who did not have medical training, simply posed the two questions and read the scenarios verbatim, as they appear in , a much different situation than that of a physician counseling a patient. Nonetheless, our results raise the possibility that increasing the number of minority physicians in the workforce, particularly in subspecialty positions, may decrease differences in procedure use between blacks and whites.
There are several limitations to this study. Most importantly, answers were purely hypothetical. Actual decision making, for example in the setting of an acute ischemic event, might be considerably different as this situation would presumably lead to marked changes in one’s perceived susceptibility to disease, as well as its seriousness. However, it is interesting that the 10% higher proportion of whites who said they would agree to CABG if their doctor recommended it is similar to the difference in acceptance rates of CABG among patients in the CASS registry.10
Second, although we asked participants to answer questions about a hypothetical situation, they may have considered their own condition in deciding whether or not to elect CABG in the scenarios presented. It is possible that the racial differences in responses that we found reflected differences in the participants’ clinical situation, rather than differences in attitudes.
Third, because all participants were patients at the Pittsburgh VAMC, they may not be representative of blacks and whites across the country. For example, patients who use the VA medical system are more likely to be male, poor, and have a lower level of education than other Americans.24
A population that included women, had higher incomes, or was more highly educated might have given different responses. On the other hand, by studying men who use the VA, we minimize the potential confounding of race by differences in income and education. Moreover, it is unlikely that the physicians caring for black and white participants in this study had made systematically different attempts at patient education, as the same internal medicine and cardiology faculty supervise or provide directly the primary and cardiac care for these patients.
In addition, the fact that we used a convenience sample, rather than a truly random sample, may have yielded an unrepresentative population. Patients who were available for an interview may be more or less willing to undergo procedures than the population in general. However, it is our impression that the vast majority of patients in this VA clinic arrive significantly in advance of their scheduled appointment, in time to be a candidate for the present study. Fewer than 5% of patients who were approached did not agree to be interviewed.
Finally, our study did not address whether increasing patient familiarity with the procedures would have led to changes in attitudes. Indeed, because it relied on self-report, we cannot be sure whether we measured familiarity with a procedure or simply the desire to appear knowledgeable. Similarly, our study could not determine whether the lack of familiarity with procedures was secondary to other attitudes such as fear or distrust of invasive procedures or the medical system in general, which might have prevented gaining familiarity with CABG or PTCA.
We believe these results provide direction for researchers and clinicians concerned about patterns of use of revascularization procedures. First, the present results should be replicated in patients who are actually facing a decision regarding whether or not to proceed to a revascularization procedure, as well as in a more scientifically selected sample of the general population. This is particularly important for patients for whom revascularization would be medically necessary—that is, when revascularization is clearly beneficial and better than any other alternative.
Second, clinicians should be careful to ensure that lower levels of familiarity with CABG and PTCA at baseline do not lead to uninformed decision making, regardless of patient race. Unfortunately, physicians may spend more time explaining risks and benefits of procedures to patients who are well educated, and paradoxically give less information to those patients who are least familiar with proposed treatments.22
Thus, clinicians should be careful to assess baseline levels of familiarity with procedures when discussing recommendations with patients. If unfamiliar with the procedure, patients could be exposed to tailored educational programs before being asked to make a decision. This might be especially important if the patients have not been exposed to such decision making, for example among friends and relatives, in the past.