种族和性别对医生关于心脏导管插入术建议的影响。

The effect of race and sex on physicians' recommendations for cardiac catheterization.

作者信息

Schulman K A, Berlin J A, Harless W, Kerner J F, Sistrunk S, Gersh B J, Dubé R, Taleghani C K, Burke J E, Williams S, Eisenberg J M, Escarce J J

机构信息

Clinical Economics Research Unit, Georgetown University Medical Center, Washington, DC 20007, USA.

出版信息

N Engl J Med. 1999 Feb 25;340(8):618-26. doi: 10.1056/NEJM199902253400806.

DOI:10.1056/NEJM199902253400806

PMID:10029647

Abstract

BACKGROUND

Epidemiologic studies have reported differences in the use of cardiovascular procedures according to the race and sex of the patient. Whether the differences stem from differences in the recommendations of physicians remains uncertain.

METHODS

We developed a computerized survey instrument to assess physicians' recommendations for managing chest pain. Actors portrayed patients with particular characteristics in scripted interviews about their symptoms. A total of 720 physicians at two national meetings of organizations of primary care physicians participated in the survey. Each physician viewed a recorded interview and was given other data about a hypothetical patient. He or she then made recommendations about that patient's care. We used multivariate logistic-regression analysis to assess the effects of the race and sex of the patients on treatment recommendations, while controlling for the physicians' assessment of the probability of coronary artery disease as well as for the age of the patient, the level of coronary risk, the type of chest pain, and the results of an exercise stress test.

RESULTS

The physicians' mean (+/-SD) estimates of the probability of coronary artery disease were lower for women (probability, 64.1+/-19.3 percent, vs. 69.2+/-18.2 percent for men; P<0.001), younger patients (63.8+/-19.5 percent for patients who were 55 years old, vs. 69.5+/-17.9 percent for patients who were 70 years old; P<0.001), and patients with nonanginal pain (58.3+/-19.0 percent, vs. 64.4+/-18.3 percent for patients with possible angina and 77.1+/-14.0 percent for those with definite angina; P=0.001). Logistic-regression analysis indicated that women (odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) and blacks (odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) were less likely to be referred for cardiac catheterization than men and whites, respectively. Analysis of race-sex interactions showed that black women were significantly less likely to be referred for catheterization than white men (odds ratio, 0.4; 95 percent confidence interval, 0.2 to 0.7; P=0.004).

CONCLUSIONS

Our findings suggest that the race and sex of a patient independently influence how physicians manage chest pain.

摘要

背景

流行病学研究报告称，根据患者的种族和性别，心血管疾病治疗手段的使用存在差异。这些差异是否源于医生建议的不同仍不确定。

方法

我们开发了一种计算机化的调查问卷，以评估医生对胸痛治疗的建议。演员在有脚本的访谈中扮演具有特定特征的患者，讲述他们的症状。在两次基层医疗医生组织的全国会议上，共有720名医生参与了这项调查。每位医生观看一段访谈录像，并获得有关一名假设患者的其他数据。然后，他或她对该患者的治疗提出建议。我们使用多变量逻辑回归分析来评估患者的种族和性别对治疗建议的影响，同时控制医生对冠状动脉疾病可能性的评估以及患者的年龄、冠状动脉风险水平、胸痛类型和运动负荷试验结果。

结果

医生对女性冠状动脉疾病可能性的平均（±标准差）估计低于男性（概率分别为64.1±19.3%和69.2±18.2%；P<0.001），年轻患者低于年长患者（55岁患者为63.8±19.5%，70岁患者为69.5±17.9%；P<0.001），非心绞痛患者低于可能心绞痛患者和明确心绞痛患者（分别为58.3±19.0%、64.4±18.3%和77.1±14.0%；P=0.001）。逻辑回归分析表明，女性（优势比为0.60；95%置信区间为0.4至0.9；P=0.02）和黑人（优势比为0.60；95%置信区间为0.4至0.9；P=0.02）接受心脏导管插入术的可能性分别低于男性和白人。种族-性别交互作用分析表明，黑人女性接受导管插入术的可能性显著低于白人男性（优势比为0.4；95%置信区间为0.2至0.7；P=0.004）。