Schneider E C, Leape L L, Weissman J S, Piana R N, Gatsonis C, Epstein A M
Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115.
Ann Intern Med. 2001 Sep 4;135(5):328-37. doi: 10.7326/0003-4819-135-5-200109040-00009.
Coronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty (PTCA) are well-established treatments for symptomatic coronary artery disease. Previous studies have documented racial differences in rates of use of these cardiac revascularization procedures. Other studies suggest that these procedures are overused: that is, they are done for patients with clinically inappropriate indications.
To test the hypothesis that the higher rate of cardiac revascularization among white patients is associated with a higher prevalence of overuse (revascularization for clinically inappropriate indications) among white patients than among African-American patients.
Observational cohort study using Medicare claims and medical record review.
173 hospitals in five U.S. states.
A stratified, weighted, random sample of 3960 Medicare beneficiaries who underwent coronary angiography during 1991 and 1992; 1692 of these patients underwent 1711 revascularization procedures within 90 days.
The proportion of CABG and PTCA procedures rated appropriate, uncertain, and inappropriate according to RAND criteria, and the multivariate odds of undergoing inappropriate revascularization among African-American patients and white patients.
After angiography, rates of PTCA (23% vs. 19%) and CABG surgery (29% vs. 17%) were significantly higher among white patients than among African-American patients. The respective rates of inappropriate PTCA and CABG surgery were 14% and 10%. Among the study states, rates of inappropriate use ranged from 4% to 24% for PTCA and 0% to 14% for CABG surgery. White patients were more likely than African-American patients to receive inappropriate PTCA (15% vs. 9%; difference, 6 percentage points [95% CI, -0.4 to 12.7 percentage points]), and difference by race was statistically significant among men (20% vs. 8%; difference, 12 percentage points [CI, 1.2 to 21.7 percentage points]). Rates of inappropriate CABG surgery did not differ by race (10% in both groups).
Among a large and diverse sample of Medicare beneficiaries in five U.S. states, overuse of PTCA was greater among white men than among other groups, but this difference did not fully account for racial disparities in revascularization. Overuse of cardiac revascularization varied significantly by geographic region.
冠状动脉旁路移植术（CABG）和经皮腔内冠状动脉成形术（PTCA）是治疗有症状冠状动脉疾病的成熟方法。以往研究记录了这些心脏血运重建手术在使用比例上的种族差异。其他研究表明这些手术存在过度使用的情况，即对临床适应证不恰当的患者进行了手术。
检验以下假设：白人患者心脏血运重建率较高与白人患者中过度使用（对临床适应证不恰当的血运重建）的患病率高于非裔美国患者有关。
使用医疗保险理赔数据和病历审查的观察性队列研究。
美国五个州的173家医院。
1991年和1992年接受冠状动脉造影的3960名医疗保险受益人的分层、加权随机样本；其中1692名患者在90天内接受了1711例血运重建手术。
根据兰德标准将CABG和PTCA手术评定为恰当、不确定和不恰当的比例，以及非裔美国患者和白人患者接受不恰当血运重建的多变量比值比。
血管造影后，白人患者的PTCA率（23%对19%）和CABG手术率（29%对17%）显著高于非裔美国患者。不恰当的PTCA和CABG手术率分别为14%和10%。在研究的各州中，PTCA的不恰当使用率在4%至24%之间，CABG手术的不恰当使用率在0%至14%之间。白人患者比非裔美国患者更有可能接受不恰当的PTCA（15%对9%；差异为6个百分点[95%CI，-0.4至12.7个百分点]），且在男性中种族差异具有统计学意义（20%对8%；差异为12个百分点[CI，1.2至21.7个百分点]）。不恰当CABG手术率在种族间无差异（两组均为10%）。
在美国五个州的大量不同医疗保险受益人样本中，白人男性PTCA的过度使用率高于其他群体，但这种差异并未完全解释血运重建中的种族差异。心脏血运重建的过度使用在不同地理区域差异显著。
