PHYSICIAN DISCRETION AND RACIAL VARIATION IN THE USE OF SURGICAL-PROCEDURES

Background: Racial variation in the use of surgical procedures raises concern about equitable access The goal of our study was to examine ra cial differences in utilization across a broad range of procedures in Massachusetts and to assess whether racial variation is related to phy sician discretion. Methods: We obtained fiscal year 1988 hospital disc harge data for all Massachusetts residents, identified 10 clinically i mportant surgical procedures, and calculated age- and sex-adjusted rat e ratios for white and black patients. Level of discretion was determi ned by using a modified Delphi technique. Results: Whites had higher r ates for eight procedures (abdominal aortic aneurysm repair, appendect omy, cardiac valve replacement, carotid endarterectomy, cholecystectom y, lumbar disk procedures, open reduction/ internal fixation of the fe mur, and tonsillectomy) and lower rates for two procedures, hysterecto my and prostatectomy. Of the eight procedures for which utilization wa s higher among whites, four were ranked as moderate- or high-discretio n procedures and four were ranked as low-discretion procedures. Hyster ectomy, the only procedure for which utilization was substantially hig her among blacks (white:black rate ratio <0.90), was ranked as a high- discretion procedure. Conclusions: With the exception of hysterectomy and prostatectomy, procedure rates for whites were greater than those for blacks for a wide range of surgical procedures. Racial variation e xists for low-discretion procedures as well as for those associated wi th moderate and high discretion. Variation among low-discretion proced ures that is not explained by medical need suggests the possibility of race-related differences in access to care or in the way patients and physicians make clinical decisions.