Underuse of cardiac procedures: Do women, ethnic minorities, and the uninsured fail to receive needed revascularization?

Background: Women, ethnic minorities, and uninsured persons receive fewer c ardiac procedures than affluent white male patients do, but rates of use ar e crude indicators of quality. The important question is, Do women, minorit ies, and the uninsured fail to receive cardiac procedures when they need th em? Objective: To measure receipt of necessary coronary artery bypass graft (CA BG) surgery and percutaneous transluminal coronary angioplasty (PTCA) overa ll; by patient sex, ethnicity, and payer status; and by availability of ons ite revascularization. Design: Retrospective, randomized medical record review. Setting: 13 of the 24 hospitals in New York City that provide coronary angi ography. Patients: 631 patients who had coronary angiography in 1992 and met the RAN D expert panel criteria for necessary revascularization. Measurements: The percentage of patients who had CABG surgery or PTCA was m easured, as were variations in use rates by sex, ethnic group, insurance st atus, and availability of on-site revascularization. Clinical and laborator y data were retrieved from medical records to identify patients who met the panel criteria for necessary revascularization. Receipt of revascularizati on was determined from state reports, medical records, and information prov ided by cardiologists. Results: Overall, 74% (95% CI, 71% to 77%) of patients who met the panel cr iteria for necessary revascularization had CABG surgery or PTCA (underuse r ate, 26%). No differences were found in use rates by patient sex, ethnic gr oup, or payer status, but hospitals that provided on-site revascularization had higher use rates (76% [CI, 74% to 79%]) than hospitals that did not pr ovide it (59% [CI, 56% to 65%]) (P < 0.01). In hospitals that did not provi de onsite revascularization, uninsured patients were less likely to have re vascularization recommended to them (52% [CI, 32% to 78%]); rates of recomm endation for patients with private insurance, Medicare, and Medicaid were 8 2%, 91%, and 75%, respectively (P = 0.026). Conclusions: Although revascularization procedures are substantially underu sed, no variations in rate of use by sex, ethnic group, or payer status wer e seen among patients treated in hospitals that provide CABG surgery and PT CA. However, underuse was significantly greater in hospitals that do not pr ovide these procedures, particularly among uninsured persons.