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

Background Epidemiologic studies have reported differences in the use of ca rdiovascular procedures according to the race and sex of the patient. Wheth er the differences stem from differences in the recommendations of physicia ns remains uncertain. Methods We developed a computerized survey instrument to assess physicians' recommendations for managing chest pain. Actors portrayed patients with pa rticular characteristics in scripted interviews about their symptoms. A tot al of 720 physicians at two national meetings of organizations of primary c are 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 t he patients on treatment recommendations, while controlling for the physici ans' assessment of the probability of coronary artery disease as well as fo r the age of the patient, the level of coronary risk, the type of chest pai n, and the results of an exercise stress test. Results The physicians' mean (+/-SD) estimates of the probability of corona ry artery disease were tower for women (probability, 64.1+/-19.3 percent, v s. 69.2+/-18.2 percent for men; P<0.001), younger patients (63.8+/-19.5 per cent for patients who were 55 years old, vs. 69.5+/-17.9 percent for patien ts who were 70 years old; P<0.001), and patients with non-anginal 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 con fidence interval, 0.4 to 0.9; P=0.02) and blacks (odds ratio, 0.60; 95 perc ent confidence interval, 0.4 to 0.9; P=0.02) were less likely to be referre d for cardiac catheterization than men and whites, respectively. Analysis o f race-sex interactions showed that black women were significantly less lik ely 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 indepen dently influence how physicians manage chest pain. (N Engl J Med 1999;340:6 18-26.) (C)1999, Massachusetts Medical Society.