This study will investigate the relationship between quality of care and differences in rates of cardiac revascularization (PTCA and CABG) by race, socioeconomic status (SES), and gender. The primary analysis will focus on two main questions: 1) was there underuse, that is were minorities, low SES patients and women less likely to receive revascularization when it was appropriate or 2) was there overuse, that is among those who received the procedure, were whites, high SES patients and men more likely to receive it for inappropriate indications. The use of cardiac procedures among populations such as minorities, patients of lower SES, and women have been shown to be much lower than among other groups. The application proposes to review patterns of care for 4650 Medicare patients - 65 to 75 years of age. Patients are identified through Medicare claims data. Patients who had angiography in six states during 1990-1991 will be included. The state Peer Review Organizations (PROs) will abstract the medical records of these patients to collect data on the indications for undergoing subsequent revascularization with CABG or PTCA. The appropriateness of performing revascularization will be assessed using guidelines developed at RAND and from the American College of Cardiology and will be based on the clinical indications in the medical record of each patient. Appropriateness criteria published by the RAND Corporation will be used as the primary mode of determining quality of care. A secondary set of criteria initially produced by the American College of Cardiology will be refined in the first steps of this current project and also applied.
Six specific aims and hypotheses will be explored. The two primary hypotheses are: 1) there is a relative underuse of revascularization among blacks, patients of lower SES and women; and 2) there is a relative overuse of revascularization in whites, patients of higher SES and men. Four secondary hypotheses relate to the characteristics of the institution in which care is delivered. Two hospital characteristics will be explored, including whether a hospital performs revascularization in house or refers patients to another facility, and, second, experience of hospitals in performing coronary angiography and revascularization, measured by the numbers of each procedure performed at each institution. The secondary hypotheses include: 1) underutilization will be greater for patients who have their angiography performed at hospitals that do not perform revascularization procedures; 2) overuse of revascularization will be greater for patients who underwent angiography at hospitals with revascularization facilities; 3) patients who underwent angiography at hospitals that perform fewer angiographys will be less likely to receive the revascularization when it is appropriate than patients who underwent angiography at hospitals that perform greater numbers of angiography and, 4) among revascularized patients, overuse will be greater for patients who had their surgery performed at hospitals which perform fewer revascularization procedures.
