The proposed research is a prospective cohort study to evaluate the reasons for the racial and gender differences in the use of procedures for coronary artery disease. A number of studies have reported racial and gender disparities in rates of performance of diagnostic and therapeutic interventions for cardiovascular disease. The data from these earlier studies (most of which have been conducted within the past 5 years) have led to growing concern that racial and gender bias in the practice of medicine, along with economic disadvantages (such as lack of health insurance) may impair access to needed medical interventions for women and African-Americans. The previous studies, upon which these findings are based, are mostly retrospective analyses of discharge data from hospitalized patients, a methodology which has posed limitations on the analyses performed and focussed only on patients who already had advanced coronary disease. As the application correctly notes, much of the problem seems to be gaining entry into the system (i.e., African-Americans and women are less likely to have their initial symptoms recognized as meriting work-up for cardiac disease). There are also questions, especially for women patients, about whether they present with the same constellation of symptoms and whether non-invasive tests for cardiac disease are able to detect disease as efficiently for this patient population as for Caucasian males. The plan is to prospectively assess the appropriateness and necessity of cardiac procedures for a cohort of 3,400 patients presenting with acute chest pain in an emergency department. Patients will be accrued to the study shortly after their initial presentation in the emergency room. They will then be followed for one year to determine subsequent rates of procedure performance and health outcomes. Of the total sample, 25% will be African-American and 50% will be women. This study will prospectively assess the appropriateness and necessity of cardiac procedures, namely the use of exercise tolerance tests (ETT), coronary angiography, coronary artery bypass graft surgery (CABG), and percutaneous transluminal coronary angioplasty (PTCA). The data collected will be used to explore the following Specific Aims: 1) determine whether race and gender influence the rate of performance of cardiac tests (exercise tolerance tests and coronary angiography) and procedures (coronary angioplasty and bypass graft surgery) in patients with acute chest pain for whom clinical data indicates that these interventions are: a) necessary; b) appropriate; c) of uncertain appropriateness; and d) inappropriate; 2) determine whether racial and gender differences in the use of coronary angiography, percutaneous transluminal coronary angioplasty, and coronary artery bypass graft surgery are correlated with attitudes toward the risk associated with these procedures; and 3) determine whether the racial and gender differences in follow-up clinical and health status outcomes for patients with chest pain are correlated with the use of cardiac tests and procedures after adjusting for clinical and socioeconomic status.
