Implicit rationing of high technology must be understood better before equitable explicit rationing policies can be designed. The proposed dissertation research pursues the following goals: 1) to examine equity in the utilization of several different surgeries in California, and, 2) to model inequity as a function of features of the technology being rationed. The utilization of seven surgical procedures will be analyzed: coronary artery bypass, pacemaker implant, carotid endarterectomy, hip arthroplasty/replacement, lithotripsy, kidney transplantation, and surgery for gastrointestinal bleeding. The research questions are, (1) Does a patient's gender, ethnicity, or insurance status influence his/her odds of receiving surgical or """"""""high tech"""""""" treatment? and, (2), Is the inequity of utilization of the procedures (i.e., the odds of nonwhite: white, uninsured insured, women:men receiving the surgery) correlated with technological characteristics of the procedures? Such characteristics include: resource intensity, the age of recipient population, the explicit social importance placed on access to the procedure, and the overall variability in utilization (for patients with relevant diagnoses). These questions will be addressed empirically in two phases, using patient discharge abstract, hospital, and census data. In the first phase, multiple logistic regression models will generate the odds of receiving surgery, given nonclinical patient characteristics such as ethnicity, gender, and insurance status. In the second research phase, these procedure-specific odds ratios will be ranked as an index of inequity associated with each procedures. The procedures will also be ranked according to an index of each of the technological features outlined in research question (2) above. To answer the second research question, Spearman's rank correlation coefficients will be used to measure correlations between the procedure-specific degree of inequity and the rank of other technological features of the procedure. For example, the uninsured: insured odds ratio rank for each procedure will be correlated with the rank of resource intensity of the procedure. The first phase of the study will contribute to the recently emerging literature on equity in access to surgery by studying utilization in California, which is significantly different from states studied to date, as well as by examining several procedures which have not previously been studied. The second phase of the study will make a theoretical as well as empirical contribution, by operationalizing the concept of """"""""technological imperative"""""""" in the organization of medical care. This inquiry will be based on organizational theory from the disciplines of political science and anthropology, which instructs that technologies possess"""""""" legislating"""""""" features which can dictate their distribution and restrict access by certain populations.
