Studies Raise Question of Racial Factor in Heart Care : Health: Blacks are more likely to die of cardiac arrest, less likely to have surgery. Some say prejudice plays role.
Raising troubling questions about health care for African-Americans, researchers report today that blacks are significantly more likely to suffer and die from sudden heart failure than whites, and that whites who are found to have heart disease are far more likely to undergo surgery to correct it than blacks.
The findings, published in separate articles in the New England Journal of Medicine, highlight striking racial differences that, in the case of the second study, cannot be attributed to socioeconomic factors such as ability to pay or access to medical care.
One explanation, experts say, is that prejudice influences physicians’ judgment, preventing white doctors from recommending certain procedures to black patients, or patients from accepting them. Only 3% of the nation’s doctors are black.
“We are dependent on the majority of the population for health services,” said Dr. Edward S. Cooper, a prominent black physician and past president of the American Heart Assn. He said white doctors and black patients may not always be able to relate to one another, adding: “If there is any breakdown in communication . . . then doctors are not going to be able to convince (patients) that they need a tube put in their heart.”
The studies also send an important message to the nation’s health care reformers that financial barriers are not the sole reason some Americans do not receive quality medical care.
“Part of health reform clearly has got to be attention not just to financing care but how we train providers and how we practice care once all Americans have financial access,” said Dr. Reed Tuckson, president of Charles Drew University of Medicine in Los Angeles, one of the nation’s four predominantly black medical schools. “Financial access to care does not mean access to good care.”
Each of the studies published today breaks new ground. The first, conducted by researchers at the University of Chicago, offers the first large-scale comparison of cardiac arrest--a sudden and most often fatal stoppage of the heart--among blacks and whites. It found that blacks were twice as likely as whites to suffer a cardiac arrest, and more than three times as likely to die of it.
The second, and in some ways more disturbing, study was a nationwide examination of nearly 430,000 patients at Pittsburgh Veterans Affairs Medical Center patients who were found to have heart disease. It found that even when finances are not a consideration, whites were two or three times as likely as blacks to undergo invasive surgical procedures such as angioplasty or coronary artery bypass surgery.
“Whether this deficit reflects racism or not, the result is the same: Black patients are less likely than white patients to receive treatments that can often relieve symptoms and sometimes prolong life,” Dr. John Z. Ayanian, who has researched race and gender bias at Harvard Medical School, wrote in a commentary published alongside the articles.
The findings add to a well-documented body of research that shows that blacks in the United States die of cardiovascular disease at a higher rate than whites. In 1989, the most recent year for which figures are available, rates of heart disease were 39% higher in black men than white men, and 68% higher in black women than white women.
Scientists do not fully understand the reasons and are investigating possible biological causes. Earlier this year, the National Heart, Lung and Blood Institute awarded eight research grants, including one to Los Angeles’ Drew University, to explore such questions as why blacks are more prone to hypertension than whites, and why blacks often have higher levels of certain fats in the blood that are associated with heart disease.
The Chicago and Pittsburgh, Pa., studies, however, focused on social issues rather than biology. In the Chicago study, Dr. Lance Becker and his colleagues in the emergency department of the University of Chicago Medical Center analyzed every cardiac arrest that occurred in their city over a two-year period, 6,451 cases in all.
Sudden cardiac arrest accounts for about 300,000 deaths each year--nearly 15% of all deaths in America. The Chicago researchers found that, black or white, chances of survival were slim; just 3% of whites survived and only 1% of blacks. The low survival rates for both groups, experts said, are typical of large urban areas, where paramedics often cannot respond quickly to emergencies.
Yet at each link in the so-called chain of survival, the researchers found, blacks were less likely to survive than whites. This was the case even though the average response time of emergency personnel, 16 minutes, was the same for whites and blacks.
Blacks had more unwitnessed cardiac arrests, which delayed their treatment, and were significantly less likely to receive cardiopulmonary resuscitation before paramedics arrived. Among those who survived long enough to be admitted to a hospital, only 13% lived, compared to 25% of whites.
There are a variety of possible explanations for the disparity, among them differences in physiology as well as diet and other health habits, such as smoking, alcohol intake and exercise, and the study drew no conclusions. “Our study . . . raises many unanswered questions about the factors responsible for racial differences in survival,” Becker wrote.
The Pittsburgh study, which analyzed the care of 428,300 male veterans over a five-year period, left less open to question. It was the first to examine treatment of heart disease among blacks and whites who had equal access to medical care and ability to pay for it.
The study looked at three surgical procedures: cardiac catheterization, in which a fine tube is inserted into the heart to investigate its condition; angioplasty, in which a balloon is introduced to constricted blood vessels in an attempt to widen them and clear blockages, and coronary artery bypass surgery, in which doctors reroute blood past blocked arteries.
The researchers found that although 19.3% of whites underwent catheterization, only 11.8% of blacks did. Angioplasty was performed on 1.8% of whites and 0.8% of blacks, and although 5% of all whites had bypass surgery, only 1.6% of blacks did.
Even after adjusting for such variables as age, other illnesses, marital status and how well equipped the hospital was to perform these procedures, whites were still more likely to receive them than blacks.
Cooper, the former Heart Assn. president, said: “This pins down that there is a racial component. It’s hard to get away from that.”
