Invited commentary

Abstract

This report by DiGiorgi and colleagues [1DiGiorgi P.L. Baumann F.G. O’Leary A.M. et al.Mitral valve disease presentation and surgical outcome in African-American patients compared with white patients.Ann Thorac Surg. 2008; 85: 89-93Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar] is only the most recent in a series of reports documenting significant racial disparities both in healthcare delivery and outcomes in this country. Although the present study was not powered to make this determination, other studies have consistently demonstrated that even when other covariates, such as socioeconomic status, education, and healthcare insurance are considered, race inevitably and inexorably emerges as a significant predictor of how healthcare is administered. Specifically, African Americans are less likely to undergo cardiac catheterization, percutaneous coronary intervention, coronary artery bypass graft surgery, knee and hip replacement, renal transplantation, or curative surgery for esophageal or lung cancer than their otherwise comparable white counterparts. Because each of the studies from which these conclusions are based is retrospective by definition, one can never completely rule out the idea that covariates that are unmeasured or immeasurable are actually responsible for the differences that appear to be attributable to race. In the healthcare disparity debate, this study by DiGiorgi and colleagues [1DiGiorgi P.L. Baumann F.G. O’Leary A.M. et al.Mitral valve disease presentation and surgical outcome in African-American patients compared with white patients.Ann Thorac Surg. 2008; 85: 89-93Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar] does provide us with some new and interesting fodder for reflection. Any reservations to the contrary notwithstanding, this report and the aggregate weight of many others overwhelmingly support the conclusion that race is indeed a significant issue in how patients get treated. The most striking new and unanticipated finding in this report is that African Americans are significantly less likely than whites to undergo mitral valve repair, and that this difference is most pronounced among those with degenerative disease. Coupled with their and our earlier observation that African American patients present at a younger age for mitral valve surgery than whites, at least two hypotheses become immediately apparent. Either African Americans with reparable valves with the same group of surgeons (and therefore, the same surgical expertise) are less likely to have their valves repaired due to unrecognized racial bias, or alternatively, African Americans with degenerative disease have more severe disease and are therefore less often candidates for repair than white patients. Thus, as with most important studies in science and medicine, this report allows us to ask questions that are arguably more interesting than the questions it answers for us. Regardless of which hypothesis is correct, we need to look carefully at how African American patients are treated and lobby to improve their access to primary care (ie, the second hypothesis) and insist on even handedness and equality in the administration of care (ie, the first hypothesis) for all of the patients we treat regardless of race. Mitral Valve Disease Presentation and Surgical Outcome in African-American Patients Compared With White PatientsThe Annals of Thoracic SurgeryVol. 85Issue 1PreviewDisparities associated with race, particularly African-American race, in access to medical and surgical care for patients with cardiac disease have previously been documented. The purpose of this study was to determine the presentation, etiology, and hospital outcome differences between African-American patients and white patients with regard to surgically corrected mitral valve disease. Full-Text PDF