Variation in cardiac procedure use and racial disparity among Veterans Affairs Hospitals

Abstract

Lower or less racially equitable cardiac procedure rates at Veterans Affairs medical centers (VAMCs) with larger minority populations may be sources of racial disparities. This study's objectives were to determine if VAMCs with higher proportions of black inpatients performed fewer cardiac procedures or had larger racial differences in procedure rates than predominantly white VAMCs. We identified 87536 potential candidates for bioprosthetic aortic valve replacement, 50517 for implanted cardioverter/defibrillator (ICD), 92292 for dual-chambered pacemaker (DCP), and 70269 for percutaneous coronary intervention (PCI) hospitalized between 1998 and 2003. Multivariate regression models were fitted that controlled for patients' demographic and clinical characteristics as well as hospital factors such as academic affiliation and inpatient racial composition. Racial differences in procedure rates both across and within hospital-level classifications were examined. Across VA hospital types, there were few significant differences in adjusted procedure rates at VAMCs with larger compared with smaller black inpatient populations. Conversely, within-hospital estimates of black versus white procedure use indicated VAMCs with >30% black inpatients had greater racial differences compared to predominantly white VAMCs (adjusted black-white odds ratios of 0.45 vs 0.81 for aortic valve replacement [P = .07], 0.54 vs 0.85 for DCPs [P < .001], 0.54 vs 0.65 for ICDs [P = .30], and 0.69 vs 0.86 for PCI [P = .01].) Although VAMCs with larger black inpatient populations performed cardiac procedures at similar rates as predominantly white VAMCs, racial differences in procedures were greater within VAMCs with larger black populations. Improving equity at VAMCs with larger minority populations is critical to achieving systemwide health care equality.