Underuse of coronary revascularization procedures: Application of a clinical method

Objectives. Our main objective was to apply a new method to determine whether coronary revascularization procedures are underused, especially among African-Americans and uninsured patients. Background. Although overuse of revascularization procedures has been studied, underuse as defined clinically has not been examined before. Methods. The study was conducted at four public and two academically affiliated private hospitals in Los Angeles; 671 patients, who underwent coronary angiography between June 1, 1990 and September 30, 1991 and met explicit clinical criteria for coronary revascularization were included. The main outcome measure was the proportion of patients undergoing an indicated procedure within 12 months (ascertained by medical record review and confirmed with a telephone survey). Adjusted relative odds of undergoing an indicated procedure for African-Americans and patients in public hospitals compared with whites and patients in private hospitals were calculated. Results. Overall, 75% of patients underwent a revascularization procedure. Of 424 patients requiring bypass surgery, 107 angioplasty and 140 either bypass surgery or angioplasty, 59%, 66% and 75% underwent the procedure, respectively. African-Americans were less likely than whites to undergo operation (adjusted odds ratio [OR] 0.49, p < 0.05) and angioplasty (adjusted OR 0.20, p < 0.05). Patients in public hospitals were less likely than those in private hospitals to undergo angioplasty (adjusted OR 0.10, p < 0.005). Conclusions. Underuse of coronary revascularization procedures is measurable and occurs to a significant degree even among insured patients attending private hospitals. Underuse is especially pronounced among African-Americans and patients attending public hospitals. Future cost-containment efforts must incorporate safeguards against underuse of necessary care.