| Abstract
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Racial differences in the use of cardiovascular procedures, including cardiac catheterization among patients hospitalized with myocardial infarction, represent a troubling feature of the US health care system. A critical appraisal of research to date suggests shortfalls in three areas. First, missing from these studies is a consideration of patient race, specifically the manner in which patient racial identification is made, and the quality of patient race identification. Misclassification of patient race, particularly if non-random, may result in biased estimates of any racial differences in treatment. Second, although studies have evaluated clinically heterogeneous populations, assessed the role of possible confounding factors, and explored the role of patient preferences as possible hypotheses for racial differences in the use of cardiac catheterization, few have focused on the appropriateness of cardiac catheterization. Racial differences in cardiac catheterization appropriateness would suggest that racial variations in cardiac catheterization use may not be clinically appropriate. Finally, it is unclear whether racial differences in cardiac catheterization extend to newer technologies that require cardiac catheterization. These three areas of concern were investigated in this dissertation. Evaluations of patients hospitalized with myocardial infarction suggest that data used to classify patient race remains of poor quality with notable inter-hospital variation, particularly for non-white and non-black patients. Future work is needed to clarify obstacles to standardizing patient race data collection. Second, racial differences in cardiac catheterization suggest lower rates of cardiac catheterization in black patients reflects both the undertreatment of black patients and the overtreatment of white patients. Efforts are needed to eliminate such variation, which reflects poor quality of care for both populations. Finally, drug-eluting stents exhibited an adoption lag in their use among black patients compared with white patients attributable to both differential treatment within hospital and lower availability of DES at centers with higher proportions of black patients. Although this novel technology was subsequently equally utilized by white patients and black patients, future work is needed to identify processes accounting for the lag in adoption of new technology by race. Continued work in these areas will ensure that the US health care system meets its promise of providing high quality health care to all patients.
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