Blacks still undergoing fewer THRs, other major surgeries

The gap between rates of black and white Medicare patients having THR increased in 17 of 20 representative hospital regions over 10 years.

Efforts by federal and state health agencies over the past decade have not caused any consistent, meaningful reductions in gaps in care between black and white Medicare patients, according to a study published in the New England Journal of Medicine.

Ashish K. Jha, MD, MPH, and colleagues at the Harvard School of Public Health in Boston and at several other institutions in the United States reviewed Medicare usage data for nine high-cost surgical procedures. The researchers sought to determine the differences in procedure rates between black and white patients over a 10-year period.

“Studies showing racial disparities in care have received wide attention in the media since the early 1990s, prompting the federal government to develop initiatives to address this problem,” the study authors said.

“Our findings show that, despite these efforts, differences between white Medicare enrollees and black Medicare enrollees ... did not change meaningfully in the 1990s,” they said.

Medicare data

Jha and colleagues reviewed data for all beneficiaries enrolled in Medicare fee-for-service programs from 1992 through 2001. They excluded any patient not listed in the denominator file on June 30 of a given year. The researchers then calculated performance rates for nine common surgical procedures with documented racial differences in performance rates. These procedures include:

abdominal aortic aneurysm repair;
back surgery;
coronary-artery bypass grafting (CABG);
percutaneous transluminal coronary angioplasty;
cardiac valve replacement;
carotid endarterectomy;
total hip replacement (THR);
total knee replacement; and
appendectomy.

The data analysis focused on differences between black patients and nonblack patients. The authors referred to nonblack patients as white, although approximately 5.5% of patients included in this group were members of other races or ethnicities, they noted.

National procedural rates

The denominator files used by the researchers included approximately 29 million patients enrolled in Medicare for each year of the study.

They found that the number of patients aged 80 to 99 years increased from 24% to 28% while the number of patients aged 65 to 69 years declined during the 1990s. During this period, the number of women or white patients remained relatively constant, according to the study.

National usage rates among the Medicare population increased throughout the study period for eight of nine procedures. Only abdominal aortic aneurysm repair showed no increase.

Procedure rates generally increased for each group when reviewed according to sex and race. In 1992, white men had higher procedural rates than black men for all nine procedures. Five procedures showed significant widening between black and white men; one showed significant narrowing and three did not show any significant change, according to the study.

The researchers found similar results for women, the authors said.

A subanalysis examining procedural rates for CABG, THR and carotid endarterectomy found varying usage patterns over time. White women, white men and black women all had increases in THR rates while rates for black men remained relatively stable, according to the study.

“In contrast, there was a sharp rise in rates of carotid endarterectomy from 1993 through 1995 for all groups, although the increase was much more pronounced among whites than among blacks,” the study authors said.

CABG rates remained relatively stable throughout the study period, with only small increases early on followed by small decreases toward the end of the study, the noted.

Hospital referral regions

The researchers also examined procedural rates for CABG, THR and carotid endarterectomy according to 20 nationally representative hospital referral regions. They again found that white patients underwent more of these three procedures than black patients in every region between 1992 and 1994.

“For example, among men ... whites had more total hip replacements than blacks, although the racial difference was statistically significant in only 17 of these hospital referral regions,” the authors said.

“Next, we found that during the study period, the gap between whites and blacks for total hip replacement widened in 17 of these 20 hospital referral regions and narrowed in three,” they said, noting that the gap widened significantly in five regions.

Most hospital referral regions showed a widening gap for carotid endarterectomy but a narrowing gap for CABG, they added.

“Finally, from 1999 through 2001, more of each of the three procedures were performed among white men than black men in every hospital referral region, and most of the differences in the rates of uses were statistically significant,” they said, noting similar findings for women.

Rates of procedural usage at the start of the study also closely predicted usage rates at the end of the study for both black patients and white patients, they added.

For more information:
Jha AK, Fisher ES, Li Z, et al. Racial trends in the use of major procedures among the elderly. N Engl J Med. 2005;353:683-691.