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(Circulation. 2009;119:2463-2470.)
© 2009 American Heart Association, Inc.

Health Services and Outcomes Research

Differences in Specialist Consultations for Cardiovascular Disease by Race, Ethnicity, Gender, Insurance Status, and Site of Primary Care

Nakela L. Cook, MD, MPH; John Z. Ayanian, MD, MPP; E. John Orav, PhD; LeRoi S. Hicks, MD, MPH

From the National Heart, Lung, and Blood Institute, Bethesda, Md (N.L.C.); Department of Health Care Policy, Harvard Medical School, Boston, Mass (J.Z.A., L.S.H.); and Division of General Medicine and Primary Care (J.Z.A., E.J.O., L.S.H.) and Center for Community Health and Health Equity (L.S.H.), Brigham and Women’s Hospital, Boston, Mass.

Correspondence to Nakela L. Cook, MD, MPH, National Heart, Lung, and Blood Institute, Rockledge II, Suite 10018, 6701 Rockledge Dr, Bethesda, MD 20892. E-mail cookn2{at}nhlbi.nih.gov

Received September 30, 2008; accepted March 9, 2009.

Background— Consultation with cardiologists may improve the quality of ambulatory care and reduce disparities for patients with heart disease. We assessed the use of cardiology consultations and the associated quality by race/ethnicity, gender, insurance status, and site of care.

Methods and Results— In a retrospective cohort, we examined electronic records of 9761 adults with coronary artery disease or congestive heart failure (CHF) receiving primary care at practices affiliated with 2 academic medical centers during 2000 to 2005. During this period, 79.6% of patients with coronary artery disease and 90.3% of patients with CHF had a cardiology consultation. In multivariate analyses, women were less likely to receive a consultation than men for both conditions (coronary artery disease: hazard ratio, 0.89; 95% CI, 0.85 to 0.93; CHF: hazard ratio, 0.93; 95% CI, 0.87 to 0.99). Women also had 15% fewer follow-up consultations than men (P<0.001). Similarly, patients at community health centers were less likely to receive a consultation (coronary artery disease: hazard ratio, 0.79; 95% CI, 0.74 to 0.84; CHF: hazard ratio, 0.77; 95% CI: 0.71 to 0.84) and had 20% fewer follow-up consultations (P<0.001) relative to those at hospital-based practices. Black and Hispanic patients with CHF had 13% fewer follow-up consultations than white patients (P=0.01 and P=0.04, respectively). In adjusted analyses, consultation was associated with better processes of care compared with no consultation (P<0.001), particularly for women (P<0.001 for interaction between consultation and gender).

Conclusions— Among ambulatory patients with coronary artery disease or CHF, women and those at community health centers have less access to cardiologists. Consultation is associated with better quality of care and narrows the gender gap in quality.

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