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(Circulation. 2005;112:2347-2353.)
© 2005 American Heart Association, Inc.

Valvular Heart Disease

Treatment Variation in Older Black and White Patients Undergoing Aortic Valve Replacement

From the Divisions of Cardiovascular Diseases (E.B.S.) and General Internal Medicine (G.E.R., M.S.V.-S.), Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City; Center for Research in the Implementation of Innovative Strategies in Practice, Iowa City VA Medical Center, Iowa City, Iowa (G.E.R., M.S.V.-S.); and Division of Cardiothoracic Surgery, Department of Surgery, Oregon Health and Science University, Portland (K.F.W.).

Reprint requests to Erik B. Schelbert, MD, Department of Internal Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, E318-5 GH, Iowa City, IA 52242. E-mail erik-schelbert{at}uiowa.edu

Received December 17, 2004; revision received July 12, 2005; accepted July 19, 2005.

Background— Most prior studies of racial differences in the delivery of cardiac care have focused on potential differences in treatment by individual physicians and hospitals. However, differential use of hospitals with variable practice patterns might also contribute to variations in care.

Methods and Results— We compared the use of bioprosthetic valves (BPVs) in 78 154 black and white Medicare beneficiaries 65 years of age undergoing aortic valve replacement in 904 US hospitals during 1999 through 2001. Generalized linear mixed models were used to account first for differences in patient characteristics and then for differences in hospitals used by black and white patients. BPV use was lower in black patients relative to white patients after adjustment for patient characteristics (relative risk, 0.93; 95% CI, 0.91 to 0.95; P<0.001). However, black patients were more likely to undergo surgery in hospitals in the lowest quintile of BPV use overall (29% versus 20% of white patients; P<0.001). After hospital-level variability in BPV use was accounted for, the use of BPVs was actually somewhat higher in black patients (relative risk, 1.06; 95% CI, 1.04 to 1.09; P<0.001). Model discrimination as measured by the c statistic was markedly higher after the addition of hospital effects (0.80 versus 0.59 for patient characteristics alone; P<0.001).

Conclusions— Accounting for differences in hospitals preferentially used by black and white patients had a major impact on estimating racial differences in the use of BPVs in patients undergoing aortic valve replacement. Hospital-level effects explained a larger proportion of the variation in BPV use than race and other patient characteristics alone.

Key Words: epidemiology • race • surgery • valves

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