Race and patient refusal of invasive cardiac procedures

OBJECTIVE: To determine whether patients' decisions are an important determinant of nonuse of invasive cardiac procedures and whether decisions vary by race. DESIGN: Observational prospective cohort. PARTICIPANTS: Patients (N = 681) enrolled at the exercise treadmill or the cardiac catheterization laboratories at a large Veterans Affairs hospital. MEASURES: Doctors' recommendations and patients' decisions were determined by both direct observation of doctor and patient verbal behavior and by review of medical charts. Performance of coronary angiography, angioplasty, and bypass surgery were determined by chart review for a minimum of 3 months follow-up. RESULTS: Coronary angiography was recommended after treadmill testing for 83 of 375 patients and 72 patients underwent angiography. Among 306 patients undergoing angiography, recommendations for coronary angioplasty or bypass surgery were given to 113 and 45 patients and were completed for 98 and 33 patients, respectively. Recommendations were not significantly different by race. However, 4 of 83 (4.8%) patients declined or did not return for recommended angiograms and this was somewhat more likely among black and Hispanic patients, compared with white patients (13% and 33% vs 2%; P = .05). No patients declined angioplasty and 2 of 45 (4.4%) patients declined or did not return for recommended bypass surgery, Other recommended procedures were not completed after further medical evaluation (n = 32). There was no difference (P > .05) by race/ethnicity in doctor-level reasons for nonreceipt of recommended invasive cardiac procedures. CONCLUSIONS: Patient decisions to decline recommended invasive cardiac procedures were infrequent and may explain only a small fraction of racial disparities in the use of invasive cardiac procedures.