Ethnic Disparities in Patient Recall of Physician Recommendations of Diagnostic and Treatment Procedures for Coronary Disease

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1 American Journal of Epidemiology Copyright 1998 by The Johns Hopkins University School of Hygiene and Public Health All rights reserved Vol. 148, No. 8 Printed in U.S.A. Ethnic Disparities in Patient Recall of Physician Recommendations of Diagnostic and Treatment Procedures for Coronary Disease Bonnie K. Sanderson, 1 James M. Raczynski, 2 Carol E. Cornell, 2 Michael Hardin, 3 and Herman A. Taylor, Jr. 1 Despite the proven benefits of many cardiac procedures, some are used less frequently for African American than for white patients with known or suspected coronary disease. This study explored differences between ethnic groups that may affect patient recall of physician recommendations of cardiac procedures. Also examined were patients' responses when asked about adhering to those recommendations. The data examined were collected from interviews with 1,333 African American and white hospital inpatients with known coronary disease admitted to the Birmingham- Health Seeking for Coronary Heart Disease Project ( ) in Alabama. Respondents were asked to recall previous health care encounters, physician recommendations of cardiac procedures, and adherence to those recommendations. Compared with whites, fewer African American patients recalled physicians recommending some cardiac procedures. If procedure recommendations were recalled, no ethnic differences were found in patient recall of adhering to those recommendations. Predictors of recall of the recommended procedures were identified by muitivariate logistic regression. Patients' knowledge of having coronary disease was the common factor that predicted their recall of all cardiac procedures. Other predictor variables included some cardiac risk factors and symptoms, socioeconomic status, and ethnicity. Although health care practice is influenced by many factors, it is important to examine variables that may lead to a reduction in ethnic disparities in coronary disease morbidity and mortality. Am J Epidemiol 1998;148: blacks; coronary disease; diagnosis; ethnic groups; physicians Coronary disease remains the leading cause of death and disability for both sexes and for all ethnic groups in the United States, but in the age group years, coronary disease mortality rates for African Americans exceed those for whites (1-3). The reasons for this excess morbidity and mortality remain unknown and continue to be a topic of interest for scientists conducting medical and behavioral research (4). Possible differences in the use of cardiac diagnostic and treatment procedures among ethnic groups are particularly important to examine. Disparities in the use of procedures may lead to differences in coronary disease management that may affect clinical outcomes between the groups (5-8). Some studies have suggested that cardiac procedures are used less frequently for Received for publication May 22, 1997, and accepted for publication March 20, Division of Cardiovascular Disease, Department of Medicine and Center for Health Promotion, University of Alabama at Birmingham, Birmingham, AL. 2 Schools of Medicine and Public Health and Center for Health Promotion, University of Alabama at Birmingham, Birmingham, AL. 3 School of Health Related Professions and Biostatistics, University of Alabama at Birmingham, Birmingham, AL. African American patients than for white patients despite the benefits of these procedures (9-13). Other studies have offered potential explanations for some ethnic disparities in cardiac procedure use, including the following: 1) health care providers' perceptions about ethnic differences in risk factors and disease severity (14-17); 2) health care systems' delivery of services based on procedure volume, payment method, and regional location (18-22); 3) accessibility of services among population subgroups (23-28); 4) patient health-care-seeking behavior, symptom perception, and perception of the cause of their symptoms (26, 27, 29-33); and 5) physician patterns of diagnosing coronary disease when patients present with suspected signs and symptoms (34-40). The aim of this study was to explore differences between ethnic groups that may affect patient recall of physician recommendations of cardiac procedures among those patients with a diagnosis of coronary disease. Also important was the role of patient adherence to physician recommendations for cardiac procedures among different ethnic groups; thus, patients' responses to questions concerning physician recommendations were also explored. 741

2 742 Sanderson et al. MATERIALS AND METHODS Sample selection The data examined here were drawn from part of the larger Birmingham- Health Seeking for Coronary Heart Disease Project. The source of the data for our study was the responses of inpatients admitted to the hospital with known coronary disease who identified themselves as belonging to the white or black race. Eligible patients were interviewed in five hospitals in three Alabama counties during The sample population was restricted to those patients who had one or more discharge diagnoses that corresponded to the following codes from the International Classification of Diseases, Ninth Revision (41): 1) 412: old myocardial infarction, 2) 413: angina pectoris, or 3) 414: other forms of coronary disease. Since recall of cardiac procedure recommendations prior to the current hospitalization was the focus of this study, patients diagnosed with acute coronary disease episodes but with no history of coronary disease were excluded. The restricted population with the identified coronary diagnoses included 1,333 patients: 782 white males, 140 African American males, 299 white females, and 112 African American females. Instrumentation Information was obtained by using medical record abstraction and patient interview. Interviews were conducted by trained personnel who received periodic retraining to ensure that consistent interviewing methods were used. The interviews were conducted in patients' rooms and lasted about 45 minutes. Respondents were asked to recall physician recommendations of five cardiac procedures (electrocardiogram, graded exercise test, coronary angiography, coronary angioplasty, and coronary artery bypass grafting) prior to their current hospital admission and whether they followed the physicians' recommendations. Also collected was information on demographics, medical insurance coverage, usual source of health care (a provider or place where patients usually went for health care), knowledge of cardiac diagnosis, previous cardiac history, risk factors, symptoms, and healthcare-seeking behaviors in response to symptoms. Data analysis Eligible respondents were stratified by sex, and key demographic characteristics were compared between ethnic groups. Chi-square analyses were used to examine differences in the frequency distribution of demographics, diagnostic code categories, self-reported cardiac risk factors, previous symptoms, health-careseeking responses to those symptoms, and patients' knowledge of their coronary disease diagnosis. Similarly, chi-square analyses were used to assess differences in patients' responses to questions concerning their recall of previously recommended cardiac procedures and their adherence to those recommendations. Positive responses regarding each recommended procedure were calculated in percentages and were analyzed within sex and between ethnic groups to determine ethnic differences in the reporting of recommended procedures prior to the current hospitalization. If patients responded "yes" to recalling a previously recommended procedure, an analysis of the percentages of procedures that the patients reported as being performed was used to examine ethnic differences within sex groups among those patients who adhered to the recommendations. Predictors of patient recall of previously recommended cardiac procedures were identified by performing multivariate logistic regression analyses separately for the five cardiac procedures. The modelbuilding strategy was conducted by using a logical sequence of decisions appropriate for modeling epidemiologic data (42-43). Prior to constructing the full predictor model, we assessed two-factor interactions on five covariates: 1) ethnicity and sex, 2) ethnicity and education, 3) ethnicity and income, 4) ethnicity and marital status, and 5) ethnicity and source of health care payment. If any significant interactions were found, we retained those covariates in the model with the other independent variables that were assessed as having a significant relation with the dependent variable. An overall logistic regression procedure was used to control for the variables included in the model using all variables, and separate logistic regression analyses were performed for males and females to examine differences between the sexes in recall of procedure recommendations. RESULTS Characteristics of the sample population The demographic characteristics of the respondents who met the eligibility criteria are summarized in table 1. A total of 922 males (782 whites and 140 African Americans) and 411 females (299 whites and 112 African Americans) were included. Nineteen percent of the eligible respondents were African Americans, and 31 percent were females. The ages of the whites and African Americans were comparable within each sex group. African American respondents reported lower education and income levels than did their white counterparts {p < 0.001). More than 88 percent of the sample reported having a usual source of health care,

3 Ethnic Disparities in Recall of Recommendations 743 TABLE 1. Characteristics of respondents with a diagnosis of coronary heart disease, Birmingham- Health Seeking for Coronary Heart Disease Project, Alabama, Characteristic Age (years) Mean Standard deviation Education (years) Mean Standard deviation Income (%) <$9,999 $10,000-19,999 >$20,000 Married (%) Usual source of health care* (%) Private insurance (%) Medicaid (%) Medicare (%) Old myocardial infarction (412)t (%) Angina pectoris (413)t (%) Other CHD* (414)t (%) (n = 782) Males (n = 140) P < (n = 299) Females (n=112) * Patients responded that they had a usual place or provider when health care was needed. t Code from ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification. CHD, coronary heart disease. and the numbers were comparable between whites and African Americans within each sex group. A higher percentage of whites than African Americans were covered by private health insurance; African American females reported the lowest percentage, whereas white males reported the highest percentage (p < 0.001). More African Americans than whites were covered by Medicaid (p < 0.001), but Medicare coverage was comparable in all groups. The percentages of those respondents in the three diagnostic groups were similar for African American and white males, but almost three times more African American than white females had a diagnosis of angina pectoris (p < 0.001). African American females also had a lower percentage of other forms of chronic ischemic heart disease as compared with their white counterparts (p < 0.001). Cardiac risk factors, symptoms, health-careseeking response, and knowledge Cardiac risk factors are presented in table 2 as a percentage of the positive responses. Diabetes was reported at a significantly higher rate by African American patients than by white patients, which was _ true for both males (p = 0.009) and females {p 0.006). Similarly, hypertension was reported at a significantly higher rate by African Americans than by P whites in both sex groups (p < 0.001). Although more whites than African Americans reported elevated cholesterol levels, the difference was not significant. A higher percentage of African American males than white males reported smoking (p < 0.009). African American females reported the highest rate (88 percent) of infrequent physical activity, which was significantly higher than the rate reported by their white counterparts (p < 0.001). More whites than African Americans of both sexes reported having a positive family history of coronary disease (male groups, p < 0.001; female groups, p = 0.002). The majority of respondents reported having cardiac symptoms prior to their current hospitalization and sought medical care in response to those symptoms. The responses about previous cardiac symptoms were similar for whites and African Americans in both sex groups. More white males than African American males reported knowing that they had a cardiac disease (p < 0.001), but more African American females than white females reported this knowledge (p = 0.048). Recall of recommendation of procedures The percentage distribution of patients who recalled physician recommendations of cardiac procedures dur-

4 744 Sanderson et al. TABLE 2. Percentage distribution of respondents reporting coronary heart disease risk factors, symptoms, health-care-seeking behavior, and knowledge, Birmingham- Health Seeking for Coronary Heart Disease Project, Alabama, Risk factor Diabetes Hypertension Hypercholesterolemia Smoking Physical inactivity* Positive family history of CHDf CHD symptoms^ Sought health care for CHD symptoms Knowledge of CHD diagnosis (n=782) Males (%) (n = 140) , p (n = 299) Females (%) (n=112) p * Percentage reporting a physical activity pattern (walking, etc.) of <1 time per week, t CHD, coronary heart disease. t Percentage reporting any of the following: pain or discomfort in the chest, back, neck, jaw, or arm; pressure or heaviness in the chest; shortness of breath or difficulty in breathing; or any other heart-related symptoms. ing previous health-care-seeking encounters is shown in table 3. males reported the highest frequency of positive responses when asked whether physicians recommended each of the procedures. Differences between the male ethnic groups were significant for four of the five procedures: electrocardiogram (p < 0.001), graded exercise test {p < 0.001), coronary angiography (p = 0.002), and coronary artery bypass grafting \p = 0.001). There was no significant difference between these groups in recalling whether coronary angioplasty had been recommended (p = 0.07). Differences between the female ethnic groups reached significance for three of the five procedures. females recalled more frequently than African Americans females the recommendations of graded exercise test (p = 0.012), coronary angioplasty (p = 0.015), and coronary artery bypass grafting (p 0.01). Significant differences were found between ethnic groups for both males and females regarding recall of recommendations for both treatment procedures: coronary angioplasty and coronary artery bypass grafting. Physician recommendations of coronary angioplasty were recalled by 14 percent of the white males and 9 percent of the African American males, whereas white females recalled physician recommendations for this procedure about four times as frequently as African American females did. Physician recommendations of coronary artery bypass grafting were recalled about twice as often by white patients (males and females) as by their African American counterparts. Recall of adherence to recommendations There were no differences found in the percentage of respondents who recalled adhering to recommended procedures. The rates of reported adherence ranged from 92 to 100 percent across ethnic and sex groups. Although there were no significant differences be- TABLJE 3. Percentage distribution of respondents who recalled physicians' recommendations for coronary heart disease diagnostic and treatment procedures, Birmingham- Health Seeking for Coronary Heart Disease Project, Alabama, Recommended procedure Diagnostic EKG* GXT* CATH* While (n=782) Males (%) (77=140) P (n=299) Females (%) (n=112) P Treatment PTCA* CABG* EKG, electrocardiogram; GXT, graded exercise test; CATH, coronary angiography; PTCA, percutaneous transluminal coronary angioplasty; CABG, coronary artery bypass grafting.

5 Ethnic Disparities in Recall of Recommendations 745 tween ethnic groups, the lowest percentage (92 percent) was reported by African American females in recalling adhering to physician recommendations to have coronary artery bypass grafting (data not shown). Predictors of recall An overall logistic regression analysis and separate analyses for males and females were conducted. Results of sex-specific analyses were similar to the overall model in identifying key predictors for recall of procedure recommendations, but because of the smaller sample size, other predictors identified in the overall model were nonsignificant in the sex-specific models. Hence, only the results of the overall multivariate logistic regression analyses for predictors of patient recall of physician recommendations for cardiac diagnostic and treatment procedures are presented in tables 4 and 5. Following univariate analysis, the significant variables were retained in the model in addition to the key demographic variables. Tables 4 and 5 include all of the variables retained in the model for multivariate logistic regression analysis. For the diagnostic procedures (table 4), the adjusted s for patients' report of knowledge of their cardiac diagnosis were 9.3 for electrocardiogram (p < 0.001), 4.4 for graded exercise test (p < 0.001), and 10.9 for coronary angiography (p < 0.001). The adjusted s for the treatment procedures, as shown in table 5, were 6.4 for coronary angioplasty {p < 0.001) and 11.7 for coronary artery bypass grafting (p < 0.001). Other factors were identified as predictors. Patients who had private insurance and hypercholesterolemia were, respectively, 2.0 (p < 0.05) and 2.3 (p < 0.05) times more likely to recall physicians recommending an electrocardiogram. Patients who were white and male and who reported having higher incomes and private insurance were, respectively, 1.8 (p < 0.01), 2.0 (p < 0.001), 1.3 (p < 0.05), and 1.5 (p < 0.01) times more likely to recall physician recommendations of a graded exercise test. Those patients who recalled physicians recommending an exercise test were 1.9 (p < 0.05) times more likely to have reported previous cardiac symptoms. Other factors associated with recall of exercise test recommendations were being less likely to be married and reporting a higher level of physical activity. Patients who reported having a higher level of education, a positive family history of coronary heart disease, cardiac symptoms, and hypercholesterolemia were, respectively, 1.04 (p < 0.05), 1.8 (p < 0.001), 2.4 (p < 0.001), and 1.4 (p < 0.05) times more likely to recall coronary angiography recommendations. Patients who recalled these recommendations were also more likely to be younger and more physically active. Factors associated with recall of physician recommendations of coronary angioplasty and coronary ar- TABLE 4. Predictors of patient recall of physicians' recommendations for coronary heart disease diagnostic procedures: summary of multivariate logistic regression analysis, Birmingham- Health Seeking for Coronary Heart Disease Project, Alabama, Variable Ethnicity: white Sex: male Age: younger Married/living as married Private insurance Medicaid Education (no. of years) Income: higher level Usual source of health careh Hypercholesterolemia Smoking Physical inactivity Positive family history of CHD Cardiac symptoms Knowledge of CHD diagnosis * * *** EKGt 95% Clt CHDt diagnostic procedure}: ( 3XTt 95% Cl 1.78** 1.99*** ** 1.54** * * * 4.39*** CATHt 95% Cl *** * 1.37* 0.52*** 1.77*** 2.35*** 10.88*** * p < 0.05; ** p < 0.01; *** p < t CHD, coronary heart disease; EKG, electrocardiogram; GXT, graded exercise test; CATH, coronary angiography; Cl, confidence interval. i Only significant variables in each model are listed for each procedure. As compared with those respondents who did not recall physicians' recommendations. H Patients responded that they had a usual place or provider when health care was needed

6 746 Sanderson et al. TABLE 5. Predictors of patient recall of physicians' recommendations for coronary heart disease treatment procedures: summary of multivariate logistic regression analysis, Birmingham- Health Seeking for Coronary Heart Disease Project, Alabama, Variable Ethnicity: white Sex: male Age: younger Married/living as married Medicare Education (no. of years) Income: higher level Hypercholesterolemia Diabetes Physical inactivity Race x education Positive family history of CHD Cardiac symptoms Knowledge of CHD diagnosis * ** 6.40*** PTCAt CHDt treatment procedure^ 95% Clt ** * 1.41* 1.46* ** 11.71*** CABGt 95% Cl * p < 0.05; ** p < 0.01; *** p < t CHD, coronary heart disease; PTCA, percutaneous transluminal coronary angioplasty; CABG, coronary artery bypass grafting; Cl, confidence interval. t Only significant variables in each model are listed for each procedure. As compared with those respondents who did not recall physicians' recommendations. tery bypass grafting are summarized in table 5. In addition to having a knowledge of their diagnosis, patients who reported having previous cardiac symptoms were 7.7 (p < 0.01) times more likely to recall angioplasty recommendations from physicians. Also, those patients who recalled such recommendations were more likely to be younger ( = 0.96, p < 0.01). Patients who were white and who reported having diabetes, hypercholesterolemia, and previous cardiac symptoms were, respectively, 2.0 (p < 0.01), 1.4 (p < 0.05), 1.4 (p < 0.05), and 2.3 (p < 0.01) times more likely to recall physicians recommending the most invasive and expensive treatment procedure, coronary artery bypass grafting. DISCUSSION The results reported in this study suggest ethnic disparities in the use of cardiac procedures by health care systems. Fewer African American than white patients with a diagnosis of coronary disease recalled physicians recommending cardiac procedures. Differences between ethnic groups remained after adjusting for demographic and socioeconomic characteristics, self-reported cardiac risk factors, symptoms, and patients' knowledge of their coronary disease diagnosis. Among those patients who recalled physicians recommending cardiac procedures, there were no differences between ethnic groups in their recall of adhering to the recommendations. The following predictor variables were identified as possibly influencing patient recall of recommendations for some cardiac procedures: having knowledge of a coronary disease diagnosis, reporting some cardiac risk factors, and reporting cardiac symptoms during previous health care encounters. In addition to the clinical factors, socioeconomic and ethnic indicators emerged as significant predictors. The one factor that predicted patient recall of all five physician-recommended procedures was their knowledge of having a coronary disease diagnosis. This sample was restricted to those patients who had a diagnosis of chronic coronary disease, so it is likely that they had previous health care experiences related to their disease. Even though this patient sample consisted of those with nonacute coronary disease, fewer African American males than white males were aware of their diagnosis. The incidence of out-of-hospital cardiac arrest has been reported to be higher among African Americans than among whites (44), which may suggest a higher incidence of undiagnosed and untreated coronary disease in African Americans. Higher levels of cardiac knowledge have been associated with higher rates of receipt of health care (32), suggesting that a lack of knowledge about coronary disease may be a barrier to accessing and receiving appropriate care. Since more African American than white females reported being aware of their coronary disease diagnosis, these explanations do not address the differences in recall of recommendations among f

7 Ethnic Disparities in Recall of Recommendations 747 this group. It is unknown whether the patients who reported a lack of knowledge of their diagnosis had previous cardiac episodes and did not seek treatment, sought treatment and remained unclear about the source of their symptoms, or were admitted with advanced coronary disease without having received any previous cardiac care. In this sample, patients' self-report of cardiac risk factors compared with other studies reporting a higher prevalence of hypertension and diabetes in African Americans than in whites and similar cholesterol levels in the two ethnic groups (15-16). The only cardiac risk factor that emerged as a predictor variable for patient recall of a cardiac procedure was hypercholesterolemia, which is strongly associated with coronary disease (14). Despite hypertension being a strong predictor of coronary disease in both ethnic groups, this variable did not emerge as a predictor of patient recall of recommendations for cardiac procedures. Reports of having previous cardiac symptoms was a predictor of patient recall of physicians recommending some but not all cardiac procedures. In this sample, all patients were hospital admissions, and there were no significant differences between the ethnic/sex groups in whether they reported cardiac symptoms during previous health care encounters. This finding contradicts other studies reporting that African Americans may be less likely than whites to report typical cardiac symptoms (26, 31 32). This difference was probably due to restricting the patient sample to those with a chronic coronary diagnosis and excluding those with acute coronary episodes in the absence of previously diagnosed disease. Because the research questions patient recall of physicians recommending cardiac procedures during previous health care encounters, the patients with chronic coronary disease had a higher probability of previous health care encounters related to their cardiac symptoms. In contrast, those patients with atypical cardiac symptoms may not have been admitted to the hospital and would not have been included in this sample. Consistent with the findings from other studies (23-28), ethnic differences in socioeconomic characteristics emerged in this patient sample; African Americans had less education and lower incomes, were less likely to have private insurance, and were more likely to have Medicaid insurance. These data add to the evidence that inequalities in our socioeconomic system are powerful threats to quality health care for the traditionally disadvantaged (23). Socioeconomic inequalities remain a major issue in addressing health care disparities among population subgroups. Discussions have suggested that ethnic differences in patients' receiving certain cardiac procedures may be due to performing some invasive procedures for white patients without a convincing clinical need to do so rather than to the inappropriateness of not performing the procedures on nonwhite groups (45). In this study, African American males recalled fewer physician recommendations of noninvasive tests (electrocardiograms and graded exercise tests) than did white males, and African American females were less likely than white females to recall physicians recommending graded exercise tests. These findings suggest that ethnic disparities in the use of cardiac procedures may begin during the initial stages of physician-patient encounters, when clinical decisions are made regarding the diagnosis of coronary disease. Although few studies have examined ethnic differences in the use of noninvasive cardiac diagnostic procedures, the results of this study differed from the findings of a study that analyzed the responses of community residents who sought medical care for cardiac symptoms. Crawford et al. (32) found no differences in the community sample in patients' reports of physicians recommending noninvasive cardiac procedures, although significant differences in recommendations for invasive procedures were reported. They also found that fewer African American community respondents, both male and female, were referred to cardiologists when presenting with cardiac symptoms (32). Although a question concerning patient recall of a cardiology referral was not included in the survey for this study, this important issue needs further exploration. Cardiologists have been reported to be more knowledgeable than generalists about the newest technologies and treatments for acute cardiac care (40). If fewer ethnic minority patients are referred to cardiologists, an additional barrier to receiving appropriate cardiac procedures may exist for these patients. A unique and important aspect of this study was that it specifically examined patients' responses to questions about following physician recommendations to have cardiac procedures performed. This is important, because a number of studies (9-13, 17-22) suggest that patient preferences may be a potential explanation for the ethnic disparities in receiving some cardiac procedures. In other words, African American versus white patients may prefer or be more comfortable with lower technology or less invasive cardiac care, so they may refuse procedures more frequently. The results of this study suggest that there were no ethnic differences in patients' adherence to physician recommendations of cardiac procedures if the patients recalled the recommendations. For all five of the cardiac procedures evaluated, percent of the patients recalled following their physicians' recommendations to have these procedures performed. This result differed from

8 748 Sanderson et al. that of Maynard et al. (10), who reported that African Americans may be less likely than whites to request major procedures or more likely to decline them when they are recommended by health care providers. A complexity of factors, including effective patientphysician communication, may contribute to the barriers to patients receiving appropriate cardiac procedures (39). Our findings suggest the importance of exploring the effects of patient-physician communication when physicians are establishing a coronary disease diagnosis. Further exploration may include evaluating patients' attitudes and knowledge about diagnostic and treatment options for coronary disease as well as physicians' responses and actions to patients' perceptions. Limitations of this study and the inferences that can be made from the reported data are acknowledged. First, the predictor measures were self-reported by patients and are subject to recall bias as well as to possible patient misunderstanding of survey questions or responding to what they perceive as the "right" answer instead of giving their true answer. Second, the data reported did not include clinical or disease severity measures that would influence the clinical decision making of physicians who recommended cardiac procedures. Although patients' coronary disease diagnoses were obtained from medical records and were classified according to International Classification of Diseases coding, these methods may be subject to error (46). Third, the data included the responses of only a select sample of inpatients who sought care and were admitted for treatment of cardiac symptoms. This selection process excluded those who never sought care or who were not referred for more extensive inpatient evaluation of coronary disease. Fourth, the data were collected from inpatients who lived in one southeastern state, so the ability to generalize these findings to other persons in different geographic regions may be limited. Our findings raise issues related to biases that may influence physicians' decisions to recommend cardiac diagnostic and treatment options. Whittle et al. (19) found small differences between ethnic groups in the use of cardiac procedures when the indications for recommending invasive procedures, such as coronary angiography after acute myocardial infarctions, were well defined; however, in situations in which physicians used more discretion, ethnic differences were more evident. Although much remains unknown about the influence of patient-physician communication on clinical decision making, subtle ethnic bias may be a result of social and cultural factors that affect communication (45). It may be that some patients, including African Americans, do not use the classic presentation style that physicians are taught to recognize when these patients describe symptoms or medical histories that suggest potential coronary disease. Subjective data have been reported to have important influences on clinical decision making in establishing a cardiac diagnosis (38, 39). It may be that physicians do not communicate effectively with different ethnic groups about available diagnostic and treatment options that may aid the management of coronary disease. There may be a lack of culturally sensitive educational material so that patients can learn about their disease process and management options. Physician education programs may also be lacking in terms of effective communication strategies for different ethnic and socioeconomic groups. However disturbing, overt ethnic bias is also a possibility that cannot be excluded as a factor that influences physicians when making clinical decisions to recommend cardiac procedures. The negative health consequences of prejudice should be considered seriously when examining factors that may affect health care disparities among population subgroups. In this study, the patient interviews were conducted in one southeastern state, where a previous study reported the highest ratio of ethnic disparity in patients' receiving invasive cardiac procedures (22). In summary, the results of our study suggest the presence of ethnic disparities in the use of cardiac procedures among patients with coronary disease. They reinforce the need for scientific efforts to explore health care practices and patient demographic and psychosocial factors to identify predictors and methods of improving patient access to appropriate procedures for coronary disease. 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