BMJ 2002;324:511-516 ( 2 March )

Papers

Ethnic differences in invasive management of coronary disease: prospective cohort study of patients undergoing angiography

Gene Feder, professor of primary care research and development, ^a Angela M Crook, statistician, ^b Patrick Magee, consultant cardiothoracic surgeon, ^c Shrilla Banerjee, specialist registrar in cardiology, ^c Adam D Timmis, consultant cardiologist, ^c Harry Hemingway, director of research and development. ^b

^a Department of General Practice and Primary Care, Barts and the London, Queen Mary's School of Medicine and Dentistry, London EN1 4NS, ^b Department of Research and Development, Kensington and Chelsea and Westminster Health Authority, London W2 6LX, ^c Bart's and The London NHS Trust, Cardiac Directorate, London E2 9JX

Correspondence to: G Feder g.s.feder{at}qmul.ac.uk

Objectives: To compare rates of revascularisation in south Asian and white patients undergoing coronary angiography in relation to the appropriateness of revascularisation and clinical outcome.
Design: Prospective cohort study of patients with two and a half years' follow up; appropriateness of revascularisation rated by nine experts with no knowledge of ethnicity of patient.
Setting: Tertiary cardiac centre in London with referral from five contiguous health authorities.
Participants: Consecutive patients (502 south Asian, 2974 white) undergoing coronary angiography in the appropriateness of coronary revascularisation study (ACRE).
Main outcome measures: Coronary revascularisation, non-fatal myocardial infarction, mortality.
Results: There was no difference between south Asian and white patients in the proportions deemed appropriate for revascularisation (72% (361) v 68% (2022)) or in the proportions for whom the physician's intended management was revascularisation (39% (196) v 41% (1218)). Among patients appropriate for revascularisation, age adjusted rates of coronary angioplasty (hazard ratio 0.69, 95% confidence interval 0.47 to 1.00, P=0.058) and coronary artery bypass grafting (0.74, 0.58 to 0.91, P=0.007) were lower in south Asian than in white patients. These differences were smaller but still present after adjustment for socioeconomic status and after restriction of analysis to those patients for whom the intended management was revascularisation. There were no differences in mortality and non-fatal myocardial infarction between south Asian and white patients (1.07, 0.78 to 1.47).
Conclusion: Among patients deemed appropriate for coronary artery bypass grafting, south Asian patients are less likely than white patients to receive it. This difference is not explained by physician bias.

What is already known on this topic US studies have shown inequity in use of cardiac revascularisation procedures between white patients and African-Americans Studies in England comparing revascularisation in white and south Asian patients have been too small for conclusive results and have not considered appropriateness of treatment What this study adds Rates of coronary revascularisation among comparable patients with coronary artery disease are lower among south Asian patients than white patients Physician bias did not explain these differences nor did socioeconomic status of patients The differences in treatment did not result in large differences in clinical outcome

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