Racial and sex differences in refusal of coronary angiography.
OBJECTIVE
To determine the effect of patient refusal on racial and sex differences in the use of coronary angiography and in outcomes among elderly patients with acute myocardial infarction.


METHODS
We included Medicare beneficiary patients admitted to hospitals performing coronary angiography from February 1994 through July 1995. In-hospital use and refusal of coronary angiography were determined, and adjusted for patient, hospital, and physician characteristics.


RESULTS
Of 124,691 patients, 53,671 (43%) underwent angiography during hospitalization and 2881 (2.3%) refused. Patients refusing angiography were more likely to be female (odds ratio [OR] = 1.37; 95% confidence interval [CI]: 1.23 to 1.53), black (OR = 1.26 vs. whites; 95% CI: 1.02 to 1.56), and older (OR = 2.25 per 10-year increase; 95% CI: 2.05 to 2.43) than patients who underwent angiography. Angiography use was lower in blacks (OR = 0.78; 95% CI: 0.72 to 0.83) than in whites, and lower in women (OR = 0.83; 95% CI: 0.80 to 0.86) than in men. Increased refusal explained 6% (95% CI: -3% to 15%) of the difference in angiography use between whites and blacks, and 16% (95% CI: 10% to 22%) of the difference between men and women. After adjustment for patient characteristics, refusal of angiography was not associated with worse survival at 1 year (OR = 0.99; 95% CI: 0.82 to 1.20).


CONCLUSIONS
Among Medicare beneficiaries, elderly female and black patients are more likely to refuse angiography than are male and white patients. However, patient refusal is uncommon and accounts for only a small fraction of the racial and sex differences in use of angiography after myocardial infarction.
Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA. heiden@stanford.edu
Paul A
PA
Heidenreich
Michael G
MG
Shlipak
Jeffrey
J
Geppert
Mark
M
McClellan
D001741:Black or African American / Q000706:statistics & numerical data*; D017677:Age Distribution; D000368:Aged; D000369:Aged, 80 and over; D002140:California; D015331:Cohort Studies; D016001:Confidence Intervals; D017023:Coronary Angiography / Q000379:methods / Q000706:statistics & numerical data*; D003327:Coronary Disease / Q000000981:diagnostic imaging* / Q000208:ethnology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010342:Patient Acceptance of Health Care / Q000208:ethnology*; D011336:Probability; D012042:Registries; D017678:Sex Distribution; D016312:Treatment Refusal / Q000208:ethnology* / Q000706:statistics & numerical data; D044465:White People / Q000706:statistics & numerical data*