title: Differences in specialist consultations for cardiovascular disease by race, ethnicity, gender, insurance status, and site of primary care.
abstract: BACKGROUND
  Consultation with cardiologists may improve the quality of ambulatory care and reduce disparities for patients with heart disease. We assessed the use of cardiology consultations and the associated quality by race/ethnicity, gender, insurance status, and site of care.
  
  
  RESULTS
  In a retrospective cohort, we examined electronic records of 9761 adults with coronary artery disease or congestive heart failure (CHF) receiving primary care at practices affiliated with 2 academic medical centers during 2000 to 2005. During this period, 79.6% of patients with coronary artery disease and 90.3% of patients with CHF had a cardiology consultation. In multivariate analyses, women were less likely to receive a consultation than men for both conditions (coronary artery disease: hazard ratio, 0.89; 95% CI, 0.85 to 0.93; CHF: hazard ratio, 0.93; 95% CI, 0.87 to 0.99). Women also had 15% fewer follow-up consultations than men (P<0.001). Similarly, patients at community health centers were less likely to receive a consultation (coronary artery disease: hazard ratio, 0.79; 95% CI, 0.74 to 0.84; CHF: hazard ratio, 0.77; 95% CI: 0.71 to 0.84) and had 20% fewer follow-up consultations (P<0.001) relative to those at hospital-based practices. Black and Hispanic patients with CHF had 13% fewer follow-up consultations than white patients (P=0.01 and P=0.04, respectively). In adjusted analyses, consultation was associated with better processes of care compared with no consultation (P<0.001), particularly for women (P<0.001 for interaction between consultation and gender).
  
  
  CONCLUSIONS
  Among ambulatory patients with coronary artery disease or CHF, women and those at community health centers have less access to cardiologists. Consultation is associated with better quality of care and narrows the gender gap in quality.
authors.affiliation: National Heart, Lung, and Blood Institute, Rockledge II, Bethesda, MD 20892, USA. cookn2@nhlbi.nih.gov
authors.forename: Nakela L
authors.initials: NL
authors.lastname: Cook
authors.forename: John Z
authors.initials: JZ
authors.lastname: Ayanian
authors.forename: E John
authors.initials: EJ
authors.lastname: Orav
authors.forename: Leroi S
authors.initials: LS
authors.lastname: Hicks
mesh_terms: D000046:Academic Medical Centers / Q000706:statistics & numerical data; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D044383:Black People / Q000706:statistics & numerical data; D002309:Cardiology / Q000706:statistics & numerical data*; D003151:Community Health Centers / Q000706:statistics & numerical data; D003324:Coronary Artery Disease / Q000208:ethnology* / Q000628:therapy; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006333:Heart Failure / Q000208:ethnology* / Q000628:therapy; D006630:Hispanic or Latino / Q000706:statistics & numerical data; D006801:Humans; D007341:Insurance / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010044:Outpatient Clinics, Hospital / Q000706:statistics & numerical data; D011320:Primary Health Care / Q000706:statistics & numerical data*; D011787:Quality of Health Care; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D017678:Sex Distribution; D044465:White People / Q000706:statistics & numerical data; D055815:Young Adult