differences in the use of cardiovascular procedures have been documented among VHA patients (Whittle et al., 1993; Peterson et al., 1994). Similarly, a large national study of almost 10,000 Medicare patients found that patients who were Black or resided in poor neighborhoods received poorer inpatient medical care and had greater instability at discharge than other patients (Kahn et al., 1994). These differences were evident in all types of hospitals, but less pronounced in urban teaching hospitals than in rural and urban nonteaching institutions. An analysis of all inpatient Medicare reimbursement claims for 1992 revealed that Blacks were less likely than Whites to receive all of the 16 most commonly received procedures by Medicare beneficiaries (McBean and Gornick, 1994). The racial differences were especially large for the newer, elective, and referral-sensitive procedures.

These racial differences in medical care are consequential and in some cases life threatening. Among the 1992 Medicare beneficiaries, Blacks had a higher 30-day postadmission mortality rate than Whites for most of the procedures (McBean and Gornick, 1994). Moreover, additional analyses of the Medicare files revealed four procedures that Black beneficiaries received more frequently than their White counterparts—all four procedures reflect delayed diagnosis, delayed initial treatment, or failure in the management of chronic disease.

1. Amputation of part of the lower limb, usually as a consequence of poor management of diabetes, was 3.6 times more likely to be performed on Blacks compared to Whites.

2. Excisional debridement, the removal of tissue usually related to poor and infrequent medical care that leads to decubitus ulcers and skin infections, was performed 2.7 times more frequently on Black than on White patients.

3. Arterial venostomy, the implantation of shunts for chronic renal dialysis, often reflective of the failure of the management of end-stage renal disease, was 5.2 times more likely to be performed on Black patients than on White.

   Bilateral orchiectomy, removal of both testes, often reflective of delayed diagnosis or initial treatment in the case of prostate cancer, was 2.2 times more likely to be performed on Black men than on White men.

Further evidence of the potential adverse effects of racial differences in medical care comes from two more recent studies. Peterson et al. (1997) studied 12,402 patients who underwent their first cardiac catherization. After adjusting for demographic factors, severity of disease, coexisting medical conditions, and access to subspeciality cardiology care, Blacks were only slightly less likely to receive coronary angioplasty but