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Winicki NM, Florissi IS, Zaheer S, Holmes SD, Alejo DE, Fonner CE, Matthew TL, Gammie JS. Racial and Ethnic Variations in Patients Undergoing Mitral and Tricuspid Valve Surgery. J Surg Res 2024; 300:309-317. [PMID: 38838428 DOI: 10.1016/j.jss.2024.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 05/05/2024] [Accepted: 05/09/2024] [Indexed: 06/07/2024]
Abstract
INTRODUCTION Prior investigations assessing the impact of race/ethnicity on outcomes after mitral valve (MV) surgery have reported conflicting findings. This analysis aimed to examine the association between race/ethnicity and operative presentation and outcomes of patients undergoing MV and tricuspid valve (TV) surgery. METHODS We retrospectively analyzed 5984 patients (2730 female, median age 63 y) who underwent MV (n = 4,534, 76%), TV (n = 474, 8%) or both MV and TV (n = 976, 16%) surgery in a statewide collaborative from 2012 to 2021. The influence of race/ethnicity on preoperative characteristics, MV and TV repair rates, and postoperative outcomes was assessed for White (n = 4,244, 71%), Black (n = 1,271, 21%), Hispanic (n = 144, 2%), Asian (n = 171, 3%), and mixed/other race (n = 154, 3%) patients. RESULTS Black patients, compared to White patients, had higher Society of Thoracic Surgeons predicted risk of morbidity/mortality (24.5% versus 13.1%; P < 0.001) and more comorbid conditions. Compared to White patients, Black and Hispanic patients were less likely to undergo an elective procedure (White 71%, Black 55%, Hispanic 58%; P < 0.001). Degenerative MV disease was more prevalent in White patients (White 62%, Black 41%, Hispanic 43%, Asian 51%, mixed/other 45%; P < 0.05), while rheumatic disease was more prevalent in non-White patients (Asian 28%, Hispanic 26%, mixed/other 25%, Black 17%, White 10%;P < 0.05). After multivariable adjustment, repair rates and adverse postoperative outcomes, including mortality, did not differ by racial/ethnic group. CONCLUSIONS Patient race/ethnicity is associated with a higher burden of comorbidities at operative presentation and MV disease etiology. Strategies to improve early detection of valvular heart disease and timely referral for surgery may improve outcomes.
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Affiliation(s)
- Nolan M Winicki
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Isabella S Florissi
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Salman Zaheer
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sari D Holmes
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Diane E Alejo
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Maryland Cardiac Services Quality Initiative Inc., Baltimore, Maryland
| | - Clifford E Fonner
- Maryland Cardiac Services Quality Initiative Inc., Baltimore, Maryland
| | - Thomas L Matthew
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James S Gammie
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Dawod MS, Alswerki MN, Ar Altamimi A, Abu Hilal M, Albadaineh A, Saber Y, Alisi MS, Al-Ajlouni J. Comparative analysis of geriatric hip fracture management outcomes in teaching and nonteaching hospitals in Jordan. Sci Rep 2024; 14:16053. [PMID: 38992060 PMCID: PMC11239659 DOI: 10.1038/s41598-024-66016-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 06/26/2024] [Indexed: 07/13/2024] Open
Abstract
Hip fractures are common orthopedic injuries that have significant impacts on patients and healthcare systems. Previous studies have shown varying outcomes for hip fracture management in different settings, with diverse postoperative outcomes and complications. While teaching hospital settings have been investigated, no studies have specifically examined hip fracture outcomes in teaching hospitals in Jordan or the broader Middle East region. Therefore, the aim of this study was to investigate this important outcome. A cohort comprising 1268 patients who underwent hip fracture fixation from 2017 to 2020 was analyzed for nine distinct outcomes. These outcomes encompassed time to surgery, ICU admissions, perioperative hemoglobin levels, length of hospital stay, readmission rates, revision procedures, and mortality rates at three time points: in-hospital, at 6-months, and at 1-year post-surgery. The analysis of 1268 patients (616 in teaching hospitals, 652 in non-teaching hospitals) showed shorter mean time to surgery in teaching hospitals (2.2 days vs. 3.6 days, p < 0.01), higher ICU admissions (17% vs. 2.6%, p < 0.01), and more postoperative blood transfusions (40.3% vs. 12.1%, p < 0.01). In-hospital mortality rates were similar between groups (2.4% vs. 2.1%, p = 0.72), as were rates at 6-months (3.1% vs. 3.5%, p = 0.65) and 1-year post-surgery (3.7% vs. 3.7%, p = 0.96). Geriatric hip fracture patients in teaching hospitals have shorter surgery times, more ICU admissions, and higher postoperative blood transfusion rates. However, there are no significant differences in readmission rates, hospital stays, or mortality rates at various intervals.
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Affiliation(s)
- Moh'd S Dawod
- Faculty of Medicine, Mutah University, Al-Karak, Jordan
| | - Mohammad N Alswerki
- Department of Orthopedic Surgery, Jordan University Hospital, P.O. Box: 13046, Amman, 11942, Jordan.
| | - Anas Ar Altamimi
- Head of Special Surgery Department, Hashemite University, Amman, Jordan
| | | | - Ashraf Albadaineh
- Al-Karak Governmental Hospital, Jordanian Ministry of Health, Amman, Jordan
| | | | - Mohammed S Alisi
- Islamic University of Gaza, Palestinian Ministry of Health, Gaza, Palestine
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Popescu I, Huckfeldt P, Pane JD, Escarce JJ. Contributions of Geography and Nongeographic Factors to the White-Black Gap in Hospital Quality for Coronary Heart Disease: A Decomposition Analysis. J Am Heart Assoc 2019; 8:e011964. [PMID: 31787056 PMCID: PMC6912970 DOI: 10.1161/jaha.119.011964] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Background Differences in hospital proximity and nongeographic factors affect disparities in hospital quality for heart disease, but their relative contributions are unknown. The current study quantifies the influences of these factors on the white‐black gap in high‐ and low‐quality hospital use for acute myocardial infarction (AMI) and coronary artery bypass grafting (CABG) surgery. Methods and Results We used Medicare claims to identify fee‐for‐service Medicare beneficiaries aged 65 and older hospitalized during 2009–2011 with AMI (n=384 443) and CABG (n=71 411). Hospital quality was measured using publicly available AMI mortality rates. In national and regional analyses, we used conditional multinomial logit models to estimate the white‐black gap in high‐ and low‐quality hospital use and decompose the gap into geographic and nongeographic contributions. Overall, more whites used high‐quality hospitals for both conditions (34.8% versus 32.4% for AMI; 39.0% versus 29.9% for CABG; P<0.001), but after accounting for distance to hospitals, the white‐black gap was significant only for CABG (9.1%; P<0.001). The nongeographic component was significant for both conditions (3.4% for AMI and 7.7% for CABG; P<0.001) and accounted for nearly the entire gap for CABG. In contrast, hospital geographic proximity was not significant. In regional analyses, white beneficiaries had higher rates of high‐quality hospital use in the Northeast (CABG) and South (AMI and CABG), whereas black had higher rates of high‐quality hospital use in the Midwest (AMI). Conclusions White‐black differences in high‐quality hospital use were significant for CABG and related to nongeographic factors. Interventions should consider health system and contextual reasons for these disparities.
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Affiliation(s)
- Ioana Popescu
- Division of General Internal Medicine and Health Services ResearchDavid Geffen School of Medicine at UCLALos AngelesCA
- RAND CorporationSanta MonicaCA
| | - Peter Huckfeldt
- University of Minnesota School of Public HealthMinneapolisMN
| | | | - José J. Escarce
- Division of General Internal Medicine and Health Services ResearchDavid Geffen School of Medicine at UCLALos AngelesCA
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Rivera-Hernandez M, Rahman M, Mukamel DB, Mor V, Trivedi AN. Quality of Post-Acute Care in Skilled Nursing Facilities That Disproportionately Serve Black and Hispanic Patients. J Gerontol A Biol Sci Med Sci 2019; 74:689-697. [PMID: 29697778 PMCID: PMC6477650 DOI: 10.1093/gerona/gly089] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 04/19/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Understanding and addressing racial and ethnic disparities in the quality of post-acute care in skilled nursing facilities is an important health policy issue, particularly as the Medicare program initiates value-based payments for these institutions. METHODS Our final cohort included 649,187 Medicare beneficiaries in either the fee-for-service or Medicare Advantage programs, who were 65 and older and were admitted to a skilled nursing facility following an acute hospital stay, from 8,375 skilled nursing facilities. We examined the quality of care in skilled nursing facilities that disproportionately serve minority patients compared to non-Hispanic whites. Three measures, all calculated at the level of the facility, were used to assess quality of care in skilled nursing facilities: (a) 30-day rehospitalization rate; (b) successful discharge from the facility to the community; and (c) Medicare five-star quality ratings. RESULTS We found that African American post-acute patients are highly concentrated in a small number of institutions, with 28% of facilities accounting for 80% of all post-acute admissions for African American patients. Similarly, just 20% of facilities accounted for 80% of all admissions for Hispanics. Skilled nursing facilities with higher fractions of African American patients had worse performance for three publicly reported quality measures: rehospitalization, successful discharge to the community, and the star rating indicator. CONCLUSIONS Efforts to address disparities should focus attention on institutions that disproportionately serve minority patients and monitor unintended consequences of value-based payments to skilled nursing facilities.
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Affiliation(s)
- Maricruz Rivera-Hernandez
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI,Address correspondence to: Maricruz Rivera-Hernandez, PhD, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Box G-S121-6, Providence, RI 02912. E-mail:
| | - Momotazur Rahman
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Dana B Mukamel
- Department of Medicine, Division of General Internal Medicine, iTEQC Research Program, Irvine, CA
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI,Providence VA Medical Center, RI
| | - Amal N Trivedi
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI,Providence VA Medical Center, RI
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Popescu I, Schrag D, Ang A, Wong M. Racial/Ethnic and Socioeconomic Differences in Colorectal and Breast Cancer Treatment Quality: The Role of Physician-level Variations in Care. Med Care 2016; 54:780-8. [PMID: 27326547 PMCID: PMC6173517 DOI: 10.1097/mlr.0000000000000561] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Despite a large body of research showing racial/ethnic and socioeconomic disparities in cancer treatment quality, the relative role of physician-level variations in care is unclear. OBJECTIVE To examine the effect of physicians on disparities in breast and colorectal cancer care. SUBJECTS Linked SEER Medicare data were used to identify Medicare beneficiaries diagnosed with colorectal and breast cancer during 1995-2007 and their treating physicians. RESEARCH DESIGN We identified treating physicians from Medicare claims data. We measured the use of NIH guideline-recommended therapies from SEER and Medicare claims data, and used logistic models to examine the relationship between race/ethnicity, socioeconomic status, and cancer quality of care. We used physician fixed effects to account for between-physician variations in treatment. RESULTS Minority and low socioeconomic status beneficiaries with breast and colorectal cancer were less likely to receive any recommended treatments as compared with whites. Overall, between-physician variation explained <20% of the total variation in quality of care. After accounting for between-physician differences, median household income explained 14.3%, 18.4%, and 13.2% of the variation in use of breast-conserving surgery, chemotherapy, and radiation for breast cancer, and 13.7%, 12.9%, and 12.6% of the within-physician variation in use of colorectal surgery, chemotherapy, and radiation for colorectal cancer, whereas race and ethnicity explained <2% of the within-physician variation in cancer care. CONCLUSIONS Between-physician variations partially explain racial disparities in cancer care. Residual within-physician disparities may be due to differences in patient-provider communication, patient preferences and treatment adherence, or unmeasured clinical severity.
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Affiliation(s)
- Ioana Popescu
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, Los Angeles, CA
| | - Deborah Schrag
- Division of Population Sciences, Dana Farber Cancer Institute and the Harvard Medical School, Boston, MA
| | - Alfonso Ang
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, Los Angeles, CA
| | - Mitchell Wong
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, Los Angeles, CA
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Khera R, Vaughan-Sarrazin M, Rosenthal GE, Girotra S. Racial disparities in outcomes after cardiac surgery: the role of hospital quality. Curr Cardiol Rep 2015; 17:29. [PMID: 25894800 PMCID: PMC4780328 DOI: 10.1007/s11886-015-0587-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Patients from racial and ethnic minorities experience higher mortality after cardiac surgery compared to white patients, both during the early postoperative phase as well as long term. A number of factors likely explain poor outcomes in black and minority patients, which include differences in biology, comorbid health conditions, socioeconomic background, and quality of hospital care. Recent evidence suggests that a major factor underlying excess mortality in these groups is due to their over-representation in low-quality hospitals, where all patients regardless of race have worse outcomes. In this review, we examine the factors underlying racial disparities in outcomes after cardiac surgery, with a primary focus on the role of hospital quality.
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Affiliation(s)
- Rohan Khera
- Department of Internal Medicine, University of Iowa Hospitals & Clinics, 200 Hawkins Drive, E325 GH, Iowa City, IA, 52242, USA,
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Freedman RA, Kouri EM, West DW, Keating NL. Racial/Ethnic Differences in Patients' Selection of Surgeons and Hospitals for Breast Cancer Surgery. JAMA Oncol 2015; 1:222-30. [PMID: 26181027 PMCID: PMC4944092 DOI: 10.1001/jamaoncol.2015.20] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IMPORTANCE Racial differences in breast cancer treatment may result in part from differences in the surgeons and hospitals from whom patients receive their care. However, little is known about differences in patients' selection of surgeons and hospitals. OBJECTIVE To examine racial/ethnic differences in how women selected their surgeons and hospitals for breast cancer surgery. DESIGN, SETTING, AND PARTICIPANTS We surveyed 500 women (222 non-Hispanic white, 142 non-Hispanic black, 89 English-speaking Hispanic, and 47 Spanish-speaking Hispanic) from northern California cancer registries with stage 0 to III breast cancer diagnosed during 2010 through 2011. We used multivariable logistic regression to assess the reasons for surgeon and hospital selection by race/ethnicity, adjusting for other patient characteristics. We also assessed the association between reasons for physician selection and patients' ratings of their surgeon and hospital. MAIN OUTCOMES AND MEASURES Reasons for surgeon and hospital selection and ratings of surgeon and hospital. RESULTS The 500 participants represented a response rate of 47.8% and a participation rate of 69%. The most frequently reported reason for surgeon selection was referral by another physician (78%); the most frequently reported reason for hospital selection was because it was a part of a patient's health plan (58%). After adjustment, 79% to 87% of black and Spanish-speaking Hispanic women reported selecting their surgeon based on a physician's referral vs 76% of white women (P = .007). Black and Hispanic patients were less likely than white patients to report selecting their surgeon based on reputation (adjusted rates, 18% and 22% of black and Hispanic women, respectively, vs 32% of white women; P = .02). Black and Hispanic women were also less likely than white women to select their hospital based on reputation (adjusted rates, 7% and 15% vs 23%, respectively; P = .003). Women who selected their surgeon based on reputation more often rated the care from their surgeon as excellent (adjusted odds ratio, 2.21; 95% CI, 1.24-3.93); those reporting their surgeon was one of the only surgeons available through the health plan less often reported excellent quality of surgical care (adjusted odds ratio, 0.56; 95% CI, 0.34-0.91). CONCLUSIONS AND RELEVANCE Compared with white patients with breast cancer, minority patients were less actively involved in physician and hospital selection, relying more on physician referral and health plans rather than on reputation. Interventions to promote involvement in surgeon and hospital selection may have potential for addressing disparities related to lower-quality care from surgeons and hospitals.
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Affiliation(s)
- Rachel A Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Elena M Kouri
- Harvard Medical School, Department of Health Care Policy, Boston, Massachusetts
| | - Dee W West
- Cancer Registry of Greater California, Public Health Institute, Sacramento
| | - Nancy L Keating
- Harvard Medical School, Department of Health Care Policy, Boston, Massachusetts4Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Pollack CE, Rastegar A, Keating NL, Adams JL, Pisu M, Kahn KL. Is Self-Referral Associated with Higher Quality Care? Health Serv Res 2015; 50:1472-90. [PMID: 25759002 DOI: 10.1111/1475-6773.12289] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To assess the extent to which patients self-refer to cancer specialists and whether self-referral is associated with better experiences and quality of care. DATA SOURCES Data from surveys and medical record abstraction collected through the Cancer Care Outcomes Research and Surveillance Consortium. STUDY DESIGN Observational study of patients with lung and colorectal cancer diagnosed from 2003 through 2005 in five geographically defined regions and five integrated health care delivery systems. METHODS Multivariable logistic regression models used to assess factors associated with self-referral and propensity score-weighted doubly robust models to test the association between self-referral and experiences/quality of care. PRINCIPAL FINDINGS Among 5,882 patients, 9.7 percent of lung cancer patients and 14.9 percent of colorectal cancer patients self-referred to at least one cancer specialist. Black patients were less likely to self-refer than white patients (odds ratio: 0.48, 95 percent confidence interval: 0.35, 0.64); patients with high incomes (vs. low) and with a college degree (vs. non-high school graduates) were significantly more likely to self-refer. Self-referral was associated with lower ratings of overall physician communication for patients with lung cancer but, conversely, higher odds of curative surgery among patients with stage I/II lung cancer. CONCLUSIONS A small but significant proportion of patients self-referred to their cancer specialists; rates varied by patient race and socioeconomic status. To the extent that self-referral is associated with quality, it may reinforce disparities in care.
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Affiliation(s)
- Craig Evan Pollack
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | | | - Nancy L Keating
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA.,Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - John L Adams
- Research & Evaluation, Kaiser Permanente, Pasadena, CA
| | - Maria Pisu
- Division of Preventive Medicine and Comprehensive Cancer Center, University of Alabama, Birmingham, AL
| | - Katherine L Kahn
- Division of General Internal Medicine, University of California, Los Angeles, CA.,RAND Corporation, Los Angeles, CA
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Singh JA, Lu X, Ibrahim S, Cram P. Trends in and disparities for acute myocardial infarction: an analysis of Medicare claims data from 1992 to 2010. BMC Med 2014; 12:190. [PMID: 25341547 PMCID: PMC4212130 DOI: 10.1186/s12916-014-0190-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Accepted: 09/22/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is unknown whether previously reported disparities for acute myocardial infarction (AMI) by race and sex have declined over time. METHODS We used Medicare Part A administrative data files for 1992 to 2010 to evaluate changes in per-capita hospitalization rates for AMI, rates of revascularization (percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG)), and 30-day mortality for four distinct patient subcohorts: black women; black men; white women; and white men, adjusted for age, comorbidities and year using logistic regression. RESULTS The study sample consisted of 4,045,267 AMI admissions between the years 1992 and 2010 (166,660 black women; 116,201 black men; 1,870,816 white women; 1,891,590 white men). AMI hospitalization rates differed significantly in 1992 to 1993 among black women (61.6 hospitalizations per 10,000 Medicare enrollees), black men (73.2 hospitalizations), white women (72.0 hospitalizations) and white men (113.2 hospitalizations) (P<0.0001). By 2009 to 2010 AMI hospitalization rates had declined substantially in all cohorts but disparities remained with significantly lower hospitalization rates among women and blacks compared to men and whites, respectively (P<0.0001). In multivariable-adjusted analyses, despite narrowing of the differences between cohorts over time, disparities in AMI hospitalization rates by race and sex remained statistically significant in 2009 to 2010 (P<0.001). In 1992 to 1993 and 2009 to 2010, rates of PCI within 30-days of AMI differed significantly among black women (8.6% in 1992 to 1993; 24.2% in 2009 to 2010), black men (10.4% and 32.6%), white women (12.8% and 30.5%), and white men (16.1% and 40.7%) (P<0.0001). In multivariable-adjusted analyses, racial disparities in procedure utilization appeared somewhat larger and sex-based disparities remained significant. Unadjusted 30-day mortality after AMI in 1992 to 1993 for black women, black men, white women and white men was 20.4%, 17.9%, 23.1% and 19.5%, respectively (P<0.0001); in 2009 to 2010 mortality was 17.1%, 15.3%, 18.2% and 16.2%, respectively (P<0.0001). In adjusted analyses, racial differences in mortality declined over time but differences by sex (higher mortality for women) persisted. CONCLUSIONS Disparities in AMI have declined modestly, but remain a problem, particularly with respect to patient sex.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service, Birmingham Veterans Affairs Medical Center, the University of Alabama at Birmingham, 510 S 20th Street, Faculty Office Tower 805B, Birmingham, AL, 35294, UK.
| | - Xin Lu
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine and CADRE, Iowa City Veterans Administration Medical Center, 451 Newton Road 200 Medicine Administration Building, Iowa City, IA, 52242, USA.
| | - Said Ibrahim
- Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, the Perelman University of Pennsylvania School of Medicine, 3400 Spruce St, Philadelphia, PA, 19104, USA.
| | - Peter Cram
- Division of General Internal Medicine and Geriatrics, University Health Network and Mount Sinai Hospitals, 200 Elizabeth Street, Eaton North 14th Floor, Toronto, ON, M5G 2C4, Canada.
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
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DuGoff EH, Bekelman JE, Stuart EA, Armstrong K, Pollack CE. Surgical quality is more than volume: the association between changing urologists and complications for patients with localized prostate cancer. Health Serv Res 2014; 49:1165-83. [PMID: 24461049 DOI: 10.1111/1475-6773.12148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES To examine the association of changing urologists on surgical complications in men with prostate cancer. DATA SOURCES/STUDY SETTING Registry and administrative claims data from the Surveillance, Epidemiology, and End Results-Medicare database from 1995 to 2005. STUDY DESIGN A cross-sectional observational study of men with prostate cancer who underwent radical prostatectomy. METHODS Subjects were classified as having "changed urologists" if they had a different urologist who diagnosed their cancer from the one who performed their surgery. "Doubly robust" propensity score weighted multivariable logistic regression models were used to investigate the effect of changing urologists on 30-day surgical complications, late urinary complications, and long-term incontinence. PRINCIPAL FINDINGS Men who changed urologists between diagnosis and treatment had significantly lower odds of 30-day surgical complications compared with men who did not change urologists (odds ratio: 0.82; 95 percent confidence interval: 0.76-0.89), after adjustment. Changing urologists was associated with lower risks of 30-day complications for both black and white men compared with staying with the same urologist for their diagnosis and surgical treatment. CONCLUSIONS Urologist changing is associated with the observed variation in complications following radical prostatectomy. This may suggest that patients are responding to aspects of surgical quality not captured in surgical volume.
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Affiliation(s)
- Eva H DuGoff
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Kronebusch K, Gray BH, Schlesinger M. Explaining racial/ethnic disparities in use of high-volume hospitals: decision-making complexity and local hospital environments. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2014; 51:51/0/0046958014545575. [PMID: 25316717 PMCID: PMC5813660 DOI: 10.1177/0046958014545575] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Racial/ethnic minorities are less likely to use higher-quality hospitals than whites. We propose that a higher level of information-related complexity in their local hospital environments compounds the effects of discrimination and more limited access to services, contributing to racial/ethnic disparities in hospital use. While minorities live closer than whites to high-volume hospitals, minorities also face greater choice complexity and live in neighborhoods with lower levels of medical experience. Our empirical results reveal that it is generally the overall context associated with proximity, choice complexity, and local experience, rather than differential sensitivity to these factors, that provides a partial explanation of the disparity gap in high-volume hospital use.
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Are African American patients more likely to receive a total knee arthroplasty in a low-quality hospital? Clin Orthop Relat Res 2012; 470:1185-93. [PMID: 21879410 PMCID: PMC3293986 DOI: 10.1007/s11999-011-2032-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2011] [Accepted: 08/08/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Total joint arthroplasty is widely performed in patients of all races with severe osteoarthritis. Prior studies have reported that African American patients tend to receive total joint arthroplasties in low-volume hospitals compared with Caucasian patients, suggesting potential racial disparity in the quality of arthroplasty care. QUESTIONS/PURPOSES We asked whether (1) a hospital outcome measure of risk-adjusted mortality or complication rate within 90 days of primary TKA can be directly used to profile hospital quality of care, and (2) African Americans were more likely to receive TKAs at low-quality hospitals (or hospitals with higher risk-adjusted outcome rate) compared with Caucasian patients. PATIENTS AND METHODS We developed a risk-adjusted, 90-day postoperative outcome measure to identify high-, intermediate-, and low-quality hospitals based on patient records in the Medicare Provider Analysis and Review files between July 1, 2002, and June 30, 2005 (the first cohort). We then analyzed a second cohort of African American and Caucasian patients receiving Medicare who underwent primary TKAs between July and December 2005 to determine the independent impact of race on admissions to high-, intermediate-, and low-quality hospitals. RESULTS The risk-adjusted postoperative mortality/complication rate varied substantially across hospitals; hospitals can be meaningfully categorized into quality groups. In the second cohort of admissions, 8% of African American patients (n = 4894) versus 9.2% of Caucasian patients (n = 86,705) were treated in high-quality hospitals whereas 14.7% of African American patients versus 12.7% of Caucasians patients were treated in low-quality hospitals. After controlling for patient demographic, socioeconomic, geographic, and diagnostic characteristics, the odds ratio for admission to low-quality hospitals was 1.28 for African American patients compared with Caucasian patients (95% CI, 1.18-1.41). CONCLUSIONS Among elderly Medicare beneficiaries undergoing TKA, African American patients were more likely than Caucasian patients to be admitted to hospitals with higher risk-adjusted postoperative rates of complications or mortality. Future work is needed to address the residential, social, and referring factors that underlie this disparity and implications for outcomes of care.
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Popescu I, Cram P, Vaughan-Sarrazin MS. Differences in admitting hospital characteristics for black and white Medicare beneficiaries with acute myocardial infarction. Circulation 2011; 123:2710-6. [PMID: 21632492 PMCID: PMC3142883 DOI: 10.1161/circulationaha.110.973628] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Accepted: 04/21/2011] [Indexed: 11/16/2022]
Abstract
BACKGROUND Racial disparities in acute myocardial infarction treatment may be due to differences in admitting hospitals. Little is known about factors associated with hospital selection for black and white acute myocardial infarction patients. METHODS AND RESULTS We identified black and white Medicare beneficiaries with acute myocardial infarction in 63 hospital referral regions with at least 50 black admissions during 2005 (n=65,633). We calculated distance from patient home to hospital referral region hospitals using ZIP code centroids. We assessed hospital quality using a composite score made up of hospital risk-adjusted 30-day mortality and acute myocardial infarction performance measures. Hospitals with a score in the top 20% were categorized as high quality, and those in the lowest 20% as low quality. We used conditional multinomial logit models to examine differences in hospital selection for blacks and whites. On average, blacks lived closer to revascularization hospitals (mean, 3.8 versus 6.8 miles; P<0.001) and to high-quality hospitals (mean, 5.6 versus 9.7 miles; P<0.001). After distance was accounted for, blacks were relatively less likely (P<0.001) to be admitted to revascularization hospitals (risk ratio [RR], 0.87; 95% confidence interval [CI], 0.80 to 0.95) and to high-quality hospitals (RR, 0.88; 95% CI, 0.801 to 0.95) but more likely (P<0.001) to be admitted to low-quality hospitals (RR, 1.17; 95% CI, 1.05 to 1.29). In analyses matched by home ZIP code, differences in admissions to revascularization (RR, 0.92; 95% CI, 0.80 to 1.05), high-quality (RR, 0.94; 95% CI, 0.81 to 1.07), and low-quality (RR, 1.15; 95% CI, 0.94 to 1.35) hospitals were not significant. CONCLUSIONS Differences in admissions to revascularization and high-quality hospitals may contribute to disparities in acute myocardial infarction care. These differences may be due in part to residential ZIP code characteristics.
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Affiliation(s)
- Ioana Popescu
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA 90024, USA.
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Spertus JA, Jones PG, Masoudi FA, Rumsfeld JS, Krumholz HM. Factors associated with racial differences in myocardial infarction outcomes. Ann Intern Med 2009; 150:314-24. [PMID: 19258559 PMCID: PMC3387537 DOI: 10.7326/0003-4819-150-5-200903030-00007] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Little information is available about factors associated with racial differences across a broad spectrum of post-myocardial infarction outcomes, including patients' symptoms and quality of life. OBJECTIVE To determine racial differences in mortality, rehospitalization, angina, and quality of life after myocardial infarction and identify the factors associated with these differences. DESIGN Prospective cohort study. SETTING 10 hospitals in the United States. PATIENTS 1849 patients who had myocardial infarction, 28% of whom were black. MEASUREMENTS Demographic, economic, clinical, psychosocial, and treatment characteristics and outcomes were prospectively collected. Outcomes included time to 2-year all-cause mortality, 1-year rehospitalization, and Seattle Angina Questionnaire-assessed angina and quality of life. RESULTS Black patients had higher unadjusted mortality (19.9% vs. 9.3%; P < 0.001) and rehospitalization rates (45.4% vs. 40.4%; P = 0.130), more angina (28.0% vs. 17.8%; P < 0.001), and worse mean quality of life (80.6 [SD, 22.5] vs. 85.9 [SD, 17.2]; P < 0.001). After adjustment for patient characteristics, black patients trended toward greater mortality (hazard ratio, 1.29 [95% CI, 0.92 to 1.81]; P = 0.142), fewer rehospitalizations (hazard ratio, 0.82 [CI, 0.66 to 1.02]; P = 0.071), and higher likelihood of angina at 1 year (odds ratio, 1.41 [CI, 1.03 to 1.94]; P = 0.032) but similar quality of life (mean difference, -0.6 [CI, -3.4 to 2.2]). Adjustment for site of care further attenuated mortality differences (hazard ratio, 1.04 [CI, 0.71 to 1.52]; P = 0.84). Adjustment for treatments had minimal effect on any association. LIMITATION Residual confounding and missing data may have introduced bias. CONCLUSION Although black patients with myocardial infarction have worse outcomes than white patients, these differences did not persist after adjustment for patient factors and site of care. Further adjustment for treatments received minimally influenced observed differences. Strategies that focus on improving baseline cardiac risk and hospital factors may do more than treatment-focused strategies to attenuate racial differences in myocardial infarction outcomes. FUNDING The National Heart, Lung, and Blood Institute Specialized Center of Clinically Oriented Research in Cardiac Dysfunction and Disease, CV Therapeutics, and Cardiovascular Outcomes.
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Affiliation(s)
- John A Spertus
- Mid America Heart Institute of Saint Luke's Hospital and University of Missouri-Kansas City, Kansas City, Missouri, USA.
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Safford MM, Brimacombe M, Zhang Q, Rajan M, Xie M, Thompson W, Kolassa J, Maney M, Pogach L. Patient complexity in quality comparisons for glycemic control: an observational study. Implement Sci 2009; 4:2. [PMID: 19126229 PMCID: PMC2632611 DOI: 10.1186/1748-5908-4-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2006] [Accepted: 01/06/2009] [Indexed: 11/25/2022] Open
Abstract
Background Patient complexity is not incorporated into quality of care comparisons for glycemic control. We developed a method to adjust hemoglobin A1c levels for patient characteristics that reflect complexity, and examined the effect of using adjusted A1c values on quality comparisons. Methods This cross-sectional observational study used 1999 national VA (US Department of Veterans Affairs) pharmacy, inpatient and outpatient utilization, and laboratory data on diabetic veterans. We adjusted individual A1c levels for available domains of complexity: age, social support (marital status), comorbid illnesses, and severity of disease (insulin use). We used adjusted A1c values to generate VA medical center level performance measures, and compared medical center ranks using adjusted versus unadjusted A1c levels across several thresholds of A1c (8.0%, 8.5%, 9.0%, and 9.5%). Results The adjustment model had R2 = 8.3% with stable parameter estimates on thirty random 50% resamples. Adjustment for patient complexity resulted in the greatest rank differences in the best and worst performing deciles, with similar patterns across all tested thresholds. Conclusion Adjustment for complexity resulted in large differences in identified best and worst performers at all tested thresholds. Current performance measures of glycemic control may not be reliably identifying quality problems, and tying reimbursements to such measures may compromise the care of complex patients.
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Affiliation(s)
- Monika M Safford
- Deep South Center on Effectiveness at Birmingham VA Medical Center and University of Alabama at Birmingham, Birmingham, AL, USA.
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Glance LG, Dick A, Mukamel DB, Li Y, Osler TM. Are high-quality cardiac surgeons less likely to operate on high-risk patients compared to low-quality surgeons? Evidence from New York State. Health Serv Res 2008; 43:300-12. [PMID: 18211531 DOI: 10.1111/j.1475-6773.2007.00753.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
CONTEXT It is unknown whether high-risk cardiac surgical patients have less access to high-quality surgeons compared with lower-risk patients. OBJECTIVE To determine whether high-quality surgeons are less likely to perform coronary artery bypass graft (CABG) surgery on high-risk patients compared with low-quality surgeons. DESIGN, SETTING, AND PATIENTS Retrospective cohort study using the New York State (NYS) CABG Surgery Reporting System (CSRS) of all patients undergoing CABG surgery in NYS who were discharged between 1997 and 1999 (51,750 patients; 2.20 percent mortality). Regression modeling was used to estimate the association between surgeon quality and patient risk of death. Surgeon quality was quantified using the observed-to-expected mortality ratio (O-to-E ratio). RESULTS Higher-risk patients are more likely to receive CABG surgery from higher-quality surgeons. For every 10 percentage point increase in patient risk of death (e.g., from 5 to 15 percent), there is an absolute reduction of 0.034 in the surgeon O-to-E ratio (p < .001). CONCLUSION This study suggests that high-risk CABG patients are significantly more likely to receive care from high-quality surgeons compared with lower risk patients.
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Affiliation(s)
- Laurent G Glance
- Department of Anesthesiology, University of Rochester Medical Center, 601 Elmwood Avenue, PO Box 604, Rochester, NY 14642, USA
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