The concentration of hospital care for black veterans in Veterans Affairs hospitals: implications for clinical outcomes

Reexamining Differences Between Black and White Veterans in Hospital Mortality and Other Outcomes in Veterans Affairs and Other Hospitals

OBJECTIVES

To examine Black-White patient differences in mortality and other hospital outcomes among Veterans treated in Veterans Affairs (VA) and non-VA hospitals.

BACKGROUND

Lower hospital mortality has been documented in older Black patients relative to White patients, yet the mechanisms have not been determined. Comparing other hospital outcomes and multiple hospital systems may help inform the reasons for these differences.

METHODS

Repeated cross-sectional analysis of hospitalization records was conducted for Veterans discharged in VA and non-VA hospitals from January 1, 2013 to December 31, 2017 in 11 states. Hospital outcomes included 30-day mortality, 30-day readmissions, inpatient costs, and length of stay. Hospitalizations were for acute myocardial infarction, coronary artery bypass graft surgery, gastrointestinal bleeding, heart failure, pneumonia, and stroke. Differences in outcomes were estimated between Black and White patients for VA and non-VA hospitals and age groups younger than 65 years or 65 years and older in regression models adjusting for patient and hospital factors.

RESULTS

There were a total of 459,574 study patients. Older Black patients had lower adjusted mortality for acute myocardial infarction, gastrointestinal bleeding, heart failure, and pneumonia. Adjusted probability of readmission was higher and adjusted mean length of stay and costs were greater for older Black patients relative to White patients in non-VA hospitals for several conditions. Fewer differences were observed in younger patients and in VA hospitals.

CONCLUSION

While older Black patients had lower mortality, other outcomes compared poorly with White patients. Differences were not fully explained by observable patient and hospital factors although social determinants may contribute to these differences.

Racial and Ethnic Disparities in Stroke Reperfusion Therapy in the USA

Racial and ethnic inequities in stroke care are ubiquitous. Acute reperfusion therapies, i.e., IV thrombolysis (IVT) and mechanical thrombectomy (MT), are central to acute stroke care and are highly efficacious at preventing death and disability after stroke. Disparities in the use of IVT and MT in the USA are pervasive and contribute to worse outcomes among racial and ethnic minority individuals with ischemic stroke. A meticulous understanding of disparities and underlying root causes is necessary in order to develop targeted mitigation strategies with lasting effects. This review details racial and ethnic disparities in the use of IVT and MT after stroke and highlights inequities in the underlying process measures as well as the contributing root causes. Furthermore, this review spotlights the systemic and structural inequities that contribute to race-based differences in the use of IVT and MT, including geographic and regional differences and differences based on neighborhood, zip code, and hospital type. In addition, recent promising trends suggesting improvements in racial and ethnic IVT and MT disparities and potential approaches for future solutions to achieve equity in stroke care are briefly discussed.

Evaluation of Changes in Veterans Affairs Medical Centers' Mortality Rates After Risk Adjustment for Socioeconomic Status

IMPORTANCE

Socioeconomic factors are associated with worse outcomes after hospitalization, but neither the Centers for Medicare & Medicaid Services (CMS) nor the Veterans Affairs (VA) health care system adjust for socioeconomic factors in profiling hospital mortality.

OBJECTIVE

To evaluate changes in Veterans Affairs medical centers' (VAMCs') risk-standardized mortality rates among veterans hospitalized for heart failure and pneumonia after adjusting for socioeconomic factors.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, retrospective data were used to assess 131 VAMCs' risk-standardized 30-day mortality rates with or without adjustment for socioeconomic covariates. The study population included 42 892 veterans hospitalized with heart failure and 39 062 veterans hospitalized with pneumonia from January 1, 2012, to December 31, 2014. Data were analyzed from March 1, 2019, to April 1, 2020.

MAIN OUTCOMES AND MEASURES

The primary outcome was 30-day mortality after admission. Socioeconomic covariates included neighborhood disadvantage, race/ethnicity, homelessness, rurality, nursing home residence, reason for Medicare eligibility, Medicaid and Medicare dual eligibility, and VA priority.

RESULTS

The study population included 42 892 veterans hospitalized with heart failure (98.2% male; mean [SD] age, 71.9 [11.4] years) and 39 062 veterans hospitalized with pneumonia (96.8% male; mean [SD] age, 71.0 [12.4] years). The addition of socioeconomic factors to the CMS models modestly increased the C statistic from 0.77 (95% CI, 0.77-0.78) to 0.78 (95% CI, 0.78-0.78) for 30-day mortality after heart failure and from 0.73 (95% CI, 0.72-0.73) to 0.74 (95% CI, 0.73-0.74) for 30-day mortality after pneumonia. Mortality rates were highly correlated (Spearman correlations of ≥0.98) in models that included or did not include socioeconomic factors. With the use of the CMS model for heart failure, VAMCs in the lowest quintile had a mean (SD) mortality rate of 6.0% (0.4%), those in the middle 3 quintiles had a mean (SD) mortality rate of 7.2% (0.4%), and those in the highest quintile had a mean (SD) mortality rate of 8.8% (0.6%). After the inclusion of socioeconomic covariates, the adjusted mean (SD) mortality was 6.1% (0.4%) for hospitals in the lowest quintile, 7.2% (0.4%) for those in the middle 3 quintiles, and 8.6% (0.5%) for those in the highest quintile. The mean absolute change in rank after socioeconomic adjustment was 3.0 ranking positions (interquartile range, 1.0-4.0) among hospitals in the highest quintile of mortality after heart failure and 4.4 ranking positions (interquartile range, 1.0-6.0) among VAMCs in the lowest quintile. Similar findings were observed for mortality rankings in pneumonia and after inclusion of clinical covariates.

CONCLUSIONS AND RELEVANCE

This study suggests that adjustments for socioeconomic factors did not meaningfully change VAMCs' risk-adjusted 30-day mortality rates for veterans hospitalized for heart failure and pneumonia. The implications of such adjustments should be examined for other quality measures and health systems.

Graph Theoretical Analysis of Genome-Scale Data: Examination of Gene Activation Occurring in the Setting of Community-Acquired Pneumonia

INTRODUCTION

We have previously reported evidence that Black individuals appear to have a significantly higher incidence of infection-related hospitalizations compared with White individuals. It is possible that the host immune response is responsible for this vital difference. In support of such a hypothesis, the aim of this study was to determine whether Black and White individuals exhibit differential whole blood gene network activation.

METHODS

We examined whole blood network activation in a subset of patients (n = 22 pairs, propensity score matched (1:1) Black and White patients) with community-acquired pneumonia (CAP) from the Genetic and Inflammatory Markers of Sepsis study. We employed day one whole blood transcriptomic data generated from this cohort and constructed co-expression graphs for each racial group. Pearson correlation coefficients were used to weight edges. Spectral thresholding was applied to ascribe significance. Innovative graph theoretical methods were then invoked to detect densely connected gene networks and provide differential structural analysis.

RESULTS

Propensity matching was employed to reduce potential bias due to confounding variables. Although Black and White patients had similar socio- and clinical demographics, we identified novel differences in molecular network activation-dense subgraphs known as paracliques that displayed complete gene connection for both White (three paracliques) and Black patients (one paraclique). Specifically, the genes that comprised the paracliques in the White patients include circadian loop, cell adhesion, mobility, proliferation, tumor suppression, NFκB, and chemokine signaling. However, the genes that comprised the paracliques in the Black patients include DNA and messenger RNA processes, and apoptosis signaling. We investigated the distribution of Black paracliques across White paracliques. Black patients had five paracliques (with almost complete connection) comprised of genes that are critical for host immune response widely distributed across 22 parcliques in the White population. Anchoring the analysis on two critical inflammatory mediators, interleukin (IL)-6 and IL-10 identified further differential network activation among the White and Black patient populations.

CONCLUSIONS

These results demonstrate that, at the molecular level, Black and White individuals may experience different activation patterns with CAP. Further validation of the gene networks we have identified may help pinpoint genetic factors that increase host susceptibility to community-acquired pneumonia, and may lay the groundwork for personalized management of CAP.

Individual and System Contributions to Race and Sex Disparities in Thrombolysis Use for Stroke Patients in the United States

BACKGROUND AND PURPOSE

Intravenous thrombolysis (IVT) is underutilized in ethnic minorities and women. To disentangle individual and system-based factors determining disparities in IVT use, we investigated race/sex differences in IVT utilization among hospitals serving varying proportions of minority patients.

METHODS

Ischemic stroke admissions were identified from the Nationwide Inpatient Sample between 2007 and 2011. Hospitals were categorized based on the percentage of minority patients admitted with stroke (<25% minority patients [white hospitals], 25% to 50% minority patients [mixed hospitals], or >50% minority patients [minority hospitals]). Logistic regression was used to evaluate the association between race/sex and IVT use within and between the different hospital strata.

RESULTS

Among 337 201 stroke admissions, white men had the highest odds of IVT among all race/sex groups in any hospital strata, and the odds of IVT for white men did not differ by hospital strata. For white women and minority men, the odds of IVT were significantly lower in minority hospitals compared with white hospitals (odds ratio, 0.83; 95% confidence interval, 0.71-0.97, for white women; and odds ratio, 0.82; 95% confidence interval, 0.69-0.99, for minority men). Race disparities in IVT use among women were observed in white hospitals (odds ratio, 0.88; 95% confidence interval, 0.78-0.99, in minority compared with white women), but not in minority hospitals (odds ratio, 0.94, 95% confidence interval, 0.82-1.09). Sex disparities in IVT use were observed among whites but not among minorities.

CONCLUSIONS

Minority men and white women have significantly lower odds of IVT in minority hospitals compared with white hospitals. IVT use in white men does not differ by hospital strata.

Methods for Measuring Racial Differences in Hospitals Outcomes Attributable to Disparities in Use of High-Quality Hospital Care

OBJECTIVE

To compare two approaches to measuring racial/ethnic disparities in the use of high-quality hospitals.

DATA SOURCES

Simulated data.

STUDY DESIGN

Through simulations, we compared the "minority-serving" approach of assessing differences in risk-adjusted outcomes at minority-serving and non-minority-serving hospitals with a "fixed-effect" approach that estimated the reduction in adverse outcomes if the distribution of minority and white patients across hospitals was the same. We evaluated each method's ability to detect and measure a disparity in outcomes caused by minority patients receiving care at poor-quality hospitals, which we label a "between-hospital" disparity, and to reject it when the disparity in outcomes was caused by factors other than hospital quality.

PRINCIPAL FINDINGS

The minority-serving and fixed-effect approaches correctly identified between-hospital disparities in quality when they existed and rejected them when racial differences in outcomes were caused by other disparities; however, the fixed-effect approach has many advantages. It does not require an ad hoc definition of a minority-serving hospital, and it estimated the magnitude of the disparity accurately, while the minority-serving approach underestimated the disparity by 35-46 percent.

CONCLUSIONS

Researchers should consider using the fixed-effect approach for measuring disparities in use of high-quality hospital care by vulnerable populations.

The Quality of Surgical and Pneumonia Care in Minority-Serving and Racially Integrated Hospitals

OBJECTIVE

To explore the association between quality of care for surgical and pneumonia patients and the racial/ethnic composition of hospitals' patients.

DATA SOURCE

Our primary data were surgical and pneumonia processes of care indicators from the 2012 Medicare Hospital Compare Data. We merged this data with information from the 2011 American Hospital Association Annual Survey of Hospitals. We computed the racial and ethnic composition of hospital patients using 2008 data from the Healthcare Costs and Utilization Project.

STUDY DESIGN

The sample included 1,198 acute care general hospitals from 11 states: AZ, CA, FL, IA, MA, MD, NC, NJ, NY, WA, and WI. We compared quality across minority-serving, racially integrated, and majority-white hospitals using unconditional quantile regression models controlling for hospital and market characteristics.

PRINCIPAL FINDINGS

We found quality differences between the lowest performing minority-serving, racially integrated, and majority-white hospitals. As we moved from 10th to 90th quantile, the quality differences between hospitals by patients' racial composition disappeared. In other words, the best minority-serving and racially integrated hospitals performed as well as the best majority hospitals.

CONCLUSIONS

Efforts to improve quality of care for patients in minority-serving and racially integrated hospitals should focus on the lowest performers.

Differences in pneumonia treatment between high-minority and low-minority neighborhoods with clinical decision support system implementation

BACKGROUND

The relationship between clinical decision support systems (CDSS) and quality is a relatively new, and in light of the new health information technology (HIT) legislation, policy-relevant area. Moreover, very few studies exist examining the link between HIT and healthcare disparities. The purpose of this article is to examine the association between CDSS and the treatment of pneumonia care within high-minority (≥29.1% non-White, non-Hispanic) and low-minority (<29.1%) Zip Code Tabulation Areas (ZCTAs).

RESEARCH DESIGN

This study employed a cross-sectional design and used 2009 data from the American Hospital Association, the Centers for Medicare and Medicaid Services and the Research Triangle Institute. Adjusted analysis controlled for a hospital's propensity to use CDSS.

RESULTS

In the unadjusted analysis, hospitals in high-minority ZCTAs had lower pneumonia quality composite scores than their low-minority counterparts. When adjusting for other hospital and ZCTA-level variables, we found that CDSS use had stronger positive associations with quality in high-minority hospitals.

CONCLUSIONS

Results support policy directives may support higher quality improvements by focusing CDSS adoption in high-minority hospitals.

Racial disparities in cancer care in the Veterans Affairs health care system and the role of site of care

OBJECTIVES

We assessed cancer care disparities within the Veterans Affairs (VA) health care system and whether between-hospital differences explained disparities.

METHODS

We linked VA cancer registry data with VA and Medicare administrative data and examined 20 cancer-related quality measures among Black and White veterans diagnosed with colorectal (n = 12,897), lung (n = 25,608), or prostate (n = 38,202) cancer from 2001 to 2004. We used logistic regression to assess racial disparities for each measure and hospital fixed-effects models to determine whether disparities were attributable to between- or within-hospital differences.

RESULTS

Compared with Whites, Blacks had lower rates of early-stage colon cancer diagnosis (adjusted odds ratio [AOR] = 0.80; 95% confidence interval [CI] = 0.72, 0.90), curative surgery for stage I, II, or III rectal cancer (AOR = 0.57; 95% CI = 0.41, 0.78), 3-year survival for colon cancer (AOR = 0.75; 95% CI = 0.62, 0.89) and rectal cancer (AOR = 0.61; 95% CI = 0.42, 0.87), curative surgery for early-stage lung cancer (AOR = 0.50; 95% CI = 0.41, 0.60), 3-dimensional conformal or intensity-modulated radiation (3-D CRT/IMRT; AOR = 0.53; 95% CI = 0.47, 0.59), and potent antiemetics for highly emetogenic chemotherapy (AOR = 0.87; 95% CI = 0.78, 0.98). Adjustment for hospital fixed-effects minimally influenced racial gaps except for 3-D CRT/IMRT (AOR = 0.75; 95% CI = 0.65, 0.87) and potent antiemetics (AOR = 0.95; 95% CI = 0.82, 1.10).

CONCLUSIONS

Disparities in VA cancer care were observed for 7 of 20 measures and were primarily attributable to within-hospital differences.

Lower use of carotid artery imaging at minority-serving hospitals

OBJECTIVE

We determined whether site of care explains a previously identified racial disparity in carotid artery imaging.

METHODS

In this retrospective cohort study, data were obtained from a chart review of veterans hospitalized with ischemic stroke at 127 Veterans Administration hospitals in 2007. Extensive exclusion criteria were applied to obtain a sample who should have received carotid artery imaging. Minority-serving hospitals were defined as the top 10% of hospitals ranked by the proportion of stroke patients who were black. Population level multivariate logistic regression models with adjustment for correlation of patients in hospitals were used to calculate predictive probabilities of carotid artery imaging by race and minority-service hospital status. Bootstrapping was used to obtain 95% confidence intervals (CIs).

RESULTS

The sample consisted of 1,534 white patients and 628 black patients. Nearly 40% of all black patients were admitted to 1 of 13 minority-serving hospitals. No racial disparity in receipt of carotid artery imaging was detected within nonminority serving hospitals. However, the predicted probability of receiving carotid artery imaging for white patients at nonminority-serving hospitals (89.7%, 95% CI [87.3%, 92.1%]) was significantly higher than both white patients (78.0% [68.3%, 87.8%] and black patients (70.5% [59.3%, 81.6%]) at minority-serving hospitals.

CONCLUSIONS

Underuse of carotid artery imaging occurred most often among patients hospitalized at minority-serving hospitals. Further work is required to explore why site of care is a mechanism for racial disparities in this clinically important diagnostic test.

Association between hospitals caring for a disproportionately high percentage of minority trauma patients and increased mortality: a nationwide analysis of 434 hospitals

OBJECTIVE

To determine whether there is an increased odds of mortality among trauma patients treated at hospitals with higher proportions of minority patients (ie, black and Hispanic patients combined).

DESIGN

Hospitals were categorized on the basis of the percentage of minority patients admitted with trauma. The adjusted odds of in-hospital mortality were compared between hospitals with less than 25% of patients who were minorities (the reference group) and hospitals with 25% to 50% of patients who were minorities and hospitals with more than 50% of patients who were minorities. Multivariate logistic regression (with generalized linear modeling and a cluster-correlated robust estimate of variance) was used to control for multiple patient and injury severity characteristics.

SETTING

A total of 434 hospitals in the National Trauma Data Bank.

PARTICIPANTS

Patients aged 18 to 64 years whose medical records were included in the National Trauma Data Bank for the years 2007 and 2008 with an Injury Severity Score of 9 or greater and who were white, black, or Hispanic.

MAIN OUTCOME MEASURES

Crude mortality and adjusted odds of in-hospital mortality.

RESULTS

A total of 311,568 patients were examined. Hospitals in which the percentage of minority patients was more than 50% also had younger patients, fewer female patients, more patients with penetrating trauma, and the highest crude mortality. After adjustment for potential confounders, patients treated at hospitals in which the percentage of minority patients was 25% to 50% and at hospitals in which the percentage of minority patients was more than 50% demonstrated increased odds of death (adjusted odds ratio, 1.16 [95% confidence interval, 1.01-1.34] and adjusted odds ratio, 1.37 [95% confidence interval, 1.16-1.61], respectively), compared with the reference group. This disparity increased further on subset analysis of patients with a blunt injury. Uninsured patients had significantly increased odds of mortality within all 3 hospital groups.

CONCLUSIONS

Patients treated at hospitals with higher proportions of minority trauma patients have increased odds of dying, even after adjusting for potential confounders. Differences in outcomes between trauma hospitals may partly explain racial disparities.