Explaining racial/ethnic disparities in use of high-volume hospitals: decision-making complexity and local hospital environments

Association Between Historical Redlining and Access to High-Volume Hospitals Among Patients Undergoing Complex Cancer Surgery in California

BACKGROUND

We sought to determine the impact of historical redlining on travel patterns and utilization of high-volume hospitals (HVHs) among patients undergoing complex cancer operations.

METHODS

The California Department of Health Care Access and Information database was utilized to identify patients who underwent esophagectomy (ES), pneumonectomy (PN), pancreatectomy (PA), or proctectomy (PR) for cancer between 2010 and 2020. Patient ZIP codes were assigned Home Owners' Loan Corporation grades (A: 'Best'; B: 'Still Desirable'; C: 'Definitely Declining'; and D: 'Hazardous/Redlined'). A clustered multivariable regression was used to assess the likelihood of patients undergoing surgery at an HVH, bypassing the nearest HVH, and total real driving time and travel distance.

RESULTS

Among 14,944 patients undergoing high-risk cancer surgery (ES: 4.7%, n = 1216; PN: 57.8%, n = 8643; PD: 14.4%, n = 2154; PR: 23.1%, n = 3452), 782 (5.2%) individuals resided in the 'Best', whereas 3393 (22.7%) individuals resided in redlined areas. Median travel distance was 7.8 miles (interquartile range [IQR] 4.1-14.4) and travel time was 16.1 min (IQR 10.7-25.8). Overall, 10,763 (ES: 17.4%; PN: 76.0%; PA: 63.5%; PR: 78.4%) patients underwent surgery at an HVH. On multivariable regression, patients residing in redlined areas were less likely to undergo surgery at an HVH (odds ratio [OR] 0.67, 95% confidence interval [CI] 0.54-0.82) and were more likely to bypass the nearest hospital (OR 1.80, 95% CI 1.44-2.46). Notably, Medicaid insurance, minority status, limited English-language proficiency, and educational level mediated the disparities in access to HVH.

CONCLUSION

Surgical disparities in access to HVH among patients from historically redlined areas are largely mediated by social determinants such as insurance and minority status.

Racial and Socioeconomic Disparities in Risk and Reason for Revision in Total Joint Arthroplasty

INTRODUCTION

Data regarding racial/ethnic and socioeconomic differences in revision total hip arthroplasty (rTHA) and revision total knee arthroplasty (rTKA) have been inconsistent. This study examined racial/ethnic and socioeconomic disparities in comorbidity-adjusted risk and reason for rTHA and rTKA.

METHODS

Patients who underwent rTHA or rTKA between 2006 and 2014 in the National Inpatient Sample were identified. Multivariable logistic regression models adjusted for payer status, hospital geographic setting, and patient characteristics (age, sex, and Elixhauser Comorbidity Index) were used to examine the effect of race/ethnicity and socioeconomic status on trends in annual risk of rTHA/rTKA and causes of rTHA/rTKA.

RESULTS

Black patients were less likely to undergo rTHA and more likely to undergo rTKA while Hispanic patients were more likely to undergo rTHA and less likely to undergo rTKA ( P < 0.001 for all) compared with White patients. Patients residing in areas of lower income quartiles were more likely to undergo rTHA and rTKA compared with those in the highest quartile ( P < 0.001), and these disparities persisted and widened over time. Black, Hispanic, and Asian patients were less likely to undergo rTHA/rTKA because of dislocation compared with White patients ( P < 0.001 for all). Patients from areas of lower income quartiles were more likely to undergo rTHA because of septic complications and less likely to require both rTHA and rTKA because of mechanical complications ( P < 0.001 for all).

DISCUSSION

Racial/ethnic and socioeconomic disparities exist in risk and cause of rTHA and rTKA. Increasing awareness and a focus on minimizing variability in hospital quality may help mitigate these disparities.

Quality of Care and Clinical Outcomes for Patients With Heart Failure at Hospitals Caring for a High Proportion of Black Adults: Get With The Guidelines-Heart Failure Registry

Importance

Black adults with heart failure (HF) disproportionately experience higher population-level mortality than White adults with HF. Whether quality of care for HF differs at hospitals with high proportions of Black patients compared with other hospitals is unknown.

Objective

To compare quality and outcomes for patients with HF at hospitals with high proportions of Black patients vs other hospitals.

Design, Setting, and Participants

Patients hospitalized for HF at Get With The Guidelines (GWTG) HF sites from January 1, 2016, through December 1, 2019. These data were analyzed from May 2022 through November 2022.

Exposures

Hospitals caring for high proportions of Black patients.

Main Outcomes and Measures

Quality of HF care based on 14 evidence-based measures, overall defect-free HF care, and 30-day readmissions and mortality in Medicare patients.

Results

This study included 422 483 patients (224 270 male [53.1%] and 284 618 White [67.4%]) with a mean age of 73.0 years. Among 480 hospitals participating in GWTG-HF, 96 were classified as hospitals with high proportions of Black patients. Quality of care was similar between hospitals with high proportions of Black patients compared with other hospitals for 11 of 14 GWTG-HF measures, including use of angiotensin-converting enzyme inhibitors/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitors for left ventricle systolic dysfunction (high-proportion Black hospitals: 92.7% vs other hospitals: 92.4%; adjusted odds ratio [OR], 0.91; 95% CI, 0.65-1.27), evidence-based β-blockers (94.7% vs 93.7%; OR, 1.02; 95% CI, 0.82-1.28), angiotensin receptor neprilysin inhibitors at discharge (14.3% vs 16.8%; OR, 0.74; 95% CI, 0.54-1.02), anticoagulation for atrial fibrillation/flutter (88.8% vs 87.5%; OR, 1.05; 95% CI, 0.76-1.45), and implantable cardioverter-defibrillator counseling/placement/prescription at discharge (70.9% vs 71.0%; OR, 0.75; 95% CI, 0.50-1.13). Patients at high-proportion Black hospitals were less likely to be discharged with a follow-up visit made within 7 days or less (70.4% vs 80.1%; OR, 0.68; 95% CI, 0.53-0.86), receive cardiac resynchronization device placement/prescription (50.6% vs 53.8%; OR, 0.63; 95% CI, 0.42-0.95), or an aldosterone antagonist (50.4% vs 53.5%; OR, 0.69; 95% CI, 0.50-0.97). Overall defect-free HF care was similar between both groups of hospitals (82.6% vs 83.4%; OR, 0.89; 95% CI, 0.67-1.19) and there were no significant within-hospital differences in quality for Black patients vs White patients. Among Medicare beneficiaries, the risk-adjusted hazard ratio (HR) for 30-day readmissions was higher at high-proportion Black vs other hospitals (HR, 1.14; 95% CI, 1.02-1.26), but similar for 30-day mortality (HR 0.92; 95% CI,0.84-1.02).

Conclusions and Relevance

Quality of care for HF was similar across 11 of 14 measures at hospitals caring for high proportions of Black patients compared with other hospitals, as was overall defect-free HF care. There were no significant within-hospital differences in quality for Black patients vs White patients.

Ambulance Transport Destinations In The US Differ By Patient Race And Ethnicity

Patients in the US belonging to racial or ethnic minority groups often receive medical care in different hospitals than White patients, which contributes to health care disparities. We explored whether ambulance transport destinations contribute to this phenomenon. Using a national emergency medical services research data set for calendar year 2020, we made within-ZIP code comparisons of the transport destinations for White patients and non-White patients transported by ambulance from emergency scenes. We used the dissimilarity index to measure transport destination discordances and decided a priori that a more than 5 percent difference in transport destinations (that is, dissimilarity index >0.05) would be practically meaningful. We found meaningful differences in the destination hospitals for White and non-White patients transported by ambulance from locations in the same ZIP code. The median ZIP code dissimilarity index was 0.08, 64 percent of ZIP codes had a dissimilarity index above 0.05, and 61 percent of patients were transported from ZIP codes with a dissimilarity index above 0.05. Forty-one percent of ZIP codes had a dissimilarity index above 0.10, and one-third of the patients were transported from those ZIP codes. These data indicate that ambulance transport destinations contribute to discordances in where White and non-White patients receive medical care.

The Effects of Social and Demographic Factors on High-Volume Hospital and Surgeon Care in Shoulder Arthroplasty

INTRODUCTION

This study seeks to evaluate (1) the relationship between hospital and surgeon volumes of shoulder arthroplasty and complication rates and (2) patient demographics/socioeconomic factors that may affect access to high-volume shoulder arthroplasty care.

METHODS

Adults older than 40 years who underwent shoulder arthroplasty between 2011 and 2015 were identified in the New York Statewide Planning and Research Cooperative System database using International Classification of Disease 9/10 and Current Procedural Terminology codes. Medical/surgical complications were compared across surgeon and facility volumes. The effects of demographic factors were analyzed to determine the relationship between such factors and surgeon/facility volume in shoulder arthroplasty.

RESULTS

Seven thousand seven hundred eighty-five patients were included. Older, Hispanic/African American, socially deprived, nonprivately insured patients were more likely to be treated by low-volume facilities. Low-volume facilities had higher rates of readmission, urinary tract infection, renal failure, pneumonia, and cellulitis than high-volume facilities. Low-volume surgeons had patients with longer hospital lengths of stay.

DISCUSSION

Important differences in patient socioeconomic factors exist in access to high-volume surgical care in shoulder arthroplasty, with older, minority, and underinsured patients markedly more likely to receive care by low-volume surgeons and facilities. This may highlight an area of potential focus to improve access to high-volume care.

Use of Flap Salvage for Lower Extremity Chronic Wounds Occurs Most Often in Competitive Hospital Markets

Wounds in the comorbid population require limb salvage to prevent amputation. Extensive health economics literature demonstrates that hospital activities are influenced by level of market concentration. The impact of competition and market concentration on limb salvage remains to be determined.

Methods

Admissions for chronic lower extremity wounds in nonrural hospitals were identified in the 2010-2011 National Inpatient Survey using ICD-9-CM diagnosis codes. The study cohort consisted of admitted patients receiving amputations, salvage without flap techniques (eg, skin grafts), or salvage with flap techniques. The all-service Herfindahl-Hirschman Index (HHI), which is a commonly used tool for market and antitrust analyses, was used to measure hospital competition. Multinomial regression analysis accounting for the complex survey design of the NIS was used to determine the relationship between the HHI and hospital adoption of limb salvage controlling for patient, hospital, and market factors.

Results

The study cohort represents 124,836 admissions nationally: 89,880 amputations, 26,715 salvage without flap techniques, and 8241 salvage flap techniques. Diabetics accounted for 64.1% of all study admissions. Hospitals in highly competitive markets performed more flaps for chronic lower extremity wounds than noncompetitive markets. Controlling for other factors, hospitals in highly competitive markets, relative to those in highly concentrated markets, were 2.48 percentage points more likely to perform limb salvage with flaps (P < 0.01). Other factors were less predictive.

Conclusion

Increased hospital competition is the strongest systems-level predictor of receipt of lower extremity flaps among patients with chronic wounds. Improving access to reconstructive limb services must consider the competitive structure of hospital markets.

Do informed consumers in Taiwan favour larger hospitals? A 10-year population-based study on differences in the selection of healthcare providers among medical professionals, their relatives and the general population

OBJECTIVES

Exploring whether medical professionals, who are considered to be 'informed consumers' in the healthcare system, favour large providers for elective treatments. In this study, we compare the inclination of medical professionals and their relatives undergoing treatment for childbirth and cataract surgery at medical centres, against those of the general population.

DESIGN

Retrospective study using a population-based matched cohort data.

PARTICIPANTS

Patients who underwent childbirth or cataract surgery between 1 January 2004 and 31 December 2013.

PRIMARY AND SECONDARY OUTCOMES MEASURES

We used multiple logistic regression to compare the ORs of medical professionals and their relatives undergoing treatment at medical centres, against those of the general population. We also compared the rate of 14-day re-admission (childbirth) and 14-day reoperation (cataract surgery) after discharge between these groups.

RESULTS

Multivariate analysis showed that physicians were more likely than patients with no familial connection to the medical profession to undergo childbirth at medical centres (OR 5.26, 95% CI 3.96 to 6.97, p<0.001), followed by physicians' relatives (OR 2.68, 95% CI 2.20 to 3.25, p<0.001). Similarly, physicians (OR 1.63, 95% CI 1.21 to 2.19, p<0.01) and their relatives (OR 1.43, 95% CI 1.13 to 1.81, p<0.01) were also more likely to undergo cataract surgery at medical centres. Physicians also tended to select healthcare providers who were at the same level or above the institution at which they worked. We observed no significant difference in 14-day re-admission rates after childbirth and no significant difference in 14-day reoperation rates after cataract surgery across patient groups.

CONCLUSIONS

Medical professionals and their relatives are more likely than the general population to opt for service at medical centres. Understanding the reasons that medical professionals and general populations both have a preferential bias for larger medical institutions could help improve the efficiency of healthcare delivery.

Medicaid Expansion and Disparity Reduction in Surgical Cancer Care at High-Quality Hospitals

BACKGROUND

The Affordable Care Act's Medicaid expansion has been heavily debated due to skepticism about Medicaid's ability to provide high-quality care. Particularly, little is known about whether Medicaid expansion improves access to surgical cancer care at high-quality hospitals. To address this question, we examined the effects of the 2001 New York Medicaid expansion, the largest in the pre-Affordable Care Act era, on this disparity measure.

STUDY DESIGN

We identified 67,685 nonelderly adults from the New York State Inpatient Database who underwent select cancer resections. High-quality hospitals were defined as high-volume or low-mortality hospitals. Disparity was defined as model-adjusted difference in percentage of patients receiving operations at high-quality hospitals by insurance type (Medicaid/uninsured vs privately insured) or by race (African American vs white). Levels of disparity were calculated quarterly for each comparison pair and then analyzed using interrupted time series to evaluate the impact of Medicaid expansion.

RESULTS

Disparity in access to high-volume hospitals by insurance type was reduced by 0.97 percentage points per quarter after Medicaid expansion (p < 0.0001). Medicaid/uninsured beneficiaries had similar access to low-mortality hospitals as the privately insured; no significant change was detected around expansion. Conversely, racial disparity increased by 0.87 percentage points per quarter (p < 0.0001) in access to high-volume hospitals and by 0.48 percentage points per quarter (p = 0.005) in access to low-mortality hospitals after Medicaid expansion.

CONCLUSIONS

Pre-Affordable Care Act Medicaid expansion reduced the disparity in access to surgical cancer care at high-volume hospitals by payer. However, it was associated with increased racial disparity in access to high-quality hospitals. Addressing racial barriers in access to high-quality hospitals should be prioritized.