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Hsia RY, Shen YC. Structural Inequities In The Adoption Of Percutaneous Coronary Intervention Services By US Hospitals, 2000-20. Health Aff (Millwood) 2024; 43:1011-1020. [PMID: 38950302 PMCID: PMC11293955 DOI: 10.1377/hlthaff.2023.01649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
Percutaneous coronary intervention (PCI) is a procedure that opens blocked arteries and restores blood flow to the heart. Timely access to hospitals offering PCI services can be a matter of life or death for patients experiencing a heart attack; however, hospitals' adoption of PCI services may vary between communities, posing potential barriers to critical care. Our cohort study of US general acute hospitals during the period 2000-20 examined PCI service adoption across communities stratified by race, ethnicity, income, and rurality and further classified as segregated or integrated. Of 5,260 hospitals, 1,621 offered PCI services in 2020 or before, 630 added PCI services between 2001 and 2010, and 225 added PCI services between 2011 and 2020. Hospitals serving Black, racially segregated communities were 48 percent less likely to adopt PCI services compared with hospitals serving non-Black, racially segregated communities, and hospitals serving Hispanic, ethnically segregated communities were 41 percent less likely to do so than those serving non-Hispanic, ethnically segregated communities. Hospitals in high-income, economically integrated communities were 1.8 times more likely to adopt PCI services than those in high-income, economically segregated communities, and rural hospitals were less likely to do so than urban hospitals. Understanding where services are expanding in relation to community need may aid in successful policy interventions.
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Affiliation(s)
- Renee Y Hsia
- Renee Y. Hsia , University of California San Francisco, San Francisco, California
| | - Yu-Chu Shen
- Yu-Chu Shen, Naval Postgraduate School, Monterey, California; and National Bureau of Economic Research, Cambridge, Massachusetts
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2
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Kim H, Mahmood A, Kedia S, Ogunsanmi DO, Sharma S, Wyant DK. Impact of Residential Segregation on Healthcare Utilization and Perceived Quality of Care Among Informal Caregivers in the United States. J Racial Ethn Health Disparities 2024:10.1007/s40615-024-02018-9. [PMID: 38758399 DOI: 10.1007/s40615-024-02018-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/10/2024] [Accepted: 05/06/2024] [Indexed: 05/18/2024]
Abstract
This study aimed to investigate the impact of racial residential segregation on healthcare utilization and perceived quality of care among informal caregivers in the US. It further assessed potential variations in the estimated impact across caregivers' race and socioeconomic status. We used data from the Health Information National Trends Survey Data Linkage Project (fielded in 2020) for a sample of 583 self-identified informal caregivers in the US. Fitting a series of regression models with the maximum likelihood estimation, we computed the beta coefficients (β) of interest and their associated Wald 95% confidence limits (CI). Caregivers who resided in areas with higher segregation, compared to those living in lower segregated areas, were less likely to visit a healthcare professional [β = - 2.08; Wald 95%CI - 2.093, - 2.067] (moderate); [β = - 2.53; Wald 95%CI - 2.549, - 2.523] (high)]. Further, caregivers residing in moderate [β = - 0.766; Wald 95%CI - 0.770, - 0.761] and high [β = - 0.936; Wald 95%CI - 0.941, - 0.932] segregation regions were less likely to perceive a better quality of care compared to those located in low segregation areas. Moreover, as segregation level increased, Black caregivers were less likely to see a health professional, less frequently used healthcare services, and had poorer perceived healthcare quality when compared to Whites. Our findings indicate that higher residential segregation is associated with lower healthcare utilization, such as visiting a healthcare professional, and poorer perceived healthcare quality among informal caregivers. Given the essential role of informal caregivers in the current healthcare system, it is vital to investigate and address challenges associated with access to and quality of essential healthcare services to improve caregivers' health and well-being, specifically for caregivers of minority backgrounds.
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Affiliation(s)
- Hyunmin Kim
- College of Nursing and Health Professions, School of Health Professions, The University of Southern Mississippi, Hattiesburg, MS, USA
| | - Asos Mahmood
- Center for Health System Improvement, College of Medicine, University of Tennessee Health Science Center, 956 Court Ave Avenue, Ste D222A, Memphis, TN, 38103, USA.
- Department of Medicine-General Internal Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Satish Kedia
- Division of Social and Behavioral Sciences, School of Public Health, The University of Memphis, Memphis, TN, USA
| | - Deborah O Ogunsanmi
- Tennessee Population Health Consortium and Institute for Health Outcomes and Policy Research, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Sadikshya Sharma
- College of Nursing and Health Professions, School of Health Professions, The University of Southern Mississippi, Hattiesburg, MS, USA
| | - David K Wyant
- Jack C. Massey College of Business, Frist College of Medicine, Belmont University, Nashville, TN, USA
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3
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Zhilkova A, Alsabahi L, Olson D, Maru D, Tsao TY, Morse ME. Hospital segregation, critical care strain, and inpatient mortality during the COVID-19 pandemic in New York City. PLoS One 2024; 19:e0301481. [PMID: 38603670 PMCID: PMC11008816 DOI: 10.1371/journal.pone.0301481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 03/16/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Hospital segregation by race, ethnicity, and health insurance coverage is prevalent, with some hospitals providing a disproportionate share of undercompensated care. We assessed whether New York City (NYC) hospitals serving a higher proportion of Medicaid and uninsured patients pre-pandemic experienced greater critical care strain during the first wave of the COVID-19 pandemic, and whether this greater strain was associated with higher rates of in-hospital mortality. METHODS In a retrospective analysis of all-payer NYC hospital discharge data, we examined changes in admissions, stratified by use of intensive care unit (ICU), from the baseline period in early 2020 to the first COVID-19 wave across hospital quartiles (265,329 admissions), and crude and risk-adjusted inpatient mortality rates, also stratified by ICU use, in the first COVID wave across hospital quartiles (23,032 inpatient deaths), based on the proportion of Medicaid or uninsured admissions from 2017-2019 (quartile 1 lowest to 4 highest). Logistic regressions were used to assess the cross-sectional association between ICU strain, defined as ICU volume in excess of the baseline average, and patient-level mortality. RESULTS ICU admissions in the first COVID-19 wave were 84%, 97%, 108%, and 123% of the baseline levels by hospital quartile 1-4, respectively. The risk-adjusted mortality rates for ICU admissions were 36.4 (CI = 34.7,38.2), 43.6 (CI = 41.5,45.8), 45.9 (CI = 43.8,48.1), and 45.7 (CI = 43.6,48.0) per 100 admissions, and those for non-ICU admissions were 8.6 (CI = 8.3,9.0), 10.9 (CI = 10.6,11.3), 12.6 (CI = 12.1,13.0), and 12.1 (CI = 11.6,12.7) per 100 admissions by hospital quartile 1-4, respectively. Compared with the reference group of 100% or less of the baseline weekly average, ICU admissions on a day for which the ICU volume was 101-150%, 151-200%, and > 200% of the baseline weekly average had odds ratios of 1.17 (95% CI = 1.10, 1.26), 2.63 (95% CI = 2.31, 3.00), and 3.26 (95% CI = 2.82, 3.78) for inpatient mortality, and non-ICU admissions on a day for which the ICU volume was 101-150%, 151-200%, and > 200% of the baseline weekly average had odds ratios of 1.28 (95% CI = 1.22, 1.34), 2.60 (95% CI = 2.40, 2.82), and 3.44 (95% CI = 3.11, 3.63) for inpatient mortality. CONCLUSIONS Our findings are consistent with hospital segregation as a potential driver of COVID-related mortality inequities and highlight the need to desegregate health care to address structural racism, advance health equity, and improve pandemic resiliency.
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Affiliation(s)
- Anna Zhilkova
- Center for Health Equity and Community Wellness at the New York City Department of Health and Mental Hygiene, Long Island City, NY, United States of America
| | - Laila Alsabahi
- Center for Health Equity and Community Wellness at the New York City Department of Health and Mental Hygiene, Long Island City, NY, United States of America
| | - Donald Olson
- Center for Health Equity and Community Wellness at the New York City Department of Health and Mental Hygiene, Long Island City, NY, United States of America
| | - Duncan Maru
- Center for Health Equity and Community Wellness at the New York City Department of Health and Mental Hygiene, Long Island City, NY, United States of America
| | - Tsu-Yu Tsao
- Center for Health Equity and Community Wellness at the New York City Department of Health and Mental Hygiene, Long Island City, NY, United States of America
| | - Michelle E. Morse
- Center for Health Equity and Community Wellness at the New York City Department of Health and Mental Hygiene, Long Island City, NY, United States of America
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4
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Popescu I, Gibson B, Matthews L, Zhang S, Escarce JJ, Schuler M, Damberg CL. The segregation of physician networks providing care to black and white patients with heart disease: Concepts, measures, and empirical evaluation. Soc Sci Med 2024; 343:116511. [PMID: 38244361 DOI: 10.1016/j.socscimed.2023.116511] [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: 04/17/2023] [Revised: 11/30/2023] [Accepted: 12/12/2023] [Indexed: 01/22/2024]
Abstract
Black-White disparities in cardiac care may be related to physician referral network segregation. We developed and tested new geographic physician network segregation measures. We used Medicare claims to identify Black and White Medicare heart disease patients and map physician networks for 169 hospital referral regions (HRRs) with over 1000 Black patients. We constructed two network segregation indexes ranging from 0 (integration) to 100 (total segregation): Dissimilarity (the unevenness of Black and White patient distribution across physicians [Dn]) and Absolute Clustering (the propensity of Black patients' physicians to have closer ties with each other than with other physicians [ACLn]). We employed conditional logit models to estimate the probability of using the best (lowest mortality) geographically available hospital for Black and White patients undergoing coronary artery bypass grafting (CABG) surgery in 126 markets with sufficient sample size at increasing levels of network segregation and for low vs. high HRR Black patient population. Physician network segregation was lower than residential segregation (Dissimilarity 21.9 vs. 48.7, and Absolute Clustering 4.8 vs. 32.4) and positively correlated with residential segregation (p < .001). Network segregation effects differed by race and HRR Black patient population. For White patients, higher network segregation was associated with a higher probability of using the best available hospitals in HRRs with few black patients but unchanged (ACLn) or lower (Dn) probability of best hospital use in HRRs with many Black patients. For Black patients, higher network segregation was not associated with a substantial change in the probability of best hospital use regardless of the HRR Black patient population size. Measuring physician network segregation is feasible and associated with nuanced effects on Black-White differences in high-quality hospital use for heart disease. Further work is needed to understand underlying mechanisms and potential uses in health equity policy.
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Affiliation(s)
- Ioana Popescu
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, 1100 Glendon Ave suite 850, Los Angeles, CA, 90024, USA; RAND Corporation, 1776 Main Street, Santa Monica, CA, 90403, USA.
| | - Ben Gibson
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90403, USA.
| | - Luke Matthews
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90403, USA.
| | - Shiyuan Zhang
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90403, USA.
| | - José J Escarce
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, 1100 Glendon Ave suite 850, Los Angeles, CA, 90024, USA.
| | - Megan Schuler
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90403, USA.
| | - Cheryl L Damberg
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90403, USA.
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5
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Jacobs MA, Schmidt S, Hall DE, Stitzenberg KB, Kao LS, Brimhall BB, Wang CP, Manuel LS, Su HD, Silverstein JC, Shireman PK. A Surgical Desirability of Outcome Ranking (DOOR) Reveals Complex Relationships Between Race/Ethnicity, Insurance Type, and Neighborhood Deprivation. Ann Surg 2024; 279:246-257. [PMID: 37450703 PMCID: PMC10787813 DOI: 10.1097/sla.0000000000005994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Develop an ordinal Desirability of Outcome Ranking (DOOR) for surgical outcomes to examine complex associations of Social Determinants of Health. BACKGROUND Studies focused on single or binary composite outcomes may not detect health disparities. METHODS Three health care system cohort study using NSQIP (2013-2019) linked with EHR and risk-adjusted for frailty, preoperative acute serious conditions (PASC), case status and operative stress assessing associations of multilevel Social Determinants of Health of race/ethnicity, insurance type (Private 13,957; Medicare 15,198; Medicaid 2835; Uninsured 2963) and Area Deprivation Index (ADI) on DOOR and the binary Textbook Outcomes (TO). RESULTS Patients living in highly deprived neighborhoods (ADI>85) had higher odds of PASC [adjusted odds ratio (aOR)=1.13, CI=1.02-1.25, P <0.001] and urgent/emergent cases (aOR=1.23, CI=1.16-1.31, P <0.001). Increased odds of higher/less desirable DOOR scores were associated with patients identifying as Black versus White and on Medicare, Medicaid or Uninsured versus Private insurance. Patients with ADI>85 had lower odds of TO (aOR=0.91, CI=0.85-0.97, P =0.006) until adjusting for insurance. In contrast, patients with ADI>85 had increased odds of higher DOOR (aOR=1.07, CI=1.01-1.14, P <0.021) after adjusting for insurance but similar odds after adjusting for PASC and urgent/emergent cases. CONCLUSIONS DOOR revealed complex interactions between race/ethnicity, insurance type and neighborhood deprivation. ADI>85 was associated with higher odds of worse DOOR outcomes while TO failed to capture the effect of ADI. Our results suggest that presentation acuity is a critical determinant of worse outcomes in patients in highly deprived neighborhoods and without insurance. Including risk adjustment for living in deprived neighborhoods and urgent/emergent surgeries could improve the accuracy of quality metrics.
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Affiliation(s)
- Michael A. Jacobs
- Department of Surgery, University of Texas Health San
Antonio, San Antonio, Texas
| | - Susanne Schmidt
- Department of Population Health Sciences, University of
Texas Health San Antonio, San Antonio, Texas
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, and
Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh
Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh,
Pittsburgh, Pennsylvania
- Wolff Center, UPMC, Pittsburgh, Pennsylvania
| | - Karyn B. Stitzenberg
- Department of Surgery, University of North Carolina, Chapel
Hill, North Carolina
| | - Lillian S. Kao
- Department of Surgery, McGovern Medical School, The
University of Texas Health Science Center at Houston, Houston, Texas
| | - Bradley B. Brimhall
- Department of Pathology and Laboratory Medicine, University
of Texas Health San Antonio, San Antonio, Texas
- University Health, San Antonio, Texas
| | - Chen-Pin Wang
- Department of Population Health Sciences, University of
Texas Health San Antonio, San Antonio, Texas
| | - Laura S. Manuel
- UT Health Physicians Business Intelligence and Data
Analytics, University of Texas Health San Antonio, San Antonio, Texas
| | - Hoah-Der Su
- Department of Biomedical Informatics, University of
Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Paula K. Shireman
- Department of Surgery, University of Texas Health San
Antonio, San Antonio, Texas
- Departments of Primary Care & Rural Medicine and
Medical Physiology, School of Medicine, Texas A&M Health, Bryan, Texas
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6
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Pack CE, Partain AT, Crowe RP, Brown LH. Ambulance Transport Destinations In The US Differ By Patient Race And Ethnicity. Health Aff (Millwood) 2023; 42:237-245. [PMID: 36745829 DOI: 10.1377/hlthaff.2022.00628] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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7
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Islek D, Ali MK, Manatunga A, Alonso A, Vaccarino V. Racial Disparities in Hospitalization Among Patients Who Receive a Diagnosis of Acute Coronary Syndrome in the Emergency Department. J Am Heart Assoc 2022; 11:e025733. [PMID: 36129027 PMCID: PMC9673746 DOI: 10.1161/jaha.122.025733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background Timely hospitalization of patients who are diagnosed with an acute coronary syndrome (ACS) at the emergency department (ED) is a crucial step to lower the risk of ACS mortality. We examined whether there are racial and ethnic differences in the risk of being discharged home among patients who received a diagnostic code of ACS at the ED and whether having health insurance plays a role. Methods and Results We examined 51 022 910 discharge records of ED visits in Florida, New York, and Utah in the years 2008, 2011, 2014, and 2016/2017 using state-specific data from the Healthcare Cost and Utilization Project. We identified ED admissions for acute myocardial infarction or unstable angina using the International Classification of Diseases, Ninth Revision (ICD-9)/International Statistical Classification of Diseases, Tenth Revision (ICD-10) diagnostic codes. We used generalized estimating equation models to compare the risk of being discharged home across racial and ethnic groups. We used Poisson marginal structural models to estimate the mediating role of health insurance status. The proportion discharged home with a diagnostic code of ACS was 12% among Black patients, 6% among White patients, 9% among Hispanic patients, and 9% among Asian/Pacific Islander patients. The incidence risk ratio for being discharged home was 1.26 (95% CI, 1.18-1.34) in Black patients, 1.23 (95% CI, 1.15-1.32) in Hispanic patients, and 1.11 (95% CI, 0.93-1.31) in Asian/Pacific Islander patients compared with White patients. Race and ethnicity were marginally associated with discharge home via pathways not mediated by health insurance. Conclusions Racial and ethnic disparities exist in the hospitalization of patients who received a diagnostic code of ACS in the ED. Possible causes need to be investigated.
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Affiliation(s)
- Duygu Islek
- Department of Epidemiology, Rollins School of Public HealthEmory UniversityAtlantaGA,Department of Epidemiology, Laney Graduate SchoolEmory UniversityAtlantaGA
| | - Mohammed K. Ali
- Department of Epidemiology, Rollins School of Public HealthEmory UniversityAtlantaGA,Hubert Department of Global Health, Rollins School of Public HealthEmory UniversityAtlantaGA,Department of Family and Preventive Medicine, School of MedicineEmory UniversityAtlantaGA
| | - Amita Manatunga
- Department of Biostatistics and Bioinformatics, Rollins School of Public HealthEmory UniversityAtlantaGA
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public HealthEmory UniversityAtlantaGA
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public HealthEmory UniversityAtlantaGA,Division of Cardiology, Department of Medicine, School of MedicineEmory UniversityAtlantaGA
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Alhuneafat L, Jabri A, Poornima IG, Alrifai N, Ali M, Elhamdani A, Kyvernitakis A, Al-Abdouh A, Mhanna M, Hadaddin F, Butt M, Cunningham C, Karim S, Ziv O. Ethnic and Racial Disparities in Resource Utilization and In-hospital Outcomes Among Those Admitted for Atrial Fibrillation: A National Analysis. Curr Probl Cardiol 2022; 47:101365. [PMID: 36031016 DOI: 10.1016/j.cpcardiol.2022.101365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 08/16/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Disparities in overall outcomes for atrial fibrillation (AF) across racial and ethnic groups have been demonstrated in prior studies. We aim to evaluate in-hospital outcomes and resource utilization across three racial/ethnic groups with AF using contemporary data. METHODS We identified patients admitted with AF in the National Inpatient Sample registry from 2015 to 2018. ICD-10-CM codes were used to identify variables of interest. The primary outcomes were in-hospital complications and resource utilization. RESULTS There were 1,250,075 AF admissions. Our sample was made up of 85.49% White, 8.12% Black, and 6.38% Hispanic patients. Black patients were younger but had a higher burden of cardiovascular comorbidities including obesity, hypertension, and chronic kidney disease. Social determinants were also less favorable in Black patients, with a higher percentage of Medicaid insurance and a high proportion of patients being in the lowest percentile for household income. Total hospital charge was highest in Hispanic patients. Despite higher rates of gastrointestinal bleed, Black patients were least likely to undergo left atrial appendage occlusion device implantation. Black and Hispanic patients were less like to undergo catheter ablation therapy. Black race was an independent predictor of mortality, stroke, mechanical ventilation, acute kidney injury, hemodynamic shock, need for vasopressor, upper GI bleed, need for blood transfusion, total hospital charges, and length of stay when compared to other groups. CONCLUSION Disparities exist in the risk of AF, and its management among racial and ethnic groups. Health care costs and inpatient outcomes disproportionately impact minorities in the United States.
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Affiliation(s)
- Laith Alhuneafat
- Department of Medicine, Allegheny Health Network, Pittsburgh, PA, USA
| | - Ahmad Jabri
- Heart and Vascular Center, MetroHealth Medical Center, Cleveland, Ohio, USA.
| | - Indu G Poornima
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - Nada Alrifai
- Department of Medicine, Allegheny Health Network, Pittsburgh, PA, USA
| | - Mustafa Ali
- Department of Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Adee Elhamdani
- Department of Cardiology, Marshall University, Huntington, WV, USA
| | | | - Ahmad Al-Abdouh
- Division of Hospital Medicine, University of Kentucky, Lexington, KY, USA
| | - Mohammed Mhanna
- Department of Cardiovascular Medicine, University of Iowa, Iowa City, IA, USA
| | - Faris Hadaddin
- Cardiovascular Medicine, Baylor college of medicine, Houston, TX, USA
| | - Muhammad Butt
- Department of Clinical Cardiac Electrophysiology, New York University Lagone, New York City, NY
| | | | - Saima Karim
- Heart and Vascular Center, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Ohad Ziv
- Heart and Vascular Center, MetroHealth Medical Center, Cleveland, Ohio, USA
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9
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Hanchate AD, Baker WE, Paasche-Orlow MK, Feldman J. Ambulance diversion and ED destination by race/ethnicity: evaluation of Massachusetts' ambulance diversion ban. BMC Health Serv Res 2022; 22:987. [PMID: 35918721 PMCID: PMC9347077 DOI: 10.1186/s12913-022-08358-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 07/19/2022] [Indexed: 11/13/2022] Open
Abstract
Background The impact of ambulance diversion on potentially diverted patients, particularly racial/ethnic minority patients, is largely unknown. Treating Massachusetts’ 2009 ambulance diversion ban as a natural experiment, we examined if the ban was associated with increased concordance in Emergency Medical Services (EMS) patients of different race/ethnicity being transported to the same emergency department (ED). Methods We obtained Medicare Fee for Service claims records (2007–2012) for enrollees aged 66 and older. We stratified the country into patient zip codes and identified zip codes with sizable (non-Hispanic) White, (non-Hispanic) Black and Hispanic enrollees. For a stratified random sample of enrollees from all diverse zip codes in Massachusetts and 18 selected comparison states, we identified EMS transports to an ED. In each zip code, we identified the most frequent ED destination of White EMS-transported patients (“reference ED”). Our main outcome was a dichotomous indicator of patient EMS transport to the reference ED, and secondary outcome was transport to an ED serving lower-income patients (“safety-net ED”). Using a difference-in-differences regression specification, we contrasted the pre- to post-ban changes in each outcome in Massachusetts with the corresponding change in the comparison states. Results Our study cohort of 744,791 enrollees from 3331 zip codes experienced 361,006 EMS transports. At baseline, the proportion transported to the reference ED was higher among White patients in Massachusetts and comparison states (67.2 and 60.9%) than among Black (43.6 and 46.2%) and Hispanic (62.5 and 52.7%) patients. Massachusetts ambulance diversion ban was associated with a decreased proportion transported to the reference ED among White (− 2.7 percentage point; 95% CI, − 4.5 to − 1.0) and Black (− 4.1 percentage point; 95% CI, − 6.2 to − 1.9) patients and no change among Hispanic patients. The ban was associated with an increase in likelihood of transport to a safety-net ED among Hispanic patients (3.0 percentage points, 95% CI, 0.3 to 5.7) and a decreased likelihood among White patients (1.2 percentage points, 95% CI, − 2.3 to − 0.2). Conclusion Massachusetts ambulance diversion ban was associated with a reduction in the proportion of White and Black EMS patients being transported to the most frequent ED destination for White patients, highlighting the role of non-proximity factors in EMS transport destination. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08358-8.
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Affiliation(s)
- Amresh D Hanchate
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157-1063, USA. .,Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, 02118, USA.
| | - William E Baker
- Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, 02118, USA.,Boston Medical Center, Boston, MA, 02118, USA
| | - Michael K Paasche-Orlow
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, 02118, USA.,Boston Medical Center, Boston, MA, 02118, USA
| | - James Feldman
- Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, 02118, USA.,Boston Medical Center, Boston, MA, 02118, USA
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10
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Shahian DM, Badhwar V, O'Brien SM, Habib RH, Han J, McDonald DE, Antman MS, Higgins RSD, Preventza O, Estrera AL, Calhoon JH, Grondin SC, Cooke DT. Social Risk Factors in Society of Thoracic Surgeons Risk Models Part 1: Concepts, Indicator Variables, and Controversies. Ann Thorac Surg 2022; 113:1703-1717. [PMID: 34998732 DOI: 10.1016/j.athoracsur.2021.11.067] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/29/2021] [Accepted: 11/02/2021] [Indexed: 11/01/2022]
Affiliation(s)
- David M Shahian
- Division of Cardiac Surgery, Department of Surgery, and Center for Quality and Safety, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown WV
| | | | | | - Jane Han
- Society of Thoracic Surgeons, Chicago, IL
| | | | | | - Robert S D Higgins
- Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore, MD
| | - Ourania Preventza
- Baylor College of Medicine, Texas Heart Institute, Baylor St. Luke's Medical Center, Houston, TX
| | - Anthony L Estrera
- McGovern Medical School at UTHealth; Memorial Hermann Heart and Vascular Institute; Houston, TX
| | - John H Calhoon
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio
| | - Sean C Grondin
- Cumming School of Medicine, University of Calgary, and Foothills Medical Centre, Calgary, Alberta, Canada
| | - David T Cooke
- Division of General Thoracic Surgery, UC Davis Health, Sacramento, CA
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Rymer JA, Li S, Pun PH, Thomas L, Wang TY. Racial Disparities in Invasive Management for Patients With Acute Myocardial Infarction With Chronic Kidney Disease. Circ Cardiovasc Interv 2021; 15:e011171. [PMID: 34915722 DOI: 10.1161/circinterventions.121.011171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Due to increased risks of contrast nephropathy, chronic kidney disease (CKD) can deter consideration of invasive management for patients with myocardial infarction (MI). Black patients have a higher prevalence of CKD. Whether racial disparities exist in the use of invasive MI management for patients with CKD presenting with MI is unknown. METHODS We examined 717 012 White and 99 882 Black patients with MI treated from 2008 to 2017 at 914 hospitals in the National Cardiovascular Data Registry Chest Pain-MI Registry. CKD status was defined as estimated glomerular filtration rate (eGFR) ≥90 mL/(min·1.73 m2; no CKD), eGFR <90 but ≥60 (mild), eGFR <60 but ≥30 (moderate), and eGFR <30 or dialysis (severe). We used multivariable logistic regression models to examine the interaction of race and CKD severity in invasive MI management. RESULTS Among those with MI, Black patients were more likely than White patients to have CKD (eGFR <90; 61.4% versus 58.5%; P<0.001). Among those with MI and CKD, Black patients were more likely than White patients to have severe CKD (21.2% versus 12.4%; P<0.001). Patients with CKD were more likely than those without CKD to have diabetes or heart failure; Black patients with CKD were more likely to have these comorbidities when compared with White patients with CKD (all P<0.0001). Black race and CKD were associated with a lower likelihood of invasive management (adjusted odds ratio, 0.78 [95% CI, 0.75-0.81]; adjusted odds ratio, 0.72 [95% CI, 0.70-0.74]; P<0.001 for both). At eGFR levels ≥10, Black patients were significantly less likely than White patients to undergo invasive management. CONCLUSIONS Black patients with MI and mild or moderate CKD were less likely to undergo invasive management compared with White patients with similar CKD severity. National efforts are needed to address racial disparities that may remain in the invasive management of MI.
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Affiliation(s)
- Jennifer A Rymer
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Shuang Li
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Patrick H Pun
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Laine Thomas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Tracy Y Wang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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12
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Diaz A, Dalmacy D, Herbert C, Mirdad RS, Hyer JM, Pawlik TM. Association of County-Level Racial Diversity and Likelihood of a Textbook Outcome Following Pancreas Surgery. Ann Surg Oncol 2021; 28:8076-8084. [PMID: 34143339 PMCID: PMC8212582 DOI: 10.1245/s10434-021-10316-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 05/01/2021] [Indexed: 12/29/2022]
Abstract
Introduction Residential racial desegregation has demonstrated improved economic and education outcomes. The degree of racial community segregation relative to surgical outcomes has not been examined. Patients and Methods Patients undergoing pancreatic resection between 2013 and 2017 were identified from Medicare Standard Analytic Files. A diversity index for each county was calculated from the American Community Survey. Multivariable mixed-effects logistic regression with a random effect for hospital was used to measure the association of the diversity index level with textbook outcome (TO). Results Among the 24,298 Medicare beneficiaries who underwent a pancreatic resection, most patients were male (n = 12,784, 52.6%), White (n = 21,616, 89%), and had a median age of 72 (68–77) years. The overall incidence of TO following pancreatic surgery was 43.3%. On multivariable analysis, patients who resided in low-diversity areas had 16% lower odds of experiencing a TO following pancreatic resection compared with patients from high-diversity communities (OR 0.84, 95% CI 0.72–0.98). Compared with patients who resided in the high-diversity areas, individuals who lived in low-diversity areas had higher odds of 90-day readmission (OR 1.16, 95% CI 1.03–1.31) and had higher odds of dying within 90 days (OR 1.85, 95% CI 1.45–2.38) (both p < 0.05). Nonminority patients who resided in low-diversity areas also had a 14% decreased likelihood to achieve a TO after pancreatic resection compared with nonminority patients in high-diversity areas (OR 0.86, 95% CI 0.73–1.00). Conclusion Patients residing in the lowest racial/ethnic integrated counties were considerably less likely to have an optimal TO following pancreatic resection compared with patients who resided in the highest racially integrated counties. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-10316-3.
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Affiliation(s)
- Adrian Diaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA. .,National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA. .,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.
| | - Djhenne Dalmacy
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Chelsea Herbert
- Ohio University Heritage College of Osteopathic Medicine, Dublin, OH, USA
| | | | - J Madison Hyer
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
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13
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Paro A, Dalmacy D, Madison Hyer J, Tsilimigras DI, Diaz A, Pawlik TM. Impact of Residential Racial Integration on Postoperative Outcomes Among Medicare Beneficiaries Undergoing Resection for Cancer. Ann Surg Oncol 2021; 28:7566-7574. [PMID: 33895902 DOI: 10.1245/s10434-021-10034-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/26/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION While social determinants of health may adversely affect various populations, the impact of residential segregation on surgical outcomes remains poorly defined. OBJECTIVE The objective of the current study was to examine the association between residential segregation and the likelihood to achieve a textbook outcome (TO) following cancer surgery. METHODS The Medicare 100% Standard Analytic Files were reviewed to identify Medicare beneficiaries who underwent resection of lung, esophageal, colon, or rectal cancer between 2013 and 2017. Shannon's integration index, a measure of residential segregation, was calculated at the county level and its impact on composite TO [no complications, no prolonged length of stay (LOS), no 90-day readmission, and no 90-day mortality] was examined. RESULTS Among 200,509 patients who underwent cancer resection, the overall incidence of TO was 56.0%. The unadjusted likelihood of achieving a TO was lower among patients in low integration areas [low integration: n = 19,978 (55.0%) vs. high integration: n = 18,953 (59.3%); p < 0.001]. On multivariable analysis, patients residing in low integration areas had higher odds of complications [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.03-1.11], extended LOS (OR 1.13, 95% CI 1.09-1.18), and 90-day mortality (OR 1.29, 95% CI 1.22-1.38) and, in turn, lower odds of achieving a TO (OR 0.87, 95% CI 0.84-0.90) versus patients from highly integrated communities. CONCLUSION Patients who resided in counties with a lower integration index were less likely to have an optimal TO following resection of cancer compared with patients who resided in more integrated counties. The data highlight the importance of increasing residential racial diversity and integration as a means to improve patient outcomes.
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Affiliation(s)
- Alessandro Paro
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Djhenne Dalmacy
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Adrian Diaz
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA.
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14
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Rodriguez F, Hu J, Kershaw K, Hastings KG, López L, Cullen MR, Harrington RA, Palaniappan LP. County-Level Hispanic Ethnic Density and Cardiovascular Disease Mortality. J Am Heart Assoc 2019; 7:e009107. [PMID: 30371295 PMCID: PMC6404884 DOI: 10.1161/jaha.118.009107] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background Hispanics are the fastest growing ethnic group in the United States, and little is known about how Hispanic ethnic population density impacts cardiovascular disease (CVD) mortality. Methods and Results We examined county‐level deaths for Hispanics and non‐Hispanic whites from 2003 to 2012 using data from the National Center for Health Statistics’ Multiple Cause of Death mortality files. Counties with more than 20 Hispanic deaths (n=715) were included in the analyses. CVD deaths were identified using International Classification of Diseases, Tenth Revision (ICD‐10), I00 to I78, and population estimates were calculated using linear interpolation from 2000 and 2010 census data. Multivariate linear regression was used to examine the association of Hispanic ethnic density with Hispanic and non‐Hispanic white age‐adjusted CVD mortality rates. County‐level age‐adjusted CVD mortality rates were adjusted for county‐level demographic, socioeconomic, and healthcare factors. There were a total of 4 769 040 deaths among Hispanics (n=382 416) and non‐Hispanic whites (n=4 386 624). Overall, cardiovascular age‐adjusted mortality rates were higher among non‐Hispanic whites compared with Hispanics (244.8 versus 189.0 per 100 000). Hispanic density ranged from 1% to 96% in each county. Counties in the highest compared with lowest category of Hispanic density had 60% higher Hispanic mortality (215.3 versus 134.2 per 100 000 population). In linear regression models, after adjusting for county‐level demographic, socioeconomic, and healthcare factors, increasing Hispanic ethnic density remained strongly associated with mortality for Hispanics but not for non‐Hispanic whites. Conclusions CVD mortality is higher in counties with higher Hispanic ethnic density. County‐level characteristics do not fully explain the higher CVD mortality among Hispanics in ethnically concentrated counties.
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Affiliation(s)
- Fatima Rodriguez
- 1 Division of Cardiovascular Medicine Stanford University School of Medicine Stanford CA
| | - Jiaqi Hu
- 2 Division of Primary Care and Population Heath Stanford University School of Medicine Stanford CA
| | - Kiarri Kershaw
- 3 Department of Preventive Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | - Katherine G Hastings
- 2 Division of Primary Care and Population Heath Stanford University School of Medicine Stanford CA
| | - Lenny López
- 4 Department of Medicine University of California San Francisco School of Medicine San Francisco CA
| | - Mark R Cullen
- 2 Division of Primary Care and Population Heath Stanford University School of Medicine Stanford CA
| | - Robert A Harrington
- 1 Division of Cardiovascular Medicine Stanford University School of Medicine Stanford CA
| | - Latha P Palaniappan
- 1 Division of Cardiovascular Medicine Stanford University School of Medicine Stanford CA.,2 Division of Primary Care and Population Heath Stanford University School of Medicine Stanford CA
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15
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Hanchate AD, Paasche-Orlow MK, Baker WE, Lin MY, Banerjee S, Feldman J. Association of Race/Ethnicity With Emergency Department Destination of Emergency Medical Services Transport. JAMA Netw Open 2019; 2:e1910816. [PMID: 31490537 PMCID: PMC6735492 DOI: 10.1001/jamanetworkopen.2019.10816] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Evidence from national studies indicates systematic differences in hospitals in which racial/ethnic minorities receive care, with most care obtained in a small proportion of hospitals. Little is known about the source of these differences. OBJECTIVES To examine the patterns of emergency department (ED) destination of emergency medical services (EMS) transport according to patient race/ethnicity, and to compare the patterns between those transported by EMS and those who did not use EMS. DESIGN, SETTING, AND PARTICIPANTS This cohort study of US EMS and EDs used Medicare claims data from January 1, 2006, to December 31, 2012. Enrollees aged 66 years or older with continuous fee-for-service Medicare coverage (N = 864 750) were selected for the sample. Zip codes with a sizable count (>10) of Hispanic, non-Hispanic black, and non-Hispanic white enrollees were used for comparison of EMS use across racial/ethnic subgroups. Data on all ED visits, with and without EMS use, were obtained. Data analysis was performed from December 18, 2018, to July 7, 2019. MAIN OUTCOMES AND MEASURES The main outcome measure was whether an EMS transport destination was the most frequent ED destination among white patients (reference ED). The secondary outcomes were (1) whether the ED destination was a safety-net hospital and (2) the distance of EMS transport from the ED destination. RESULTS The study cohort comprised 864 750 Medicare enrollees from 4175 selected zip codes who had 458 701 ED visits using EMS transport. Of these EMS-transported enrollees, 26.1% (127 555) were younger than 75 years, and most were women (302 430 [66.8%]). Overall, the proportion of white patients transported to the reference ED was 61.3% (95% CI, 61.0% to 61.7%); this rate was lower among black enrollees (difference of -5.3%; 95% CI, -6.0% to -4.6%) and Hispanic enrollees (difference of -2.5%; 95% CI, -3.2% to -1.7%). A similar pattern was found among patients with high-risk acute conditions; the proportion transported to the reference ED was 61.5% (95% CI, 60.7% to 62.2%) among white enrollees, whereas this proportion was lower among black enrollees (difference of -6.7%; 95% CI, -8.3% to -5.0%) and Hispanic enrollees (difference of -2.6%; 95% CI, -4.5% to -0.7%). In major US cities, a larger black-white discordance in ED destination was observed (-9.3%; 95% CI, -10.9% to -7.7%). Black and Hispanic patients were more likely to be transported to a safety-net ED compared with their white counterparts; the proportion transported to a safety-net ED among white enrollees (18.5%; 95% CI, 18.1% to 18.7%) was lower compared with that among black enrollees (difference of 2.7%; 95% CI, 2.2% to 3.2%) and Hispanic enrollees (difference of 1.9%; 95% CI, 1.3% to 2.4%). Concordance rates of non-EMS-transported ED visits were statistically significantly lower than for EMS-transported ED visits; the concordance rate among white enrollees of 52.9% (95% CI, 52.1% to 53.6%) was higher compared with that among black enrollees (difference of -4.8%; 95% CI, -6.4% to -3.3%) and Hispanic enrollees (difference of -3.0%; 95% CI, -4.7% to -1.3%). CONCLUSIONS AND RELEVANCE This study found race/ethnicity variation in ED destination for patients using EMS transport, with black and Hispanic patients more likely to be transported to a safety-net hospital ED compared with white patients living in the same zip code.
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Affiliation(s)
- Amresh D. Hanchate
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Michael K. Paasche-Orlow
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
- Boston Medical Center, Boston, Massachusetts
| | - William E. Baker
- Boston Medical Center, Boston, Massachusetts
- Department of Emergency Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Meng-Yun Lin
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Souvik Banerjee
- Disparities Research Unit, The Mongan Institute, Massachusetts General Hospital, Boston
| | - James Feldman
- Boston Medical Center, Boston, Massachusetts
- Department of Emergency Medicine, Boston University School of Medicine, Boston, Massachusetts
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16
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Kwan GF, Enserro DM, Benjamin EJ, Walkey AJ, Wiener RS, Magnani JW. Racial Differences in Hospital Death for Atrial Fibrillation: The National Inpatient Sample 2001-2012. PROCLINS CARDIOLOGY 2018; 1:1005. [PMID: 31008458 PMCID: PMC6472918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND Understanding racial differences in outcomes for atrial fibrillation (AF) may guide interventions to diminish health inequities. METHODS AND RESULTS In a retrospective, cross-sectional study of adults hospitalized with a principal diagnosis of AF using the 2001-2012 National Inpatient Sample, we assessed racial differences for in-hospital. We accounted for case-mix and clustering by race within hospitals to estimate odds ratios (OR) for death associated with individual patient race and hospital racial composition. We identified 676,567 hospitalizations (mean age 71.8 years, 53.6% women) with principal diagnosis of AF (84.2% White, 7.1% Black, 5.0% Hispanic). Black (vs. White) race was associated with 1.63-fold (95% CI, 1.50-1.78) risk of death. Other races had similar risk of death as Whites. Risk of death for Blacks (vs. Whites) declined over time [2001: OR 1.78(95% CI 1.31-2.43); 2012: OR 1.23(95% CI 0.92-1.64)]. Racial differences in deaths within hospitals narrowed, while hospitals with larger proportions of Blacks had persistently worse outcomes than hospitals with fewer Blacks (OR 1.08 per 10% increase in Blacks in 2001 and 2012). CONCLUSION Black patients with a principal diagnosis of AF were more likely to suffer in-hospital death than Whites. Our findings suggest racial disparities based upon individual patients' race improved over time, but outcomes were persistently worse at hospitals with higher proportions of Black patients, regardless of patients' races.
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Affiliation(s)
- Gene F. Kwan
- Department of Medicine, Boston University School of Medicine, USA,Corresponding author: Gene F. Kwan, Department of Medicine, Boston University School of Medicine, 88 East Newton St., D-8, Boston, MA 02115, USA, Tel: 617-638-8771;
| | | | - Emelia J. Benjamin
- Department of Medicine, Boston University School of Medicine, USA,Department of Epidemiology, Boston University School of Public Health, USA
| | - Allan J. Walkey
- Department of Epidemiology, Boston University School of Public Health, USA
| | - Renda Soylemez Wiener
- Department of Epidemiology, Boston University School of Public Health, USA,Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial VA Hospital, USA
| | - Jared W. Magnani
- Department of Medicine, Division of Cardiology, Heart and Vascular Institute, University of Pittsburgh, USA
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17
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McCarthy AM, Bristol M, Domchek SM, Groeneveld PW, Kim Y, Motanya UN, Shea JA, Armstrong K. Health Care Segregation, Physician Recommendation, and Racial Disparities in BRCA1/2 Testing Among Women With Breast Cancer. J Clin Oncol 2016; 34:2610-8. [PMID: 27161971 PMCID: PMC5012689 DOI: 10.1200/jco.2015.66.0019] [Citation(s) in RCA: 138] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Racial disparities in BRCA1/2 testing have been documented, but causes of these disparities are poorly understood. The study objective was to investigate whether the distribution of black and white patients across cancer providers contributes to disparities in BRCA1/2 testing. PATIENTS AND METHODS We conducted a population-based study of women in Pennsylvania and Florida who were 18 to 64 years old and diagnosed with invasive breast cancer between 2007 and 2009, linking cancer registry data, the American Medical Association Physician Masterfile, and patient and physician surveys. The study included 3,016 women (69% white, 31% black), 808 medical oncologists, and 732 surgeons. RESULTS Black women were less likely to undergo BRCA1/2 testing than white women (odds ratio [OR], 0.40; 95% CI, 0.34 to 0.48; P < .001). This difference was attenuated but not eliminated by adjustment for mutation risk, clinical factors, sociodemographic characteristics, and attitudes about testing (OR, 0.66; 95% CI, 0.53 to 0.81; P < .001). The care of black and white women was highly segregated across surgeons and oncologists (index of dissimilarity 64.1 and 61.9, respectively), but adjusting for clustering within physician or physician characteristics did not change the size of the testing disparity. Black women were less likely to report that they had received physician recommendation for BRCA1/2 testing even after adjusting for mutation risk (OR, 0.66; 95% CI, 0.54 to 0.82; P < .001). Adjusting for physician recommendation further attenuated the testing disparity (OR, 0.76; 95% CI, 0.57 to 1.02; P = .06). CONCLUSION Although black and white patients with breast cancer tend to see different surgeons and oncologists, this distribution does not contribute to disparities in BRCA1/2 testing. Instead, residual racial differences in testing after accounting for patient and physician characteristics are largely attributable to differences in physician recommendations. Efforts to address these disparities should focus on ensuring equity in testing recommendations.
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Affiliation(s)
- Anne Marie McCarthy
- Anne Marie McCarthy, Mirar Bristol, Younji Kim, and Katrina Armstrong, Massachusetts General Hospital; Anne Marie McCarthy and Katrina Armstrong, Harvard Medical School, Boston, MA; Susan M. Domchek, Peter W. Groeneveld, U. Nkiru Motanya, and Judy A. Shea, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Mirar Bristol
- Anne Marie McCarthy, Mirar Bristol, Younji Kim, and Katrina Armstrong, Massachusetts General Hospital; Anne Marie McCarthy and Katrina Armstrong, Harvard Medical School, Boston, MA; Susan M. Domchek, Peter W. Groeneveld, U. Nkiru Motanya, and Judy A. Shea, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Susan M Domchek
- Anne Marie McCarthy, Mirar Bristol, Younji Kim, and Katrina Armstrong, Massachusetts General Hospital; Anne Marie McCarthy and Katrina Armstrong, Harvard Medical School, Boston, MA; Susan M. Domchek, Peter W. Groeneveld, U. Nkiru Motanya, and Judy A. Shea, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Peter W Groeneveld
- Anne Marie McCarthy, Mirar Bristol, Younji Kim, and Katrina Armstrong, Massachusetts General Hospital; Anne Marie McCarthy and Katrina Armstrong, Harvard Medical School, Boston, MA; Susan M. Domchek, Peter W. Groeneveld, U. Nkiru Motanya, and Judy A. Shea, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Younji Kim
- Anne Marie McCarthy, Mirar Bristol, Younji Kim, and Katrina Armstrong, Massachusetts General Hospital; Anne Marie McCarthy and Katrina Armstrong, Harvard Medical School, Boston, MA; Susan M. Domchek, Peter W. Groeneveld, U. Nkiru Motanya, and Judy A. Shea, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - U Nkiru Motanya
- Anne Marie McCarthy, Mirar Bristol, Younji Kim, and Katrina Armstrong, Massachusetts General Hospital; Anne Marie McCarthy and Katrina Armstrong, Harvard Medical School, Boston, MA; Susan M. Domchek, Peter W. Groeneveld, U. Nkiru Motanya, and Judy A. Shea, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Judy A Shea
- Anne Marie McCarthy, Mirar Bristol, Younji Kim, and Katrina Armstrong, Massachusetts General Hospital; Anne Marie McCarthy and Katrina Armstrong, Harvard Medical School, Boston, MA; Susan M. Domchek, Peter W. Groeneveld, U. Nkiru Motanya, and Judy A. Shea, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Katrina Armstrong
- Anne Marie McCarthy, Mirar Bristol, Younji Kim, and Katrina Armstrong, Massachusetts General Hospital; Anne Marie McCarthy and Katrina Armstrong, Harvard Medical School, Boston, MA; Susan M. Domchek, Peter W. Groeneveld, U. Nkiru Motanya, and Judy A. Shea, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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18
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Keating NL, Kouri EM, He Y, Freedman RA, Volya R, Zaslavsky AM. Location Isn't Everything: Proximity, Hospital Characteristics, Choice of Hospital, and Disparities for Breast Cancer Surgery Patients. Health Serv Res 2016; 51:1561-83. [PMID: 26800094 DOI: 10.1111/1475-6773.12443] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Assess the relative importance of proximity and other hospital characteristics in the choice of hospital for breast cancer surgery by race/ethnicity. DATA SEER-Medicare data. STUDY DESIGN Observational study of women aged >65 years receiving surgery for stage I/II/III breast cancer diagnosed in 1992-2007 in Detroit (N = 10,746 white/black), Atlanta (N = 4,018 white/black), Los Angeles (N = 9,433 white/black/Asian/Hispanic), and San Francisco (N = 4,856 white/black/Asian). We calculated the distance from each patient's census tract of residence to each area hospital. We estimated discrete choice models for the probability of receiving surgery at each hospital based on distance and assessed whether deviations from these predictions entailed interactions of hospital characteristics with the patient's race/ethnicity. We identified high-quality hospitals by rates of adjuvant radiation therapy and by survey measures of patient experiences, and we assessed how observed surgery rates at high-quality hospitals deviated from those predicted based on distance alone. PRINCIPAL FINDINGS Proximity was significantly associated with hospital choice in all areas. Minority more often than white breast cancer patients had surgery at hospitals with more minority patients, those treating more Medicaid patients, and in some areas, lower quality hospitals. CONCLUSIONS Residential location alone does not explain concentration of racial/ethnic-minority breast cancer surgery patients in certain hospitals that are sometimes of lower quality.
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Affiliation(s)
- Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, MA.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Elena M Kouri
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Yulei He
- Office of Research and Methodology, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD
| | - Rachel A Freedman
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA
| | - Rita Volya
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Alan M Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, MA
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Schnittker J, Uggen C, Shannon SKS, McElrath SM. The Institutional Effects of Incarceration: Spillovers From Criminal Justice to Health Care. Milbank Q 2015; 93:516-60. [PMID: 26350929 DOI: 10.1111/1468-0009.12136] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
POLICY POINTS The steady increase in incarceration is related to the quality and functioning of the health care system. US states that incarcerate a larger number of people show declines in overall access to and quality of care, rooted in high levels of uninsurance and relatively poor health of former inmates. Providing health care to former inmates would ease the difficulties of inmates and their families. It might also prevent broader adverse spillovers to the health care system. The health care system and the criminal justice system are related in real but underappreciated ways. CONTEXT This study examines the spillover effects of growth in state-level incarceration rates on the functioning and quality of the US health care system. METHODS Our multilevel approach first explored cross-sectional individual-level data on health care behavior merged to aggregate state-level data regarding incarceration. We then conducted an entirely aggregate-level analysis to address between-state heterogeneity and trends over time in health care access and utilization. FINDINGS We found that individuals residing in states with a larger number of former prison inmates have diminished access to care, less access to specialists, less trust in physicians, and less satisfaction with the care they receive. These spillover effects are deep in that they affect even those least likely to be personally affected by incarceration, including the insured, those over 50, women, non-Hispanic whites, and those with incomes far exceeding the federal poverty threshold. These patterns likely reflect the burden of uncompensated care among former inmates, who have both a greater than average need for care and higher than average levels of uninsurance. State-level analyses solidify these claims. Increases in the number of former inmates are associated simultaneously with increases in the percentage of uninsured within a state and increases in emergency room use per capita, both net of controls for between-state heterogeneity. CONCLUSIONS Our analyses establish an intersection between systems of care and corrections, linked by inadequate financial and administrative mechanisms for delivering services to former inmates.
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Gaskin DJ, Zare H, Haider AH, LaVeist TA. The Quality of Surgical and Pneumonia Care in Minority-Serving and Racially Integrated Hospitals. Health Serv Res 2015; 51:910-36. [PMID: 26418717 DOI: 10.1111/1475-6773.12394] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Darrell J Gaskin
- Department of Health Policy and Management, Hopkins Center of Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Hossein Zare
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.,Faculty Appointments & Services, University of Maryland University College (UMUC), Adelphi, MD
| | - Adil H Haider
- Center for Surgery and Public Health, Brigham and Women's Hospitals, Boston, MA
| | - Thomas A LaVeist
- Department of Health Policy and Management, Hopkins Center of Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Examining Causes of Racial Disparities in General Surgical Mortality: Hospital Quality Versus Patient Risk. Med Care 2015; 53:619-29. [PMID: 26057575 DOI: 10.1097/mlr.0000000000000377] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Racial disparities in general surgical outcomes are known to exist but not well understood. OBJECTIVES To determine if black-white disparities in general surgery mortality for Medicare patients are attributable to poorer health status among blacks on admission or differences in the quality of care provided by the admitting hospitals. RESEARCH DESIGN Matched cohort study using Tapered Multivariate Matching. SUBJECTS All black elderly Medicare general surgical patients (N=18,861) and white-matched controls within the same 6 states or within the same 838 hospitals. MEASURES Thirty-day mortality (primary); others include in-hospital mortality, failure-to-rescue, complications, length of stay, and readmissions. RESULTS Matching on age, sex, year, state, and the exact same procedure, blacks had higher 30-day mortality (4.0% vs. 3.5%, P<0.01), in-hospital mortality (3.9% vs. 2.9%, P<0.0001), in-hospital complications (64.3% vs. 56.8% P<0.0001), and failure-to-rescue rates (6.1% vs. 5.1%, P<0.001), longer length of stay (7.2 vs. 5.8 d, P<0.0001), and more 30-day readmissions (15.0% vs. 12.5%, P<0.0001). Adding preoperative risk factors to the above match, there was no significant difference in mortality or failure-to-rescue, and all other outcome differences were small. Blacks matched to whites in the same hospital displayed no significant differences in mortality, failure-to-rescue, or readmissions. CONCLUSIONS Black and white Medicare patients undergoing the same procedures with closely matched risk factors displayed similar mortality, suggesting that racial disparities in general surgical mortality are not because of differences in hospital quality. To reduce the observed disparities in surgical outcomes, the poorer health of blacks on presentation for surgery must be addressed.
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22
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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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23
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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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24
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Saunders MR, Lee H, Alexander GC, Tak HJ, Thistlethwaite JR, Ross LF. Racial disparities in reaching the renal transplant waitlist: is geography as important as race? Clin Transplant 2015; 29:531-8. [PMID: 25818547 DOI: 10.1111/ctr.12547] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND In the United States, African Americans and whites differ in access to the deceased donor renal transplant waitlist. The extent to which racial disparities in waitlisting differ between United Network for Organ Sharing (UNOS) regions is understudied. METHODS The US Renal Data System (USRDS) was linked with US census data to examine time from dialysis initiation to waitlisting for whites (n = 188,410) and African Americans (n = 144,335) using Cox proportional hazards across 11 UNOS regions, adjusting for potentially confounding individual, neighborhood, and state characteristics. RESULTS Likelihood of waitlisting varies significantly by UNOS region, overall and by race. Additionally, African Americans face significantly lower likelihood of waitlisting compared to whites in all but two regions (1 and 6). Overall, 39% of African Americans with ESRD reside in Regions 3 and 4--regions with a large racial disparity and where African Americans comprise a large proportion of the ESRD population. In these regions, the African American-white disparity is an important contributor to their overall regional disparity. CONCLUSIONS Race remains an important factor in time to transplant waitlist in the United States. Race contributes to overall regional disparities; however, the importance of race varies by UNOS region.
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Affiliation(s)
- Milda R Saunders
- Department of Medicine, Section of Hospital Medicine, University of Chicago Medical Center, Chicago, IL, USA.,MacLean Center for Clinical Medical Ethics, University of Chicago Medical Center, Chicago, IL, USA
| | - Haena Lee
- Department of Medicine, Section of Hospital Medicine, University of Chicago Medical Center, Chicago, IL, USA.,Department of Sociology, University of Chicago, Chicago, IL, USA
| | - G Caleb Alexander
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Hyo Jung Tak
- Department of Health Management and Policy, University of North Texas Health Science Center School of Public Health, Fort Worth, TX, USA
| | - J Richard Thistlethwaite
- Section of Transplantation, Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Lainie Friedman Ross
- MacLean Center for Clinical Medical Ethics, University of Chicago Medical Center, Chicago, IL, USA.,Section of Transplantation, Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA.,Department of Pediatrics, University of Chicago Hospitals, Chicago, IL, USA
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25
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Zhang Y. The Association Between Dialysis Facility Quality and Facility Characteristics, Neighborhood Demographics, and Region. Am J Med Qual 2015; 31:358-63. [DOI: 10.1177/1062860615580429] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Yue Zhang
- The University of Toledo, Toledo, OH
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26
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Affiliation(s)
- Adolfo Correa
- From the Department of Medicine, University of Mississippi Medical Center, Jackson, MS (A.C., M.S.); and the Division for Cardiovascular Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (S.G.).
| | - Sophia Greer
- From the Department of Medicine, University of Mississippi Medical Center, Jackson, MS (A.C., M.S.); and the Division for Cardiovascular Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (S.G.)
| | - Mario Sims
- From the Department of Medicine, University of Mississippi Medical Center, Jackson, MS (A.C., M.S.); and the Division for Cardiovascular Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (S.G.)
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27
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Mitchell J, Probst JC, Bennett KJ, Glover S, Martin AB, Hardin JW. Differences in pneumonia treatment between high-minority and low-minority neighborhoods with clinical decision support system implementation. Inform Health Soc Care 2014; 41:128-42. [PMID: 25325354 DOI: 10.3109/17538157.2014.965304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Jordan Mitchell
- a Department of Healthcare Administration , University of Houston Clear Lake , Houston , TX , USA
| | - Janice C Probst
- b Department of Health Services Policy and Management , University of South Carolina , Columbia , SC , USA
| | | | - Saundra Glover
- d Institute for Partnerships to Eliminate Health Disparities
| | - Amy Brock Martin
- e Department of Stomatology , University of South Carolina , Columbia , SC , USA , and
| | - James W Hardin
- f Edwards College of Medicine, Medical University of South Carolina , Charleston , SC , USA
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Dimick J, Ruhter J, Sarrazin MV, Birkmeyer JD. Black patients more likely than whites to undergo surgery at low-quality hospitals in segregated regions. Health Aff (Millwood) 2014; 32:1046-53. [PMID: 23733978 DOI: 10.1377/hlthaff.2011.1365] [Citation(s) in RCA: 223] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Research has shown that black patients more frequently undergo surgery at low-quality hospitals than do white patients. We assessed the extent to which living in racially segregated areas and living in geographic proximity to low-quality hospitals contribute to this disparity. Using national Medicare data for all patients who underwent one of three high-risk surgical procedures in 2005-08, we found that black patients actually tended to live closer to higher-quality hospitals than white patients did but were 25-58 percent more likely than whites to receive surgery at low-quality hospitals. Racial segregation was also a factor, with black patients in the most segregrated areas 41-96 percent more likely than white patients to undergo surgery at low-quality hospitals. To address these disparities, care navigators and public reporting of comparative quality could steer patients and their referring physicians to higher-quality hospitals, while quality improvement efforts could focus on improving outcomes for high-risk surgery at hospitals that disproportionately serve black patients. Unfortunately, existing policies such as pay-for-performance, bundled payments, and nonpayment for adverse events may divert resources and exacerbate these disparities.
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Affiliation(s)
- Justin Dimick
- Division of Minimally Invasive Surgery, University of Michigan, Ann Arbor, Michigan, USA.
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29
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Ko M, Needleman J, Derose KP, Laugesen MJ, Ponce NA. Residential segregation and the survival of U.S. urban public hospitals. Med Care Res Rev 2013; 71:243-60. [PMID: 24362646 DOI: 10.1177/1077558713515079] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Residential segregation is associated geographic disparities in access to care, but its impact on local health care policy, including public hospitals, is unknown. We examined the effects of racial residential segregation on U.S. urban public hospital closures from 1987 to 2007, controlling for hospital, market, and policy characteristics. We found that a high level of residential segregation moderated the protective effects of Black population composition, such that a high level of residential segregation, in combination with a high percentage of poor residents, conferred a higher likelihood of hospital closure. More segregated and poorer communities face disadvantages in access to care that may be compounded as a result of instability in the health care safety net. Policy makers should consider the influence of social factors such as residential segregation on the allocation of the safety net resources.
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Affiliation(s)
- Michelle Ko
- 1University of California, San Francisco, CA, USA
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30
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Abstract
BACKGROUND We examined whether dialysis facility characteristics, neighborhood demographics, and region are associated with Centers for Medicare and Medicaid Services (CMS) dialysis facility quality measures in order to determine the most important targets for intervention. METHODS We linked US census data to the CMS Dialysis Compare File which contains information for facility outcomes for all CMS-certified dialysis facilities in 2007 (n=5616). We then used linear and logistic regression to characterize the association between dialysis facility quality--worse than expected patient survival, and the proportion of individuals in a facility achieving dialysis adequacy (urea reduction rate >65) or target hemoglobin (10<Hgb<12 g/dL)--and dialysis facility characteristics, neighborhood demographics, and region. RESULTS Only an increasing proportion of African Americans in the neighborhood is consistently associated with worse dialysis facility outcomes, even after controlling for neighborhood poverty. Facilities with the highest proportion of African Americans in the neighborhood had worse patient survival [odds ratio (OR) 4.6; 95% confidence interval (CI), 2.8-7.6], were less likely to have adequate dialysis (β -1.4; 95% CI, -2.3 to -0.6), and achieve targeted hemoglobin (β -3.1; 95% CI, -4.7 to -1.6) compared to those with the lowest proportion. No other predictor-facility, neighborhood, or region--was consistently associated with dialysis facility quality. CONCLUSIONS The proportion of African Americans in the dialysis facility neighborhood is strongly and consistently associated with lower facility quality. Quality improvement efforts are particularly needed for dialysis facilities in minority communities.
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Do diabetic patients living in racially segregated neighborhoods experience different access and quality of care? Med Care 2012; 50:692-9. [PMID: 22525608 DOI: 10.1097/mlr.0b013e318254a43c] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Place of residence, particularly residential segregation, has been implicated in health and health care disparities. However, prior studies have not focused on care for diabetes, a prevalent condition for minority populations. OBJECTIVE To examine the association of residential segregation with a range of access and quality of care outcomes among black and Hispanics with diabetes using a nationally representative US sample. RESEARCH DESIGN Cross-sectional study using data for 1598 adult patients with diabetes from the 2006 Medical Expenditure Panel Survey linked to residential segregation information for blacks and Hispanics on the basis of the 2000 census. Relationships of 5 dimensions of residential segregation (dissimilarity, isolation, clustering, concentration, and centralization) with access and quality of care outcomes were examined using linear, logistic, and multinomial logistic regression models, controlling for respondent characteristics and community utilization and hospital capacity. RESULTS Black and Hispanics with diabetes had comparable or better access to providers, but received fewer recommended services. Living in a segregated community was associated with more recommended services received, but also problems with seeing a specialist. The relationship of residential segregation to diabetes care varied depending on type of segregation and race/ethnic group assessed. CONCLUSIONS Residential segregation influences the care experience of patients with diabetes in the United States. Our study highlights the importance of investigating how different types of segregation may affect diabetes care received by patients from different race and ethnic groups.
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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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Gaskin DJ, Spencer CS, Richard P, Anderson G, Powe NR, LaVeist TA. Do minority patients use lower quality hospitals? INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2012; 48:209-20. [PMID: 22235546 DOI: 10.5034/inquiryjrnl_48.03.06] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Employing three years of inpatient discharge data from 11 states and inpatient and patient safety quality indicators from the Agency for Healthcare Research and Quality (AHRQ), this paper explored whether minority (black, Hispanic, and Asian) patients used lower quality hospitals. We found that the association between the share of minority patients and hospital quality depended on how quality was measured and varied by race and ethnicity. Hospitals serving Hispanics performed well on most patient safety measures. Higher percentages of all three minority patient groups corresponded to lower quality for only one measure, postoperative sepsis. Our analysis indicates that it is incorrect to generalize that minorities use lower quality hospitals. Analysts and policymakers should be cautious when making generalizations about the overall service quality of hospitals that treat minority patients.
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Affiliation(s)
- Darrell J Gaskin
- Hopkins Center for Health Disparities Solutions, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Suite 441, Baltimore, MD 21205, USA.
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Gaskin DJ, Dinwiddie GY, Chan KS, McCleary R. Residential segregation and disparities in health care services utilization. Med Care Res Rev 2011; 69:158-75. [PMID: 21976416 DOI: 10.1177/1077558711420263] [Citation(s) in RCA: 144] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Using data from the 2006 Medical Expenditure Panel Survey and the 2000 Census, the authors explored whether race/ethnic disparities in health care use were associated with residential segregation. They used five measures of health care use: office-based physician visits, outpatient department physician visits, visits to nurses and physician's assistants, visits to other health professionals, and having a usual source of care. For each individual, the authors controlled for age, gender, marital status, insurance status, income, educational attainment, employment status, region, and health status. The authors used the racial-ethnic composition of the zip code to control for residential segregation. The findings suggest that disparities in health care utilization are related to both individuals' racial and ethnic identity and the racial and ethnic composition of their communities. Therefore, efforts to improve access to health care services and to eliminate health care disparities for African Americans and Hispanics should not only focus on individual-level factors but also include community-level factors.
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Affiliation(s)
- Darrell J Gaskin
- Department of Health Policy and Management, Hopkins Center for Health Disparities Solutions, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA.
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Race and timeliness of transfer for revascularization in patients with acute myocardial infarction. Med Care 2011; 49:662-7. [PMID: 21677592 DOI: 10.1097/mlr.0b013e31821d98b2] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVES Patients with acute myocardial infarction (AMI) who are admitted to hospitals without coronary revascularization are frequently transferred to hospitals with this capability. We sought to determine whether the timeliness of hospital transfer and quality of destination hospitals differed between black and white patients. METHODS We evaluated all white and black Medicare beneficiaries admitted with AMI at nonrevascularization hospitals in 2006 who were transferred to a revascularization hospital. We compared hospital length of stay before transfer and the transfer destination's 30-day risk-standardized mortality rate for AMI between black and white patients. We used hierarchical regression to adjust for patient characteristics and examine within and across-hospital effects of race on 30-day mortality and length of stay before transfer. RESULTS A total of 25,947 (42%) white and 2345 (37%) black patients with AMI were transferred from 857 urban and 774 rural nonrevascularization hospitals to 928 revascularization hospitals. Median (interquartile range) length of stay before transfer was 1 day (1 to 3 d) for white patients and 2 days (1 to 4 d) for black patients (P<0.001). In adjusted models, black patients tended to be transferred more slowly than white patients, a finding because of both across and within-hospital effects. For example, within a given urban hospital, black patients were transferred an additional 0.24 days (95% confidence interval 0.03-0.44 d) later than white patients. In addition, the lengths of stay before transfer for all patients at urban hospitals increased by 0.37 days (95% confidence interval 0.28-0.47 d) for every 20% increase in the proportion of AMI patients who were black. These results were attenuated in rural hospitals. The risk-standardized mortality rate of the revascularization hospital to which patients were ultimately sent did not differ between black and white patients. CONCLUSIONS Black patients are transferred more slowly to revascularization hospitals after AMI than white patients, resulting from both less timely transfers within hospitals and admission to hospitals with greater delays in transfer; however, 30-day mortality of the revascularization hospital to which both groups were sent to appeared similar. Race-based delays in transfer may contribute to known racial disparities in outcomes of AMI.
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Gaskin DJ, Price A, Brandon DT, Laveist TA. Segregation and disparities in health services use. Med Care Res Rev 2009; 66:578-89. [PMID: 19460811 DOI: 10.1177/1077558709336445] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We compared race disparities in health services use in a national sample of adults from the 2002 Medical Expenditure Panel Survey and data from the Exploring Health Disparities in Integrated Communities Project, a 2003 survey of adult residents from a low-income integrated urban community in Maryland. In the Medical Expenditure Panel Survey data, African Americans were less likely to have a health care visit compared with Whites. However, in the Exploring Health Disparities in Integrated Communities Project, the integrated community, African Americans were more likely to have a health care visit than Whites. The race disparities in the incidence rate of health care use among persons who had at least one visit were similar in both samples. Our findings suggest that disparities in health care utilization may differ across communities and that residential segregation may be a confounding factor.
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Affiliation(s)
- Darrell J Gaskin
- African American Studies Department, College of Behavioral and Social Sciences, University of Maryland, 2169 LeFrak Hall, College Park, MD 20742, USA.
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