Minorities,
uninsured less likely to receive care at high-volume hospitals
Newswise — Compared to white patients, black, Asian and Hispanic
patients and those who are uninsured are less likely to undergo
complex surgery at high-volume hospitals, which have been
associated with better outcomes, according to a study in the
October 25 issue of JAMA.
Efforts to improve the quality of surgical care in the United
States have led many organizations to advocate the use of
high-volume hospitals for certain procedures, since a number of
studies have reported of a direct volume-outcome relationship
for certain procedures, with patients at high-volume hospitals
consistently having better outcomes. It appears there are
important differences in the racial and socioeconomic status of
patients who receive care at high- and low-volume hospitals,
according to background information in the article. These
differences may affect the ability to access or receive care at
a high-volume hospital.
Jerome H. Liu, M.D., M.S.H.S., of the David Geffen School of
Medicine at the University of California-Los Angeles, and
colleagues conducted a study to determine whether the use of
high-volume hospitals varies by race/ethnicity or insurance
status in a broad population of patients undergoing complex
surgical care. The researchers examined patient
characteristics and use of high-volume hospitals across 10
hospital-based procedures with known volume-outcome
relationships among Californians during a 5-year period
(2000-2004), collecting data from California’s Office of
Statewide Health Planning and Development patient discharge
database.
The procedures included elective abdominal aortic aneurysm
repair, coronary artery bypass grafting, carotid
endarterectomy, esophageal cancer resection, hip fracture
repair, lung cancer resection, cardiac valve replacement,
coronary angioplasty, pancreatic cancer resection, and total
knee replacement.
According to this database, a total of 719,608 patients received
1 of the 10 operations. The researchers found that “in general,
blacks, Asians, Hispanics, patients with Medicaid, and uninsured
patients were less likely to go to high-volume hospitals for
complex surgical procedures but more likely to go to low-volume
hospitals, when compared with whites and patients with Medicare.
Furthermore, patients with private insurance were significantly
more likely to go to high-volume hospitals for 3 of the surgical
procedures.”
For all 10 operations, black patients were significantly less
likely to receive care at high-volume hospitals in 6 of the
operations, Asians less likely in 5, and Hispanics less likely
in 9.
Medicaid patients were significantly less likely than Medicare
patients to receive care at high-volume hospitals for 7 of the
operations, while uninsured patients were less likely to be
treated at high-volume hospitals for 9.
“ … our study demonstrates robust findings in a large (12
percent of the U.S. population), ethnically diverse population
that includes all patients undergoing the selected procedures
without restrictions based on demographics, insurance, or
sampling. While there is significant interest among health care
policy experts in improving quality by directing patients to
high-volume hospitals, policy development should include
explicit efforts to identify the patient and system factors
required to reduce current inequities in the receipt of care at
such hospitals,” the authors conclude.
(JAMA. 2006;296:1973-1980. Available pre-embargo to the media at
http://www.jamamedia.org.)
Editor’s Note: Please see the article for additional
information, including other authors, author contributions and
affiliations, financial disclosures, funding and support, etc.
Editorial: Delivering Quality to Patients
In an accompanying editorial, Samuel R. G. Finlayson, M.D.,
M.P.H., of Dartmouth Medical School, Hanover, N.H., comments on
the findings of Liu and colleagues.
“In a sense, volume-based referral policies are an ‘end run’
around the issue of quality: they neither require that the
essential components of quality be identified (they just measure
volume as a proxy for quality), nor do they require that quality
is improved at hospitals (they simply direct the patient to
specific centers that already meet that standard). The central
focus of quality improvement should be the task of delivering
quality care to patients, not the other way around.
Granted, there probably is a role for volume-based referral for
the few procedures for which the volume-outcome association is
particularly strong (e.g., pancreatic surgery). However, an
approach that simultaneously sidesteps the task of improving
quality and ignores the vast majority of surgical procedures
should not be the crown jewel of the surgical quality movement.”
(JAMA. 2006;296:2026-2027. Available pre-embargo to the media at
http://www.jamamedia.org.)
Editor’s Note: Financial disclosures – none reported.