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Minorities Less Likely to Receive Care at High-Volume Hospitals

This trend may indicate lower quality of surgical care, studies suggest

TUESDAY, Oct. 24, 2006 (HealthDay News) -- Race matters, at least when it comes to medical care received in big hospitals and Medicare managed-care plans.

Two studies in the Oct. 25 issue of the Journal of the American Medical Association found that racial minorities generally received lower quality care than whites or had less access to better care.

According to the first paper, black, Asian and Hispanic patients, as well as uninsured patients, were less likely to undergo complex surgery at high-volume hospitals that specialize in that type of surgery. These hospitals are thought to produce better results because they perform so many of the procedures.

To see who was actually using high-volume hospitals, the authors looked at the characteristics of 719,608 patients who underwent 10 inpatient procedures in California from 2000 to 2004. The procedures were: 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.

Overall, nonwhites, Medicaid recipients and uninsured patients were less likely to receive care at high-volume hospitals and more likely to go to low-volume hospitals.

Blacks were "significantly" -- 28 percent to 60 percent -- less likely than whites to receive surgical care at high-volume hospitals for six of the 10 operations. Asians were 9 percent to 40 percent less likely to receive care at high-volume hospitals for five of the procedures, while Hispanics were 12 percent to 54 percent less likely to receive care at high-volume hospitals for nine of the procedures.

Medicaid patients were 34 percent to 78 percent less likely than Medicare patients to receive their surgical care at high-volume hospitals for seven of the operations, while uninsured patients were 19 percent to 80 percent less likely to be treated at high volume hospitals for nine of the surgeries.

Right now, the goal is to send all patients in need of a specific type of procedure to hospitals that routinely perform such procedures and have the best results. But this might not be feasible or equitable. Rather than try to refer nonwhites and Medicaid recipients to high-volume hospitals, "the question becomes how to improve the quality of low-volume hospitals, raise the tide and lift all the boats," said Dr. Clifford Ko, senior author of the study and professor of surgery and director of the center for surgical outcomes and quality at the University of California, Los Angeles.

"There is no single, perfect way to improve quality and, even though we've put a lot of stock into volume, it is not perfect," Ko continued. "We need to find additional ways that hospitals can improve quality."

The second study found that black enrollees in Medicare managed-care plans do less well when it comes to managing conditions such as high blood pressure, diabetes or high cholesterol, compared to white patients. The study authors looked at 431,573 individual-level observations in 151 Medicare health plans from 2002 to 2004. They were interested in gauging how well the plans performed on key clinical measures -- controlling blood pressure, cholesterol and blood sugar.

"If people have those measures under control, they're less likely to have heart attacks, strokes and are less likely to die prematurely," said study lead author Dr. Amal N. Trivedi, assistant professor of community health at Brown Medical School in Providence, R.I. "These are very important clinical outcomes." Trivedi started the research while at Harvard Medical School.

"There were large racial disparities in performance in the system as a whole with an absolute gap of 7 percent for blood pressure control all the way up to 14 percent for controlling cholesterol after a heart attack," Trivedi said.

The real question was whether there was any connection between these disparities and the overall quality of the plans. The answer was no, Trivedi said.

"There was basically no connection between the overall quality of the plan and how big its racial disparity, so this isn't an issue that affects just a few low-performing plans," Trivedi said. "We found that it's basically universal among Medicare managed care."

The bottom line is that managed-care plans need to start collecting this information, Trivedi said.

Stephen Thomas is director of the Center for Minority Health at the University of Pittsburgh School of Public Health. He said, "These articles tell us more of the same. The fundamental question is what are we going to do? What we need now is third generation health disparity research that is focused on solutions. Institutions need to be accountable to implementing solutions."

More information

The Kaiser Family Foundation has more on race, ethnicity and health care.

SOURCES: Clifford Y. Ko, M.D., professor of surgery and director, Center for Surgical Outcomes and Quality, University of California, Los Angeles; Amal N. Trivedi, M.D., assistant professor of community health, Brown Medical School, Providence, R.I.; Stephen Thomas, Ph.D., director, Center for Minority Health, University of Pittsburgh School of Public Health; Oct. 25, 2006, Journal of the American Medical Association
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