Disparities Within and Disparities Within and Between Hospitals for Between Hospitals for Inpatient Quality of Inpatient Quality of

Care: Targeting Care: Targeting Resources to Close the Resources to Close the

GapGapRomana Hasnain-Wynia, PhDRomana Hasnain-Wynia, PhD

Director, Center for Healthcare EquityDirector, Center for Healthcare Equity

Associate ProfessorAssociate Professor

Institute for Health Care StudiesInstitute for Health Care Studies

Division of General Internal MedicineDivision of General Internal Medicine

Northwestern University, Feinberg School of MedicineNorthwestern University, Feinberg School of Medicine

The authors acknowledge the assistance of the IFQHC and the Centers for Medicare andMedicaid Services (CMS) in providing data which made this research possible. Theconclusions prescribed are solely those of the author(s) and do not represent those of IFQHC or CMS. The study was funded by the Commonwealth Fund and the Robert Wood Johnson Foundation’s Changes in Health Care Financing and Organization (HCFO) Initiative

Co-AuthorsCo-Authors

Raymond Kang

Mary Beth Landrum

Christine Vogeli

David W. Baker

Joel S. Weissman

BackgroundBackground

Racial and ethnic disparities in quality of care Racial and ethnic disparities in quality of care persistpersist

Studies suggest that factors related to patient-Studies suggest that factors related to patient-physician encounter such as physician encounter such as miscommunication, cultural misunderstanding, miscommunication, cultural misunderstanding, racism, and bias contribute to disparitiesracism, and bias contribute to disparities

Other studies suggest that differential quality Other studies suggest that differential quality in treatment settings contribute to disparitiesin treatment settings contribute to disparities

QuestionQuestion

Who You Are?:

Patient-Centered Care

Where You Go?:

Quality differences in

various settings

“… hospitals that were lower performers tended to serve a larger proportion of minority patients…”

Hasnain-Wynia R, Baker DW, Nerenz, D, et al. Archives of Internal Medicine, June 2007

Disparities in Health Care Are Driven by Where Minority Patients Seek Care

Examination of Hospital Quality Alliance Measures

Disparities in Health Care Are Driven by Where Minority Patients Seek Care

Examination of Hospital Quality Alliance Measures

Bottom performing hospitals had a much higher percentages Bottom performing hospitals had a much higher percentages of minority patients compared with top performing hospitalsof minority patients compared with top performing hospitals

10 20 30 40 50 60

AMI SmokingCessation

HF SmokingCessation

CAP SmokingCessation

CHF D/CInstructions

% MINORITY PATIENTS

Bottom Performers Top Performers

Hasnain-Wynia, R., Baker, DW, Nerenz, DR, et al. “Are Disparities Driven by Who You Are or Where You Go: An Examination of the Hospital Quality Alliance Measures: Archives of Internal Medicine June 25, 2007 627:1233-1239..

Limitations of Previous Limitations of Previous StudiesStudies

Looked only at Medicare patientsLooked only at Medicare patients Focused only on one condition such as AMIFocused only on one condition such as AMI Examined only hospital level variables such Examined only hospital level variables such

as proportion of minorities treated, without as proportion of minorities treated, without examining if disparities existedexamining if disparities existed

Examined quality in teaching hospitals onlyExamined quality in teaching hospitals only Limited to comparisons with larger groups Limited to comparisons with larger groups

(Blacks, Hispanics).(Blacks, Hispanics).

Current HQA StudyCurrent HQA Study

Previously unavailable, patient-level Previously unavailable, patient-level HQA database obtained from CMSHQA database obtained from CMS

Expanded list of measuresExpanded list of measures n = 19n = 19

All U.S. acute care hospitals All U.S. acute care hospitals n > 4000 hospitalsn > 4000 hospitals n > 2 million patients n > 2 million patients

Groups by Race/Ethnicity Groups by Race/Ethnicity

BlackBlack HispanicHispanic AsianAsian American Indian/Alaska NativeAmerican Indian/Alaska Native Native Hawaiian/Pacific IslanderNative Hawaiian/Pacific Islander WhiteWhite

MethodsMethods

Multivariate modelsMultivariate models Model 1: unadjustedModel 1: unadjusted Model 2: adjusted for individual Model 2: adjusted for individual

characteristics, including co-characteristics, including co-morbidities, payer, age, gender (Total morbidities, payer, age, gender (Total Disparity)Disparity)

Model 3: Model 2 + adjusted for Model 3: Model 2 + adjusted for organizational effects ( random organizational effects ( random effects, between hospital variation)effects, between hospital variation)

Results

Within and Between Disparities Within and Between Disparities Depend Depend

on the Quality Metric and on the Quality Metric and Racial/Ethnic GroupRacial/Ethnic Group

•Constructed 95 disparities measures

•Clinically and statistically significant disparities in 37 measures

•Disparity eliminated when adjusting for site of care: 11 measures

•Magnitude of disparity reduced when adjusting for site of care : 26 measures

HF-Smoking CessationHF-Smoking CessationSmoking Cessation

Unadjusted Adjusted, patient characteristics

Adjusted, patient characteristics plus hospital effect

Success Rate 83.1

83.4 85.2

Disparities Black NS NS NS Hispanic 5.8 *** 5.5 *** 1.2 * Asian 9.0 *** 8.1 *** 1.7 AI/AN

7.1*** 7.4 ***

3.4*

NH/PI 10.9 ***

11.6 *

0.8

*** P<.001** P<.01* P<.05

HF Discharge HF Discharge InstructionsInstructionsDischarge

Instructions Unadjusted Adjusted,

patient characteristics

Adjusted, patient characteristics plus hospital effect

Success Rate 58.5

58.4 58.8

Disparities Black NS NS NS Hispanic 6.6 *** 6.3 *** -0.1 Asian 9.4 (*** 8.9 *** 2.8 *** AI/AN

10.3 *** 10.3 ***

3.3**

NH/PI 11.4 ***

10.9 ***

1.3

*** P<.001** P<.01* P<.05

AMI-PCIAMI-PCIPCI within 120 minutes

Unadjusted Adjusted, patient characteristics

Adjusted, patient characteristics plus hospital effect

Success Rate 68.9 69.1 68.3 Disparities Black 14.9*** 13.0*** 10.5*** Hispanic 9.1 *** 8.6*** 3.9** Asian 6.5** 6.8** 4.5 * AI/AN NS NS NS NH/PI 28.9*** 29.4*** 27.8***

*** P<.001** P<.01* P<.05

PN-PN VaccinationPN-PN VaccinationPneumonia Vaccination

Unadjusted Adjusted, patient characteristics

Adjusted, patient characteristics plus hospital effect

Success Rate 63.9

63.8 62.0

Disparities Black 14.9*** 13.5*** 10.9 *** Hispanic 16.6 *** 15.2 *** 9.4 *** Asian 18.1*** 16.7*** 9.0 *** AI/AN

6.7 *** 5.9*

8.8***

NH/PI 23.3***

22.0***

13.9***

*** P<.001** P<.01* P<.05

Place-Based Disparities: Place-Based Disparities: Policy ImplicationsPolicy Implications

Disparities are multi-factorial—who you Disparities are multi-factorial—who you are are andand where you go where you go

Continued segregation in health care Continued segregation in health care Under-resourced institutions serve Under-resourced institutions serve

minority communitiesminority communities Focus incentives toward institutions Focus incentives toward institutions

serving a large % of minority patients.serving a large % of minority patients. Target resources to areas of greatest Target resources to areas of greatest

impact impact

Policy ImplicationsPolicy Implications

Risks of unintended consequences of Risks of unintended consequences of forcing action through P4P and public forcing action through P4P and public reportingreporting

Need protections of vulnerable Need protections of vulnerable populationspopulations Pay for improvementPay for improvement Pay for disparity reductionsPay for disparity reductions