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Health Disparities

HD: Availability and Access to Healthcare (2009)


Hasnain-Wynia R, Baker DW, Nerenz D, Feinglass J, Beal AC, Landrum MB, Behal R, Weissman JS. Disparities in health care are driven by where minority patients seek care: Examination of the hospital quality alliance measures. Arch Intern Med. 2007 Jun 25; 167 (12): 1,233-1,239. Erratum in: Arch Intern Med. 2007 Oct 22; 167 (19): 2,147.

PubMed ID: 17592095
Study Design:
Cross-sectional study
D - Click here for explanation of classification scheme.
Quality Rating:
Positive POSITIVE: See Quality Criteria Checklist below.
Research Purpose:

To assess racial or ethnic disparities using the Hospital Quality Alliance (HQA) Inpatient Quality of Care Indicators.

Inclusion Criteria:

Teaching hospitals reporting to the University HealthSystem Consortium (UHC)*.

*UHC is an alliance of academic medical centers and their affiliate hospitals in the United States. Of 1,100 teaching hospitals, 245 are UHC members.

Exclusion Criteria:
  • Patients who were younger than 18 years old
  • Patients whose race or ethnicity was classified as unknown
  • Patients from hospitals that reported fewer than 50 total cases or fewer than 15 minority cases for any of the three conditions.
Description of Study Protocol:


Subjects were not recruited; information was obtained from the University HealthSystem Consortium (UHC) clinical database. 


  • This was an observational study involving 123 teaching hospitals reporting to the UHC using patient-level data for
    • Acute myocardial infarction (AMI): Five care measures
    • Congestive heart failure (CHF): Two care measures
    • Community-acquired pneumonia (CAP): Two care measures
    • Patient counseling: Four care measures.
  • Hospital performance was examined on 13 of 17 measures from the third quarter of 2002 to the first quarter of 2005. Four measures were excluded because there were not a sufficient number of cases to make meaningful comparisons.
  • The UHC merged the Centers for Medicare and Medicaid Services data with inpatient discharge data to obtain information about sociodemographic characteristics and comorbidities. Categories included: Age (older than 60 years), sex, race or ethnicity (minority or non-minority) and payer (Medicaid or indigent vs. other). 
    • "Medicaid or indigent payer" was defined as Medicaid, county medically-indigent services and no charge
    • "Other" defined as Medicare, Blue Cross/Blue Shield, managed care, self-pay and third-payer insurance
    • "Minority" patients included those identified as African American, Hispanic, Asian, and other.

Statistical Analysis

  • Patient-level multivariate logistic regression to estimate the likelihood of receiving the specified service
  • Confidence intervals (CI) and standard deviation (SD).
Data Collection Summary:

Timing of Measurements

From the third quarter of 2002 to the first quarter of 2005.

Dependent Variables

  • Age (older than 60 years)
  • Sex
  • Race or ethnicity (minority or non-minority)
  • Payer (Medicaid or indigent vs. other) 
  • Severity of illness 
  • Comorbidities.

Independent Variables

  •  AMI measures
    • Aspirin at arrival at the hospital: Patients with AMI without aspirin contraindications who received aspirin therapy within 24 hours before or after hospital arrival
    • Aspirin at hospital discharge: Patients with AMI without aspirin contraindications who were prescribed aspirin at hospital discharge
    • ACE inhibitor for Left Ventricular Systolic Dysfunction (LVSD): Patients with AMI with LVSD and without ACE inhibitor contraindications who were prescribed an ACE inhibitor at hospital discharge
    • Beta-blocker at arrival at the hospital: Patients with AMI without beta-blocker contraindications who received a beta-blocker within 24 hours after arrival at the hospital
    • Beta-blocker at hospital discharge: Patients with AMI without beta-blocker contraindications who were prescribed a beta-blocker at hospital discharge.
  • CHF measures
    • LV function assessment: Patients with CHF with documentation that LV function was assessed before arrival, during hospitalization or is planned after hospital discharge
    • ACE inhibitor for LVSD: Patients with CHF with LVSD and without ACE inhibitor contraindications who were prescribed an ACE inhibitor at hospital discharge.
  • CAP measures
    • Oxygen assessment: Increased awareness of the importance of oxygenation assessment, which can improve outcomes in patients with CAP
    • Initial antibiotic therapy within eight hours of arrival at the hospital: Time-line of antibiotic administration for inpatients with pneumonia.
  • Counseling measures: 
    • AMI: Smoking cessation advice or counseling. Patients with AMI with a history of smoking cigarettes who are given smoking cessation advice or counseling during hospital stay
    • CHF: Smoking cessation advice or counseling. Patients with CHF with a history of smoking cigarettes who are given smoking cessation advice or counseling during their hospital stay
    • CAP: Smoking cessation advice or counseling. Ensure that adult patients with CAP are educated about behavioral risk factors that contribute to the disease
    • CHF: Discharge instructions. Patients with CHF discharged to home with written instructions or educational material given to patient or caregiver at discharge or during hospital stay addressing all of the following: Activity level, diet, discharge medications, follow-up appointment, weight monitoring and what to do if symptoms worsen.
Description of Actual Data Sample:
  • Initial N: Data subset for 123 hospitals, involving 320,970 patients
  • Attrition (final N): 320,970 patients (123 hospitals)
  • Age: 18 years and older
  • Ethnicity: 40% were racial or ethnic minorities; minority patients were identified as African-American, Hispanic, Asian and other.

Other Relevant Demographics

  • All 123 hospitals were teaching hospitals
  • 62% had at least 300 beds.


Were not collected.


123 hospitals throughout the US:

  • 10.8% in the Northeast
  • 19.2% in the Mid-Atlantic
  • 18.3 in the Southeast
  • 35.9% in the Midwest
  • 15.8% in the West.
Summary of Results:
  • The number of hospitals differed for each measure because of individual patient eligibility criteria for denominator cases plus hospital-level exclusion criteria
  • Minority patients were those identified as African-American, Hispanic, Asian and other. Preliminary analyses showed that the patients in each of these sub-groups displayed similar trends. Therefore, these sub-groups were combined to this one category for analytical purposes.

Success Rates for HQA Measures

  • HQA performance rates were greater than 90% for all AMI measures with statistically-significant (P<0.05), but small absolute differences, the exception being ACE inhibitor use
  • CHF showed small but statistically-significant (P<0.001) differences between minority and non-minority patients
  • Minority patients were more likely to receive ACE inhibitors
  • CAP measures showed significant (P<0.001) differences for oxygenation assessment and receipt of antibiotic therapy within eight hours of arrival
  • Counseling measures had lower overall performance rates (well below 90%). Minority patients were significantly less likely to receive these services (P<0.001) and the overall differences were consistently large. 

Adjusted and Unadjusted Racial or Ethnic Disparities in the HQA Measures

  • Adjusting for individual patient characteristics had little effect on success rates for most measures. The exception was in "minority patients with CHF receiving ACE inhibitors more often," reduced from 4.5% to 1.9%.
  • The unadjusted differences ranged from 1.54% for AMI beta-blocker at discharge (95% CI, 0.5 to 2.68) to 14.58% for CAP-smoking cessation counseling (95% CI, 2.74 to 26.1)
  • The magnitudes of the racial or ethnic disparities decreased substantially when adjusting for site of care
  • The 10% point difference (unadjusted, 9.61; 95% CI, 4.44 to 14.74; P<0.001) in the likelihood of receiving discharge instructions among patients with CHF was eliminated once they controlled for site of care (adjusted, 0.49; 95% CI, -0.92 to 1.89; P=0.50).


  • Hospitals that perform less well on HQA measures tend to serve a higher percentage of minority patients. Only 20% of patients were minorities in top-performing hospitals compared with 70% of patients in lower-performing hospitals for AMI smoking cessation.
  • Trend reversal for two ACE inhibitor measures: The top-performing hospitals had a higher percentage of minority patients than did the lower-performing hospitals.
Author Conclusion:
  • Quality care for minority patients is often lower than for non-minority patients
  • Disparities in clinical process of care measures are largely the result of differences in where minority and non-minority patients seek care
  • Disparities in services requiring counseling exist within hospitals after controlling for site of care.
Funding Source:
Other: The Commonwealth Fund
Reviewer Comments:
  • Recent study
  • Large database
  • Much detail given
  • Type of clinician who provided service, counseling, advice or prescription was not identified.
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? Yes
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? No
  2.4. Were the subjects/patients a representative sample of the relevant population? Yes
3. Were study groups comparable? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) Yes
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? Yes
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) Yes
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? Yes
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) Yes
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? Yes
  4.1. Were follow-up methods described and the same for all groups? N/A
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) N/A
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? No
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) N/A
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? No
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? Yes
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? Yes
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? N/A
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? N/A
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? N/A
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? Yes
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes