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
To assess racial or ethnic disparities using the Hospital Quality Alliance (HQA) Inpatient Quality of Care Indicators.
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.
- 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.
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 Medic aid, 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 A frican American, Hispanic, Asian, and other.
- Patient-level multivariate logistic regression to estimate the likelihood of receiving the specified service
- Confidence intervals (CI) and standard deviation (SD).
Timing of Measurements
From the third quarter of 2002 to the first quarter of 2005.
- Age (older than 60 years)
- Race or ethnicity (minority or non-minority)
- Payer (Medicaid or indigent vs. other)
- Severity of illness
- 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.
- 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.
- 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.
- 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.
|Other:||The Commonwealth Fund|
- 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
|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|
|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|