Abstract
Although studies have described differences in hospital outcomes by patient race and socioeconomic status, it is not clear whether such disparities are driven by hospitals themselves or by broader systemic effects. To determine patterns of racial and socioeconomic disparities in outcomes within and between hospitals for patients with acute myocardial infarction, heart failure, and pneumonia. Retrospective cohort study initiated before February 2013, with additional analyses conducted during the peer-review process. Hospitals in the United States treating at least 25 Medicare fee-for-service beneficiaries aged 65 years or older in each race (ie, black and white) and neighborhood income level (ie, higher income and lower income) for acute myocardial infarction, heart failure, and pneumonia between 2009 and 2011 were included. For within-hospital analyses, risk-standardized mortality rates and risk-standardized readmission rates for race and neighborhood income subgroups were calculated at each hospital. The corresponding ratios using intraclass correlation coefficients were then compared. For between-hospital analyses, risk-standardized rates were assessed according to hospitals' proportion of patients in each subgroup. These analyses were performed for each of the 12 analysis cohorts reflecting the unique combinations of outcomes (mortality and readmission), demographics (race and neighborhood income), and conditions (acute myocardial infarction, heart failure, and pneumonia). Between 74% (3545 of 4810) and 91% (4136 of 4554) of US hospitals lacked sufficient racial and socioeconomic diversity to be included in this analysis, with the number of hospitals eligible for analysis varying among cohorts. The 12 analysis cohorts ranged in size from 418 to 1265 hospitals and from 144 417 to 703 324 patients. Within included hospitals, risk-standardized mortality rates tended to be lower among black patients (mean [SD] difference between risk-standardized mortality rates in black patients compared with white patients for acute myocardial infarction, -0.57 [1.1] [P = .47]; for heart failure, -4.7 [1.3] [P < .001]; and for pneumonia, -1.0 [2.0] [P = .05]). However, risk-standardized readmission rates among black patients were higher (mean [SD] difference between risk-standardized readmission rates in black patients compared with white patients for acute myocardial infarction, 4.3 [1.4] [P < .001]; for heart failure, 2.8 [1.8] [P < .001], and for pneumonia, 3.7 [1.3] [P < .001]). Intraclass correlation coefficients ranged from 0.68 to 0.79, indicating that hospitals generally delivered consistent quality to patients of differing races. While the coefficients in the neighborhood income analysis were slightly lower (0.46-0.60), indicating some heterogeneity in within-hospital performance, differences in mortality rates and readmission rates between the 2 neighborhood income groups were small. There were no strong, consistent associations between risk-standardized outcomes for white or higher-income neighborhood patients and hospitals' proportion of black or lower-income neighborhood patients. Hospital performance according to race and socioeconomic status was generally consistent within and between hospitals, even as there were overall differences in outcomes by race and neighborhood income. This finding indicates that disparities are likely to be systemic, rather than localized to particular hospitals.
Highlights
Achieving health equity is a long-standing goal for the American health care system, disparities in health outcomes persist.[1,2] Hospitals can play a key role in influencing patients’ outcomes, and encouraging trends in hospital performance have been documented[3,4,5]; it is important to know whether hospital performance differs according to patients’ race and socioeconomic status
Risk-standardized mortality rates tended to be lower among black patients
Risk-standardized readmission rates among black patients were higher
Summary
Achieving health equity is a long-standing goal for the American health care system, disparities in health outcomes persist.[1,2] Hospitals can play a key role in influencing patients’ outcomes, and encouraging trends in hospital performance have been documented[3,4,5]; it is important to know whether hospital performance differs according to patients’ race and socioeconomic status. A key question is whether disparities in outcomes vary within hospitals, and if so, whether their magnitude is consistent across all hospitals, suggesting a systemic effect, or varies, with some hospitals having larger differences in performance by race and income than others. A closely related question is whether disparities are driven by the concentration of patients of different races and socioeconomic status in high- or low-performing hospitals. To determine whether disparities were concentrated in specific institutions or represented a more systemic problem, we used patient-level Medicare claims data to investigate differences in outcomes in acute myocardial infarction (AMI), heart failure (HF), and pneumonia within and between hospitals. We determined whether there were within-hospital differences in performance between patient groups defined by race and socioeconomic status. We used 30-day risk-standardized mortality rates (RSMRs) and risk-standardized readmission rates (RSRRs) to determine absolute differences in outcomes between race and neighborhood income subgroups and the corresponding riskstandardized ratios, which describe hospitals’ expected performance relative to their predicted performance reflecting patient mix, to determine whether performance was similar across patient subgroups treated at the same hospital relative to how other hospitals treated those groups
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