Disparities In Quality Of Care Research Articles

Association of Medicare Advantage Star Ratings With Racial, Ethnic, and Socioeconomic Disparities in Quality of Care.

Medicare Advantage (MA) plans, which disproportionately enroll racial/ethnic minorities and persons with socioeconomic disadvantage, receive bonus payments on the basis of overall performance on a 5-star rating scale. The association between plans' overall quality and disparities in quality is not well understood. To examine the association between MA star ratings and disparities in care for racial/ethnic minorities and enrollees with lower income and educational attainment. This cross-sectional study included 1 578 564 MA enrollees from 454 contracts across the 2015 and 2016 calendar years. Data analyses were conducted between June 2019 and June 2020. Self-reported race and ethnicity and low socioeconomic status (SES) (defined by low income or less than a high school education) vs high SES (neither low income nor low educational attainment). Performance on 22 measures of quality and satisfaction determined at the individual enrollee level, aggregated into simulated star ratings (scale, 2-5) stratified by SES and race/ethnicity. A total of 1 578 564 enrollees were included in this analysis (55.8% female; mean [SD] age, 71.4 [11.3] years; 65.8% White; 12.3% Black; 14.6% Hispanic). Enrollees with low SES had simulated stratified star ratings 0.5 stars lower (95% CI, 0.4-0.6 stars) than individuals with high SES in the same contract. Black and Hispanic enrollees had simulated star ratings that were 0.3 stars (95% CI, 0.2-0.4 stars) and 0.1 stars (95% CI, -0.04 to 0.2 stars) lower than White enrollees within the same contracts. Black enrollees had a 0.4-star lower rating (95% CI, 0.1-0.7 stars) in 4.5- to 5-star contracts and a no statistical difference in 2.0- to 2.5-star-rated contracts (difference, 0.3 stars; 95% CI, -0.02 to 0.7 stars). Hispanic enrollees had a 0.6-star lower simulated rating (95% CI, 0.2-1.0 stars) in 4.5- to 5-star contracts and no statistical difference in 2- to 2.5-star contracts (difference, -0.01 stars; 95% CI, -0.5 to 0.4 stars). There was low correlation between simulated ratings for enrollees of low SES and high SES (difference, 0.2 stars; 95% CI, 0.03-0.4 stars) and between simulated ratings for White and Black enrollees (difference, 0.4 stars; 95% CI, 0.3-0.5 stars) and White and Hispanic enrollees (difference, 0.3 stars; 95% CI, 0.2-0.4 stars). As the proportion of Black and Hispanic enrollees increased in a contract, racial/ethnic disparities in ratings decreased. In this cross-sectional study, simulated MA star ratings were only weakly correlated with those for enrollees of low SES in the same contract, and contracts with higher star ratings had larger disparities in quality. Measures of equity in MA plans' quality of care may be needed.

Abstract P878: Racial and Ethnic Disparities in Early Hypertension Control After Intracerebral Hemorrhage

Introduction: Survivors of Intracerebral Hemorrhage (ICH) are at high risk of recurrent stroke. This risk is inversely proportional to average Blood Pressure (BP) after ICH. Racial/ethnic minority ICH survivors in the US demonstrate greater hypertension severity after ICH and are at higher risk of recurrent cerebral bleeding. Since most recurrent strokes occur within 12-18 months of index ICH, rapidly achieving BP control is likely to be crucial. We investigated the frequency, prognostic impact, and racial/ethnic disparities in uncontrolled short-term hypertension (HTN) after ICH. Methods: We analyzed data from prospective ICH cohort studies at Massachusetts General Hospital (MGH-ICH, n=1305) and the University of Hong Kong (HK-ICH, n=523). We classified HTN as controlled, uncontrolled or treatment-resistant and determined: 1) risk factors for uncontrolled and treatment-resistant HTN; and 2) whether HTN control at 3 months is associated with long-term BP control, stroke recurrence and mortality across self-reported race/ethnicity groups. Results: We followed 1828 ICH survivors (1128 White, 565 Asian, 59 Hispanic, 49 Black, 27 other) for a median of 46.2 months. Only 9 of 172 (5%) recurrent strokes occurred before 3 months after ICH. At 3 months, 713 participants (39%) had controlled HTN, 755 (41%) had undertreated HTN, and 360 (20%) had treatment-resistant HTN. BP measurements at 3 months were highly correlated with measurements during follow-up (p<0.001). Black, Hispanic and Asian race/ethnicity were associated with higher prevalence of uncontrolled HTN at 3 months (all p<0.05). Both undertreated and uncontrolled HTN at 3 months were associated with increased risk of recurrent stroke and mortality during follow-up (all p<0.05). Conclusions: Most ICH survivors have inadequate HTN control 3 months after ICH, with under-treatment accounting for the majority of cases. Three-month BP measurements are associated with inadequate long-term HTN control, higher recurrent stroke risk and mortality. ICH survivors self-reporting as Black, Hispanic or Asian appear to be at highest risk for uncontrolled HTN. Optimizing HTN control at 3 months is a unique opportunity to address racial/ethnic disparities in quality of care among survivors of primary ICH.

Hospital efficiency and quality of prostate cancer care.

223 Background: There is no consistent evidence with respect to the role of hospital efficiency in improving quality of prostate cancer care. Study objective was to examine the association between hospital efficiency and quality of care in African American, Hispanic, and white Medicare beneficiaries with prostate cancer. Methods: Population-based cohort study using Surveillance, Epidemiological, and End Results-Medicare (SEER-Medicare) data from 2000–2016 for prostate cancer patients aged 66 or older. SEER-Medicare data was linked to American Hospital Association data. We computed hospital technical efficiency using data envelopment analysis. Outcomes were emergency room visits, complications, hospitalizations, cost, treatment and mortality (all-cause and prostate cancer-specific). We used competing risk analysis for survival, log-link GLM models for cost, and Poisson (zero inflated) models for count data. Propensity score and instrumental variable approaches were used to minimize potential biases. Results: We identified 87,117 eligible prostate cancer patients. Of these, 86% were white, 11% were African American, and 3% were Hispanic. Table shows the association between four quartiles of efficiency and outcomes. Higher hospital efficiency was consistently associated with decreased all-cause mortality, prostate cancer-specific mortality and emergency room visits. Association between hospital efficiency and mortality varied between racial and ethnic groups. Conclusions: Increasing hospital efficiency may reduce some of the disparity in prostate cancer outcomes. Our findings indicate important racial and ethnic differences that should be considered while planning hospital efficiency models to improve quality of prostate cancer care. Policies to redirect minority patients to hospital with higher efficiency may reduce racial and ethnic disparity in quality of care and outcomes. [Table: see text]

The Potential for Health Information Technology Tools to Reduce Racial Disparities in Maternal Morbidity and Mortality.

Health information technology (health IT) potentially is a promising vital lever to address racial and ethnic, socioeconomic, and geographic disparities in maternal morbidity and mortality (MMM). This is especially relevant given that approximately 60% of maternal deaths are considered preventable.1–36 Interventions that leverage health IT tools to target the underlying drivers of disparities at the patient, clinician, and health care system levels potentially could reduce disparities in quality of care throughout the continuum (antepartum, intrapartum, and postpartum) of maternity care. This article presents an overview of the research (and gaps) on the potential of health IT tools to document SDoH and community-level geocoded data in EHR-based CDS systems, minimize implicit bias, and improve adherence to clinical guidelines and coordinated care to inform multilevel (patient, clinician, system) interventions throughout the continuum of maternity care for health disparity populations impacted by MMM. Telemedicine models for improving access in rural areas and new technologies for risk assessment and disease management (e.g., regarding preeclampsia) also are discussed.

Assessment of Racial Disparities in Primary Care Physician Specialty Referrals

Disparities in quality of care according to patient race and socioeconomic status persist in the US. Differential referral patterns to specialist physicians might be associated with observed disparities. To examine whether differences exist between Black and White Medicare beneficiaries in the observed patterns of patient sharing between primary care physicians (PCPs) and physicians in the 6 specialties to which patients were most frequently referred. This cross-sectional observational study of Black and White Medicare beneficiaries used claims data from 2009 to 2010 on 100% of traditional Medicare beneficiaries who were seen by PCPs and selected high-volume specialists in 12 health care markets with at least 10% of the population being Black. Statistical analyses were conducted from December 20, 2017, to September 30, 2020. Differences in patterns of patient sharing among Black and White patients. Primary care physician and specialist degree (the number of other PCPs or specialists to whom each physician is connected) and strength (the number of shared patients per connection, overall, for Black patients and White patients and after equalizing the numbers of Black and White patients per PCP), as well as distance between PCP and patient and specialist zip code centroids. The 12 selected markets ranged in size from Manhattan, New York (187 054 Black or White beneficiaries seen by at least 2 physicians within an episode of care; 9794 total physicians), to Tallahassee, Florida (44 644 Black or White beneficiaries seen by at least 2 physicians within an episode of care; 847 total physicians). The percentage of Black beneficiaries ranged from 11.5% (Huntsville, Alabama) to 46.8% (Chicago, Illinois). The mean PCP-specialist degree (number of specialists with whom a PCP shares patients) was lower for Black patients than for White patients. For instance, the mean PCP-cardiologist degree across all markets for White patients was 17.5 compared with 8.8 for Black patients. After sampling White patients to equalize the numbers of patients seen, the degree differences narrowed but were still not equivalent in many markets (eg, for all specialties in Baton Rouge, Louisiana: 4.5 for Black patients vs 5.7 for White patients). Specialist networks among White patients were much larger than those constructed based just on Black patients (eg, for cardiology across all markets: 135 for Black patients vs 330 for White patients), even after equalizing the numbers of patients seen per PCP (123 for Black patients vs 211 for White patients). The overall test for differences in referral patterns was statistically significant for all 6 specialties examined in 7 of the 12 markets and in 5 specialties for another 3. This study suggests that differences exist in specialist referral patterns by race among Medicare beneficiaries. This is an observational study, and thus some differences might have resulted from patient-initiated visits to specialists.

Racial Differences in Post-Acute Transition After Hip Fracture in Medicare Patients With ADRD

The incidence of hip fractures in patients with Alzheimer’s disease and related dementias (ADRD) is 2.7 times higher than it is in those without ADRD. However, there are no standardized post-acute transition models for patients with ADRD after hip fracture. Additionally, there is a lack of knowledge on how post-acute transitions vary by race/ethnicity. Using 100% Medicare data (2016-2017) for 120,179 older adults with ADRD, we conduct multinomial logistic regression, to examine the association between race and post-acute discharge locations (proportion discharged to skilled nursing facility [SNF], inpatient rehabilitation facility [IRF], and Home with Home Health Care [HHC]), after accounting for patient characteristics. Compared to non-Hispanic Whites, Hispanics have a significantly lower odds ratio for discharge to HHC 0.62 (95%CI=0.53-0.73), IRF 0.44 (CI=0.39-0.51), and SNF 0.26 (CI=0.23-0.30). Improving care in patients with ADRD and reducing racial and ethnic disparities in quality of care and health outcomes will be discussed.

Accountable care organizations and racial and ethnic disparities among patients with Alzheimer’s and related dementia diseases

AbstractBackgroundThe accountable care organization (ACO) is a new care coordination model and reimbursement mechanism that incentivizes providers to deliver high‐quality and well‐coordinated care. This study is the first to provide evidence on the ACOs enrollment and quality of enrolled ACOs among patients with ADRD, and evidence associated with racial disparities in quality of care for persons with ADRD.MethodOur study used 2017 Centers for Medicare and Medicaid Services Medicare inpatient claims data and Medicare Beneficiary Summary File. Our study focused on patients who had a diagnosis of ADRD. We further linked the CMS claims data with the 2017 MSSP ACO data to capture the patient’s participation of the ACO. The CMS ACO quality measures were used to examine the quality of the ACOs among those who enrolled in the ACOs. In this study, we examined four 4 ACO quality measures related to hospital care quality: risk standardized, all condition readmission (ACO 8), all‐cause unplanned admissions for patients with diabetes (ACO 36), heart failure (ACO 37), and multiple chronic conditions (ACO 38). Finally, we merged our data with the 2017 American Community Survey, Area Health Resource File, and the American Hospital Annual survey to capture the geographic and hospital characteristics.ResultsIn 2017, 37% of Medicare beneficiaries with ADRD were enrolled in the ACO. Substantial variation of the ACO participation by patients’ races and ethnicities was observed, ranging from 38% among the white to 14% among the Native ADRD patients. Regression results showed that compared to white, African American, Hispanic, Asian, and Native Medicare beneficiaries with ADRD were significantly less likely to enroll in the ACOs. Among those enrolled in the ACOs, we further observed ACO 8, ACO 36, ACO 37, ACO 38 were significantly higher, i.e. worse quality, among African American, Hispanic, and Native ADRD patients.ConclusionsResults suggested that policymakers should create incentives for minority‐serving providers to participate in ACOs and provide minority‐serving ACOs with structural assistance to ensure that they can successfully attain their performance goals.

Abstract PO-119: Separate and unequal: Examining the role of race and site of care on patient-reported outcomes among patients with metastatic cancer (AFT-39)

Abstract Background Racial disparities in patient-reported outcomes (PROs; e.g., symptoms, financial burden) among patients with cancer are well documented. Prior studies have attributed such disparities to patient- and provider-level factors, but less is known about the contribution of practice-level factors. Hospital racial composition of patients has been linked to disparities in care quality and outcomes, but questions remain regarding whether oncology practice racial composition mediates racial disparities. Using 2017-2020 data from the Patient-Reported Outcomes to Enhance Cancer Treatment (PRO-TECT) trial (ClinicalTrials.gov NCT03249090), we examined racial disparities in PROs among patients with metastatic cancer, and whether oncology practice racial composition accounted for observed disparities. Methods Our sample included 1099 patients (n=198 Black; n=901 White) from 51 community oncology practices across the US. Predictors of interest were patient race (Black vs. White) and practice-reported racial composition (Black patient population >20% vs. ≤20%). Patient-reported outcome metrics included pain, appetite loss, fatigue, nausea, dyspnea, insomnia, constipation, diarrhea, and financial burden, measured at baseline and at 1- and 3-month follow-up using the EORTC Quality of Life Core Questionnaire (QLQ-C30). Raw EORTC QLQ-C30 scores were standardized to range from 0 (best) to 100 (worst). We estimated multilevel linear mixed models predicting each PRO as a function of patient race, adjusting for clinical and sociodemographic factors, followed by further adjustment for practice racial composition. Results Twelve out of fifty-one (23.5%) practices reported a Black racial composition of >20%, with 41.6% of Blacks and 14.5% Whites receiving care at these practices. Across all practices, Blacks reported worse pain (β=5.5, p=0.02), nausea (β=2.5, p=0.04) and financial burden (β=7.6, p<0.01), but less fatigue (β=-4.1, p=0.05) when compared with Whites. Regardless of race, patients receiving care at practices with a Black racial composition of >20% reported more pain (β=5.5, p=0.01), appetite loss (β=8.1, p<0.01), fatigue (β=5.1, p=0.01), nausea (β=2.3, p=0.05), dyspnea (β=4.3, p=0.04), and insomnia (β=4.8, p=0.03) than patients receiving care at practices comprised of ⇐20% Blacks. Practice racial composition did not mediate racial disparities in PROs. Conclusion Racial disparities in PROs were observed among patients treated at US community oncology practices. Practice racial composition was associated with multiple PROs, regardless of patient race, but racial disparities in PROs were not explained by practice racial composition. These findings suggest that identifying and addressing the needs of practices serving a disproportionate share of Black patents may be one effective strategy to mitigate practice-level disparities in cancer outcomes. Citation Format: Cleo A. Samuel, Olive Mbah, Wendi Elkins, Marjory Charlot, Amylou Dueck, Brenda F. Ginos, Jennifer Jansen, Deborah Schrag, Patty Spears, Angela Stover, Ethan Basch. Separate and unequal: Examining the role of race and site of care on patient-reported outcomes among patients with metastatic cancer (AFT-39) [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-119.

Investigating the geographic disparity in quality of care the case of hospital readmission after acute myocardial infarction in Italy

Investigating the geographic disparity in quality of care the case of hospital readmission after acute myocardial infarction in Italy

Investigating the geographic disparity in quality of care: the case of hospital readmission after acute myocardial infarction in Italy

Unwarranted variation in the quality of care challenges the sustainability of healthcare systems. Especially in decentralised healthcare systems, it is crucial to understand the drivers behind regional differences in hospital qualities such as unplanned readmissions. This paper examines the factors that influence the risk of unplanned hospital readmission and the geographic disparity of readmission rate in Italy. We use hospital discharge data from 2010 to 2015 for patients above 65 years old admitted with Acute Myocardial Infarction. Employing hierarchical models, we identified the patient and hospital-level determinants for unplanned readmission. In line with the literature, the risk of readmission increases with age and being male, while hospitals with higher patient volume and capacity tend to have lower unplanned readmission. In particular, we find that after patient risk-adjustments, there are differential effects of hospitalisation length-of-stay on the probability of readmission across the hospitals that are governed by different payment systems. For hospitals under a prospective payment system, the effect of length-of-stay in reducing the probability of readmission is weaker than hospitals under an ex-post global budget, but the overall readmission rates are the lowest. Moreover, there are substantial geographic variations in readmission rate across Local Health Authority and regions, and these variations of unplanned readmission are explained by differences in hospital length-of-stay and surgical procedures used. Our results demonstrate that differential hospital behaviours can be one of the potential mechanisms that drive geographic quality disparities.

Antecedents of Geographical Expansion Strategy: A Case of Federally Qualified Health Centers

FQHCs play a pivotal role as a safety-net primary care provider in the US health system. While ample evidence suggests that the overall number of FQHCs and FQHC sites has been on a steady rise, little is known about a vast difference in the number of FQHC sites across FQHCs and communities. Wide variations in the number of sites between FQHCs have important implications such as differential access that may perpetuate disparities in quality of care. Understanding the gap, this study examines the association between an array of organizational and environmental factors and the number of FQHC sites. The result indicated that FQHC patient volume and competition in the area were significantly associated with the extent to which FQHCs operating more sites in different locations. The result also indicated that the variance in the number of FQHC sites is largely due to between-FQHC differences meaning that the overall growth of the FQHC program may not occur just by FQHCs growing over time. Our results imply that managers and policymakers should appropriately address underlying factors in an effort to foster even growth of FQHCs.

Gender differences in COPD management in a Sicilian general practice setting: a cohort study evaluating the impact of educational interventions.

AimThe aim of this study was to measure gender differences among COPD patients' quality of care (QOC) before and after two educational interventions in Southern Italy.MethodsIn this prospective cohort study, COPD patients were identified from primary care electronic medical records (EMRs). Twelve process indicators concerning diagnosis, preventative measures and therapeutic processes were developed as a measure of QOC. Educational interventions consisted of clinical seminars and audits on COPD QOC at baseline, and at 12 and 24 months. QOC indicators were stratified by gender: odds ratios (ORs) (males as reference group) of having a good QOC indicator were calculated at baseline, 12 and 24 months, with 95% confidence intervals (CIs) using hierarchical generalised linear models.ResultsOf 46 326 people registered in the EMRs, 1463 COPD patients (3.1%) were identified, of which 37% were women. QOC indicators reflecting best practice 24 months after the educational programme were generally not different to baseline, often favouring men. On the other hand, the composite global QOC indicator suggested that while a good overall QOC at baseline was significantly higher in men than women (OR: 0.74; 95% CI: 0.57–0.96), it became nonsignificant at 24 months (OR: 0.96; 95% CI: 0.72–1.29).ConclusionsSpecific QOC indicators among COPD patients often favoured men. However, several gender disparities seen at baseline disappeared at 24 months, suggesting that even general educational interventions which do not target gender can improve the gender disparity in QOC.

Understanding Risk Factors for Amputation in Patients With Diabetes and/or Peripheral Arterial Disease in a Highly Rural State

Amputation is a devastating but prevenTable complication of diabetes and peripheral arterial disease (PAD). It is a marker of severe disease and of disparities in quality of care. Rural populations have multiple risk factors for amputation; however, there is a significant gap in amputation research in rural communities. This study sought to identify risk factors for amputation in the highly rural state of West Virginia using a large, longitudinal institutional database. The West Virginia Clinical and Translational Science Institute Integrated Data Repository, a longitudinal database of more than 2 million patients, containing electronic health record data for all inpatient and outpatient encounters at West Virginia University and West Virginia University-affiliated hospitals and clinics comprised the sample for analyses. Adults (≥18 years) with recorded diagnoses of diabetes and/or PAD between 2011 and 2016 were included based on International Classification of Diseases, 9th clinical modification, and 10th edition clinical modification codes. Major and minor amputations were identified using Current Procedural Terminology codes. Trauma patients were excluded. Descriptive analyses and multivariable logistic regression models examining factors associated with major, minor and any amputation were performed. During the study period, 50,276 patients were treated for diabetes and/or PAD, 369 (7.3/1000) had any amputation over the study period; 210 had major (4.2/1000) amputations, 128 had minor (2.5/1000) amputations and 31 patients had both (0.6/1000). On multivariable analyses (Table I), male sex, self-pay, Medicaid, and Medicare insurance status all had significantly higher risk for major amputation. Minor amputation, which is often considered protective for major amputation, was found to increase the odds of major amputation 11.7 times. PAD patients had 12.3 times higher odds of any amputation compared to patients with diabetes, while patients with both diabetes and PAD had a 51.8 times higher odds of any amputation compared to patients with diabetes alone. C-statistics for all models were over 0.8, indicating a strong model. This unique longitudinal dataset has allowed us to identify several important features of diabetes and PAD-related amputation in our patient population: the first is that West Virginians undergo amputation for diabetes and/or PAD at rates more than double (7.3/1000 compared to the national prevalence of 2.4/1000) the rest of the country. In addition, patients with PAD alone or PAD plus diabetes had strikingly higher odds for amputation compared to diabetes alone. This suggests that population-based interventions for amputation prevention may be more successful if focused on PAD risk factor modification, such as tobacco cessation and medical optimization, rather than just simple diabetic foot care measures.TableMultivariable analysis of odds of major, minor and any amputation in patients with diabetes and/or peripheral artery disease (PAD) in West VirginiaVariableMajor (adjusting for minor)Minor (excluding majors)Any amputationMinora11.79 (7.19-19.33)––Rural (defined using Rural-urban community area code)1.09 (0.8-1.48)0.82 (0.52-1.29)0.98 (0.77-1.27)Tobacco user0.91 (0.57-1.44)0.9 (0.48-1.71)0.9 (0.62-1.31)Male vs female2.15 (1.61-2.85)2.63 (1.77-3.9)2.43 (1.93-3.07)Medicaid vs private1.79 (1.18-2.71)0.88 (0.51-1.51)1.35 (0.98-1.87)Medicare vs private1.54 (1.04-2.26)0.7 (0.43-1.15)1.12 (0.83-1.52)Self-pay vs private1.83 (1.09-3.07)1.42 (0.76-2.66)1.69 (1.13-2.52)Age0.99 (0.98-1)0.99 (0.97-1.01)0.99 (0.98-1)CAD0.36 (0.27-0.49)0.18 (0.12-0.28)0.26 (0.2-0.33)PAD vs diabetes13.78 (7.75-24.49)8.4 (4.18-16.85)12.29 (7.93-19.07)PAD and diabetes vs diabetes41.07 (23.27-72.46)52.52 (27.43-100.53)51.81 (33.85-79.3)CHF1.11 (0.79-1.54)1.5 (0.94-2.38)1.24 (0.95-1.62)CKD1.83 (1.32-2.54)1.5 (0.95-2.36)1.75 (1.34-2.27)COPD0.99 (0.73-1.34)1.07 (0.7-1.64)1 (0.78-1.29)Hypercholesterolemia0.97 (0.73-1.3)0.76 (0.52-1.13)0.89 (0.71-1.13)Obesity0.92 (0.68-1.25)0.92 (0.61-1.4)0.93 (0.73-1.19)Renal failure1.47 (0.97-2.24)0.85 (0.43-1.7)1.24 (0.87-1.77)C-statistic0.8500.8160.841Text in bold indicates statistically significant findings.aFor those with both major and minor amputations, we only counted minors occurring before major to see if that led to higher odds of major amputations. Open table in a new tab

Results of a Qualitative Study to Understand Risk Factors for Amputation in Patients With Diabetes and/or Peripheral Arterial Disease in a Highly Rural State

Amputation is a devastating but preventable complication of diabetes and peripheral arterial disease (PAD). It serves as a marker for severe disease as well as for disparities in quality of care. The majority of studies on this issue use quantitative methods, which are useful for identifying prevalence rates and patterns of disease, but have difficulty providing deeper explanations about why certain groups have higher risks for amputation than others. Qualitative methods are ideal for providing rich, meaningful answers for such questions. The purpose of this study was to use a qualitative approach to understand barriers to limb preservation in patients with diabetes and/or PAD in the highly rural state of West Virginia. Participant recruitment was directed by preliminary research identifying high-risk areas for amputation across the state. Focus groups and interviews were conducted by a moderator using a semistructured interview guide focused on barriers to limb preservation. Four groups were interviewed: diabetic and/or PAD patients who have undergone amputation (and their caretakers), vascular providers and surgeons, wound care providers, and primary care providers. Audio recordings of each session were transcribed verbatim and data were analyzed by two coders using NVivo software. Conventional content analysis was carried out to develop a codebook and analyze data for themes related to patient and provider barriers. Eight focus groups, three phone interviews, and three in-person interviews (n = 64) were conducted. Lack of education was the most frequently cited barrier by both patients and providers across all sessions. Geographic isolation, lack of transportation, and cultural norms also emerged as barriers to limb preservation. There was also consensus that health care costs, access to care, and care coordination were major obstacles patients faced when attempting to manage their conditions. Providers emphasized that patient adherence to care plans was a significant barrier to limb preservation. In addition to these barriers, three main risk factors related to patient care emerged: depression, diabetes, and tobacco use. This qualitative study identified important themes contributing to the risk of amputation in West Virginia from the perspective of patients and providers. These include (1) lack of education, (2) geographic and cultural barriers, (3) difficulty with care coordination, (4) poor patient adherence and (5) depression, diabetes and tobacco use. Based on these themes, amputation prevention efforts in West Virginia should be directed toward improving patient education, improving access to care, improving social and mental health support systems, and providing culturally sensitive approaches to patient care.

Racial/Ethnic Disparities Among Extremely Preterm Infants in the United States From 2002 to 2016

Racial/ethnic disparities in quality of care among extremely preterm infants are associated with adverse outcomes. To assess whether racial/ethnic disparities in major outcomes and key care practices were changing over time among extremely preterm infants. This observational cohort study used prospectively collected data from 25 US academic medical centers. Participants included 20 092 infants of 22 to 27 weeks' gestation with a birth weight of 401 to 1500 g born at centers participating in the National Institute of Child Health and Human Development Neonatal Research Network from 2002 to 2016. Of these infants, 9316 born from 2006 to 2014 were eligible for follow-up at 18 to 26 months' postmenstrual age (excluding 5871 infants born before 2006, 2594 infants born after 2014, and 2311 ineligible infants including 64 with birth weight >1000 g and 2247 infants with gestational age >26 6/7 weeks), of whom 745 (8.0%) did not have known follow-up outcomes at 18 to 26 months. Rates of mortality, major morbidities, and care practice use over time were evaluated using models adjusted for baseline characteristics, center, and birth year. Data analyses were conducted from 2018 to 2019. In total, 20 092 infants with a mean (SD) gestational age of 25.1 (1.5) weeks met the inclusion criteria and were available for the primary outcome: 8331 (41.5%) black infants, 3701 (18.4%) Hispanic infants, and 8060 (40.1%) white infants. Hospital mortality decreased over time in all groups. The rate of improvement in hospital mortality over time did not differ among black and Hispanic infants compared with white infants (black infants went from 35% to 24%, Hispanic infants went from 32% to 27%, and white infants went from 30% to 22%; P = .59 for race × year interaction). The rates of late-onset sepsis among black infants (went from 37% to 24%) and Hispanic infants (went from 45% to 23%) were initially higher than for white infants (went from 36% to 25%) but decreased more rapidly and converged during the most recent years (P = .02 for race × year interaction). Changes in rates of other major morbidities did not differ by race/ethnicity. Death before follow-up decreased over time (from 2006 to 2014: black infants, 14%; Hispanic infants, 39%, white infants, 15%), but moderate-severe neurodevelopmental impairment increased over time in all racial/ethnic groups (increase from 2006 to 2014: black infants, 70%; Hispanic infants, 123%; white infants, 130%). Rates of antenatal corticosteroid exposure (black infants went from 72% to 90%, Hispanic infants went from 73% to 83%, and white infants went from 86% to 90%; P = .01 for race × year interaction) and of cesarean delivery (black infants went from 45% to 59%, Hispanic infants went from 49% to 59%, and white infants went from 62% to 63%; P = .03 for race × year interaction) were initially lower among black and Hispanic infants compared with white infants, but these differences decreased over time. Among extremely preterm infants, improvements in adjusted rates of mortality and most major morbidities did not differ by race/ethnicity, but rates of neurodevelopmental impairment increased in all groups. There were narrowing racial/ethnic disparities in important care practices, including the use of antenatal corticosteroids and cesarean delivery.

Prevalence and Inpatient Hospital Outcomes of Malignancy-Related Ascites in the United States

Malignancy-related ascites (MRA) is the terminal stage of many advanced cancers, and the treatment is mainly palliative. This study looked for epidemiology and inpatient hospital outcomes of patients with MRA in the United States using a national database. The current study was a cross-sectional analysis of 2015 National Inpatient Sample data and consisted of patients ≥18 years with MRA. Descriptive statistics were used for understanding demographics, clinical characteristics, and MRA hospitalization costs. Multivariate regression models were used to identify predictors of length of hospital stay and in-hospital mortality. There were 123 410 MRA hospitalizations in 2015. The median length of stay was 4.7 days (interquartile range [IQR]: 2.5-8.6 days), median cost of hospitalization was US$43 543 (IQR: US$23 485-US$82 248), and in-hospital mortality rate was 8.8% (n = 10 855). Multivariate analyses showed that male sex, black race, and admission to medium and large hospitals were associated with increased hospital length of stay. Factors associated with higher in-hospital mortality rates included male sex; Asian or Pacific Islander race; beneficiaries of private insurance, Medicaid, and self-pay; patients residing in large central and small metro counties; nonelective admission type; and rural and urban nonteaching hospitals. Our study showed that many demographic, socioeconomic, health care, and geographic factors were associated with hospital length of stay and in-hospital mortality and may suggest disparities in quality of care. These factors could be targeted for preventing unplanned hospitalization, decreasing hospital length of stay, and lowering in-hospital mortality for this population.

Effect of the Patient-Centered Medical Home on Racial Disparities in Quality of Care.

Research demonstrates that the patient-centered medical home (PCMH) is associated with improved clinical outcomes and quality of care, and the populations that can most benefit from this model require long-term management, e.g., persons with chronic illness and behavioral health conditions. However, different populations may not benefit equally from the PCMH, and empirical evidence about the effects of this model on racial disparities is limited. Estimate the association between enrollment in National Committee for Quality Assurance (NCQA)-recognized PCMHs and racial disparities in quality of care for adults with major depressive disorder (MDD) and comorbid medical conditions. Applying a quasi-experimental instrumental variable design to account for differential selection into the PCMH, we used generalized estimating equations to determine the probability of receiving eight disease-specific quality measures. Medicaid enrollees in three states not dually enrolled in Medicare, ages 18-64 with MDD and > 1 other chronic condition. A subgroup analysis was conducted for enrollees with comorbid diabetes. Enrollment in an NCQA-recognized PCMH. Disease-specific quality indicators for MDD (e.g., antidepressant use, receipt of psychotherapy), and for diabetes, (e.g.A1c testing, LDL-C testing, retinal exams, and medical attention for nephropathy). PCMH enrollment was associated with an increase in the overall likelihood of receiving six of eight recommended services and a decrease in the likelihood of receiving any psychotherapy (4.94 percentage points, p < 0.01) and retinal exams (5.51 percentage points, p < 0.05). Although both groups improved, PCMH enrollment was associated with an exacerbation of the Black-white disparity in adequate antidepressant use by 4.20 percentage points (p < 0.01). While PCMH enrollment may improve the overall quality of care, the effect is inconsistent across racial groups and not always associated with reductions in racial disparities in quality.

(UN)EQUAL BURDEN OF CARE: STAFF PERSPECTIVES ON NURSING HOME CARE AND QUALITY OF LIFE FOR RESIDENTS OF COLOR

Racial disparities in quality of care (QoC) and quality of life (QoL) for nursing home (NH) residents persist even as the proportion of minorities is significantly increasing. Staff of color are a growing part of the long-term care workforce and staffing is a key component for delivering quality care. This study looks at staff (n=60) perspectives on resident QOL through semi-structured interviews, using thematic analysis in six Minnesota high proportion minority NHs. Key findings show that staff of color are concerned about the QoC and QoL residents of color experience, and take extra steps to provide care that goes beyond addressing their clinical needs. This agency of providing extra care is a factor in burnout among staff of color. More research on how this unequal burden of care impacts QoC/QoL is important to address the disproportionate role that staff of color play in reducing disparities in resident QoC and QoL.

Sex differences in the treatment and outcome of emergency general surgery.

BackgroundSociodemographic characteristics, such as sex, have been shown to influence health care delivery. Acute care surgery models are effective in decreasing mortality and morbidity after emergency surgeries, but sex-based differences in delivery and outcomes have not been explored. Our objective was to explore sex associated differences in the patient characteristics and clinical outcomes of those admitted to emergency general surgery.MethodsA post-hoc analysis of 512 emergency general surgical patients admitted consecutively to two tertiary care hospitals in Alberta Canada, between April 1, 2014 and July 31, 2015. We measured associations between sex and patient demographics, pre-, intra- and post-operative delivery of care, as well as post-operative outcomes.FindingsOf those excluded from the analysis, older females were more likely to undergo conservative management compared to older men (41% vs 34%, p = 0.03). Overall, there were no differences between sexes for time from admission to surgery, time spent in surgery, overall complication rate, mortality, hospital length of stay, or discharge disposition. Women were more likely to have a cancer diagnosis [OR 4.12 (95% CI: 1.61–10.5), p = 0.003, adjusted for age], while men were more likely to receive hernia surgery [OR 2.33 (95% CI 1.35–4.02), p = 0.002, adjusted for age and Charlson Comorbidity Index]. Finally, men were more likely to have a major respiratory complication [OR 2.73 (95% CI: 1.19–6.24), p = 0.02, adjusted for age].ConclusionsOnly two differences in peri and post-operative complications between sexes were noted, which suggests sex-based disparity in quality of care is limited once a decision has been made to operate. Future studies with larger databases are needed to corroborate our findings and investigate potential sex biases in surgical versus conservative management.

Racial/Ethnic Disparities in Neonatal Intensive Care: A Systematic Review.

Racial and ethnic disparities in health outcomes of newborns requiring care in the NICU setting have been reported. The contribution of NICU care to disparities in outcomes is unclear. To conduct a systematic review of the literature documenting racial/ethnic disparities in quality of care for infants in the NICU setting. Medline/PubMed, Scopus, Cumulative Index of Nursing and Allied Health, and Web of Science were searched until March 6, 2018, by using search queries organized around the following key concepts: "neonatal intensive care units," "racial or ethnic disparities," and "quality of care." English language articles up to March 6, 2018, that were focused on racial and/or ethnic differences in the quality of NICU care were selected. Two authors independently assessed eligibility, extracted data, and cross-checked results, with disagreements resolved by consensus. Information extracted focused on racial and/or ethnic disparities in quality of care and potential mechanism(s) for disparities. Initial search yielded 566 records, 470 of which were unique citations. Title and abstract review resulted in 382 records. Appraisal of the full text of the remaining 88 records, along with the addition of 5 citations from expert consult or review of bibliographies, resulted in 41 articles being included. Quantitative meta-analysis was not possible because of study heterogeneity. Overall, this systematic review revealed complex racial and/or ethnic disparities in structure, process, and outcome measures, most often disadvantaging infants of color, especially African American infants. There are some exceptions to this pattern and each area merits its own analysis and discussion.