Use Of High-volume Hospitals Research Articles

ACA Medicaid expansion reduced disparities in use of high-volume hospitals for pancreatic surgery

BackgroundEarly evaluation of the Affordable Care Act’s Medicaid expansion demonstrated persistent disparities among Medicaid beneficiaries in use of high-volume hospitals for pancreatic surgery. Longer-term effects of expansion remain unknown. This study evaluated the impact of expansion on the use of high-volume hospitals for pancreatic surgery among Medicaid and uninsured patients. MethodsState inpatient databases (2012-2017), the American Hospital Association Annual Survey Database, and the Area Resource File from the Health Resources and Services Administration, were used to examine 8,264 non-elderly adults who underwent pancreatic surgery in nine expansion and two non-expansion states. High-volume hospitals were defined as performing 20 or more resections/year. Linear probability triple differences models measured pre- and post-Affordable Care Act utilization rates of pancreatic surgery at high-volume hospitals among Medicaid and uninsured patients versus privately insured patients in expansion versus non-expansion states. ResultsThe Affordable Care Act’s expansion was associated with increased rates of utilization of high-volume hospitals for pancreatic surgery by Medicaid and uninsured patients (48% vs 55.4%, P = .047) relative to privately insured patients in expansion states (triple difference estimate +11.7%, P = .022). A pre-Affordable Care Act gap in use of high-volume hospitals among Medicaid and uninsured patients in expansion states versus non-expansion states (48% vs 77%, P < .0001) was reduced by 15.1% (P = .001) post Affordable Care Act. A pre Affordable Care Act gap between expansion versus non-expansion states was larger for Medicaid and uninsured patients relative to privately insured patients by 24.9% (P < .0001) and was reduced by 11.7% (P = .022) post Affordable Care Act. Rates among privately insured patients remained unchanged. ConclusionMedicaid expansion was associated with greater utilization of high-volume hospitals for pancreatic surgery among Medicaid and uninsured patients. These findings are informative to non-expansion states considering expansion. Future studies should target understanding referral mechanism post-expansion.

Racial and Socioeconomic Differences in the Use of High-Volume Commission on Cancer-Accredited Hospitals for Cancer Surgery in the United States.

Although major cancer surgery at a high-volume hospital is associated with lower postoperative mortality, the use of such hospitals may not be equally distributed. Our aim was to study socioeconomic and racial differences in cancer surgery at Commission on Cancer (CoC)-accredited high-volume hospitals. The National Cancer Database (NCDB) was used to identify patients undergoing surgery for colon, esophageal, liver, and pancreatic cancer from 2003 to 2012. Annual hospital volume for each cancer was categorized using quartiles of patient volume. Patient-level predictors of surgery at a high-volume hospital, trends in the use of a high-volume hospital, and adjusted likelihood of surgery at a high-volume hospital in 2012 versus 2003 were analyzed. African American patients were less likely to undergo surgery at a high-volume hospital for esophageal (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.49-0.73) and pancreatic cancer (OR 0.83, 95% CI 0.74-0.92), while uninsured patients and those residing in low educational attainment zip codes were less likely to undergo surgery at a high-volume hospital for esophageal, liver, and pancreatic cancer. In 2012, African Americans, uninsured patients, and those from low educational attainment zip codes were no more likely to undergo surgery at a high-volume hospital than in 2003 for any cancer type. These differences were not seen in colon cancer patients, for whom significant regionalization was not seen. Differences in the use of CoC-accredited high-volume hospitals for major cancer surgery were seen nationwide and persisted over the duration of the study. Strategies to increase referrals and/or access to high-volume hospitals for African American and socioeconomically disadvantaged patients should be explored.

Racial and Ethnic Disparities in Utilization Rate, Hospital Volume, and Perioperative Outcomes After Total Knee Arthroplasty.

Previous studies of racial disparities in total joint replacement, particularly total knee arthroplasty, in the U.S. have predominantly focused on disparities between blacks and whites and were limited to Medicare patients or veterans, populations that are not representative of the entire U.S. We sought to study racial disparities in the utilization of total knee arthroplasty, the use of high-volume hospitals, and total knee arthroplasty outcomes, including mortality and complications, using all-payer databases. We analyzed data from 8 years and 8 racially diverse states in the State Inpatient Databases (SID). Patient race was categorized according to the SID as white, black, Hispanic, Asian, Native American, and mixed race. Both crude and adjusted racial and/or ethnic disparities were evaluated. In comparison with whites (4.65 per 1000 population per year), black (3.90), Hispanic (3.71), Asian (3.89), Native American (4.40), and mixed-race (3.69) populations had lower rates of total knee arthroplasty utilization (p < 0.0001). After risk adjustment, the rate of total knee arthroplasty utilization was significantly lower for blacks (odds ratio [OR] = 0.87 [95% confidence interval (CI), 0.85 to 0.89]; p < 0.0001), Hispanics (OR = 0.76 [95% CI, 0.68 to 0.83]; p < 0.0001), Asians (OR = 0.83 [95% CI, 0.78 to 0.89]; p < 0.0001), Native Americans (OR = 0.87 [95% CI, 0.81 to 0.93]; p < 0.0001), and mixed race (OR = 0.84 [95% CI, 0.79 to 0.90]; p < 0.0001) compared with the rate for whites. Lower rates of total knee arthroplasty utilization for blacks, Hispanics, and mixed-race groups became worse over the years. Patients from minority groups were less likely to undergo total knee arthroplasty in high-volume hospitals than were whites. Moreover, the rates of mortality were significantly higher for blacks (OR = 1.52 [95% CI, 1.17 to 1.97]; p = 0.0017), Native Americans (OR = 6.52 [95% CI, 4.63 to 9.17]; p < 0.0001), and mixed-race patients (OR = 4.35 [95% CI, 3.24 to 5.84]; p < 0.0001). Blacks (OR = 1.08 [95% CI, 1.01 to 1.15]; p = 0.01) and mixed-race patients (OR = 1.17 [95% CI, 1.001 to 1.36]; p = 0.04) had higher rates of complications than whites. Minorities had lower rates of total knee arthroplasty utilization but higher rates of adverse health outcomes associated with the procedure, even after adjusting for patient-related and health-care system-related characteristics. Utilization rates were based on overall population as the proportion of the population with osteoarthritis requiring arthroplasty is unknown. Future studies that consider specific patient-level information with psychosocial and behavioral factors are needed. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Editorial Comment

This well-written analysis clearly demonstrates that the overall number of simple prostatectomies being performed for benign prostatic hyperplasia is trending downwards. 1 Pariser J.J. Pearce S.M. Patel S.G. Bales G.T. National trends of simple prostatectomy for benign prostatic hyperplasia with an analysis of risk factors for adverse perioperative outcomes. Urology. 2015; 86: 721-726 Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar The incremental increase seen in the use of minimally invasive surgical techniques has not stopped the overall decline. National Trends of Simple Prostatectomy for Benign Prostatic Hyperplasia With an Analysis of Risk Factors for Adverse Perioperative OutcomesUrologyVol. 86Issue 4PreviewTo examine the national trends of simple prostatectomy (SP) for benign prostatic hyperplasia (BPH) focusing on perioperative outcomes and risk factors for complications. Full-Text PDF ReplyUrologyVol. 86Issue 4PreviewSimilar to our findings, insidious racial disparities have been reported across multiple urologic procedures. For example, black race has been associated with worse perioperative outcomes during open and minimally invasive radical prostatectomy.1,2 Interestingly, for radical prostatectomy, black men have a markedly lower use of high volume hospitals and surgeons.2 More specifically, for benign prostatic hyperplasia, non-Caucasian race has been shown to be an independent predictor of increased morbidity and mortality during endoscopic surgery. Full-Text PDF

Factors that influence minority use of high-volume hospitals for colorectal cancer care.

Previous studies suggest that minorities cluster in low-quality hospitals despite living close to better performing hospitals. This may contribute to persistent disparities in cancer outcomes. The purpose of this work was to examine how travel distance, insurance status, and neighborhood socioeconomic factors influenced minority underuse of high-volume hospitals for colorectal cancer. The study was a retrospective, cross-sectional, population-based study. All hospitals in California from 1996 to 2006 were included. Patients with colorectal cancer diagnosed and treated in California between 1996 and 2006 were identified using California Cancer Registry data. Multivariable logistic regression models predicting high-volume hospital use were adjusted for age, sex, race, stage, comorbidities, insurance status, and neighborhood socioeconomic factors. A total of 79,231 patients treated in 417 hospitals were included in the study. High-volume hospitals were independently associated with an 8% decrease in the hazard of death compared with other settings. A lower proportion of minorities used high-volume hospitals despite a higher proportion living nearby. Although insurance status and socioeconomic factors were independently associated with high-volume hospital use, only socioeconomic factors attenuated differences in high-volume hospital use of black and Hispanic patients compared with white patients. The use of cross-sectional data and racial and ethnic misclassifications were limitations in this study. Minority patients do not use high-volume hospitals despite improved outcomes and geographic access. Low socioeconomic status predicts low use of high-volume settings in select minority groups. Our results provide a roadmap for developing interventions to increase the use of and access to higher quality care and outcomes. Increasing minority use of high-volume hospitals may require community outreach programs and changes in physician referral practices.

Disparities in selective referral for cancer surgeries: implications for the current healthcare delivery system

ObjectivesAmong considerable efforts to improve quality of surgical care, expedited measures such as a selective referral to high-volume institutions have been advocated. Our objective was to examine whether racial, insurance...

Explaining racial/ethnic disparities in use of high-volume hospitals: decision-making complexity and local hospital environments.

Racial/ethnic minorities are less likely to use higher-quality hospitals than whites. We propose that a higher level of information-related complexity in their local hospital environments compounds the effects of discrimination and more limited access to services, contributing to racial/ethnic disparities in hospital use. While minorities live closer than whites to high-volume hospitals, minorities also face greater choice complexity and live in neighborhoods with lower levels of medical experience. Our empirical results reveal that it is generally the overall context associated with proximity, choice complexity, and local experience, rather than differential sensitivity to these factors, that provides a partial explanation of the disparity gap in high-volume hospital use.

Racial Variation in the Quality of Surgical Care for Prostate Cancer

Difference in the quality of care may contribute to the less optimal prostate cancer treatment outcomes among black men compared with white men. We determined whether a racial quality of care gap exists in surgical care for prostate cancer, as evidenced by racial variation in the use of high volume surgeons and facilities, and in the quality of certain outcome measures of care. We performed cross-sectional and cohort analyses of administrative data from the Healthcare Cost and Utilization Project all-payer State Inpatient Databases, encompassing all nonfederal hospitals in Florida, Maryland and New York State from 1996 to 2007. Included in analysis were men 18 years old or older with a diagnosis of prostate cancer who underwent radical prostatectomy. We compared the use of surgeons and/or hospitals in the top quartile of annual volume for this procedure, inpatient blood transfusion, complications, mortality and length of stay between black and white patients. Of 105,972 patients 81,112 (76.5%) were white, 14,006 (13.2%) were black, 6,999 (6.6%) were Hispanic and 3,855 (3.6%) were all other. In mixed effects multivariate models, black men had markedly lower use of high volume hospitals (OR 0.73, 95% CI 0.70-0.76) and surgeons (OR 0.67, 95% CI 0.64-0.70) compared to white men. Black men also had higher odds of blood transfusion (OR 1.08, 95% CI 1.01-1.14), longer length of stay (OR 1.07, 95% CI 1.06-1.07) and inpatient mortality (OR 1.73, 95% CI 1.02-2.92). Using an all-payer data set, we identified concerning potential quality of care gaps between black and white men undergoing radical prostatectomy for prostate cancer.

The Volume-Outcome Relationship for Immediate Breast Reconstruction

Efforts to improve the quality of surgical care in the United States have led many organizations to advocate the use of high-volume hospitals for complex surgical procedures and/or comprehensive multidisciplinary care. The benefits, if any, of selective referral to high-volume hospitals for immediate breast reconstruction are relatively unknown. It is this gap in knowledge that forms the basis for the current study. Using California's Office of Statewide Health Planning and Development discharge database, all patients undergoing immediate breast reconstruction from January 1, 1998, to December 31, 1999, were identified. Information regarding demographic, comorbidity, complication, and hospital volume characteristics was obtained. Patient comorbidity was graded using a modified version of the Charlson score. Annual hospital volume was categorized into patient quartiles. Multivariate logistic regression was performed to identify predictors of surgical complications. A total of 2691 patients were included: 1271 had immediate autogenous tissue reconstruction and 1420 had immediate tissue expander placement. The complication rate was 11.6 percent among patients undergoing autogenous reconstruction and 2.4 percent among patients receiving tissue expanders. For autogenous reconstruction, complications were more likely in patients with comorbidities (odds ratio, 2.24) and in patients receiving care at very-low-volume (less than eight) and medium-volume (20 to 41) hospitals (odds ratio,1.81 and 1.90, respectively). For tissue expander reconstruction, patient comorbidity (odds ratio, 2.42) was the only significant predictor of complications. Hospital volume appears to be an important predictor of patient outcome with regard to autogenous reconstruction but not tissue expander reconstruction. Patient comorbidity predicts complications for both autogenous and tissue expander reconstruction. Risk, III.

73 RACIAL VARIATION IN THE UTILIZATION OF HIGH-VOLUME SURGEONS AND HOSPITALS FOR RADICAL PROSTATECTOMY

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness1 Apr 201173 RACIAL VARIATION IN THE UTILIZATION OF HIGH-VOLUME SURGEONS AND HOSPITALS FOR RADICAL PROSTATECTOMY Daniel Barocas, Darryl Gray, Jay Fowke, Stephen Kappa, Jeffrey Blume, Nathaniel Mercaldo, Sam Chang, Michael Cookson, Joseph A. Smith, and David Penson Daniel BarocasDaniel Barocas Nashville, TN More articles by this author , Darryl GrayDarryl Gray Rockville, MD More articles by this author , Jay FowkeJay Fowke Nashville, TN More articles by this author , Stephen KappaStephen Kappa Nashville, TN More articles by this author , Jeffrey BlumeJeffrey Blume Nashville, TN More articles by this author , Nathaniel MercaldoNathaniel Mercaldo Nashville, TN More articles by this author , Sam ChangSam Chang Nashville, TN More articles by this author , Michael CooksonMichael Cookson Nashville, TN More articles by this author , Joseph A. SmithJoseph A. Smith Nashville, TN More articles by this author , and David PensonDavid Penson Nashville, TN More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.137AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Differences in quality of care may contribute to racial variation in outcomes of men with prostate cancer. Quality indicators in men undergoing radical prostatectomy (RP) include surgeon and hospital volume. We compared African-American (AA) and Caucasian men's use of high-volume surgeons (HVSs) and high-volume hospitals (HVHs) for RP and determined whether differential use of HVSs and HVHs were associated with differences in short-term outcomes (in-hospital mortality and length of stay [LOS]). METHODS We used public-access versions of the Healthcare Cost and Utilization Project's State Inpatient Databases, selecting NY, FL, and MD (1996–2007), because they consistently included race and surgeon identifiers. Cases were identified by ICD-9-CM codes. Surgeon and hospital volume were defined as the number of RPs performed within a calendar year, with quartiles defined by state and year. Use of HVSs and HVHs (highest quartile) was compared across racial groups using logistic regression, adjusting for age, insurance, state and year of surgery. We performed logistic regression for in-hospital mortality, adjusting for age, LOS and comorbidity score; we then added terms for use of HVH and HVS to determine whether the effect of race on in-hospital mortality was attenuated by procedure volume. We did a similar linear regression for LOS, controlling for age, payer, comorbidity and state, with and without terms for use of HVSs and HVHs. RESULTS There were 106,000 RPs; 76.5% White, 13.2% AA, 10.2% Other. Fewer AA than White men utilized HVSs (59.1% vs. 70.0%, p<0.001) and HVHs (66.1% vs. 74.3%, p<0.001). Compared to Whites, AA men had lower adjusted odds of utilizing HVSs (0.81, 95% CI [0.77, 0.85], p<0.001) and HVHs (0.65, [0.62, 0.67], p<0.001). AA men had higher in-hospital mortality than Whites (0.16% vs. 0.07%, p=0.004), but the effect was attenuated with adjustment for HVH, HVS and other factors (OR 1.55 [0.91, 2.65], p=0.11). Similarly, AA race was associated with longer LOS on univariate analysis (Coefficient 0.50 [0.46, 0.54], p<0.001) and the effect was attenuated in multivariate analysis including use of HVH and HVS (Coefficient 0.36 [0.32, 0.40], p<0.001). CONCLUSIONS As indicators of healthcare quality, utilization of HVSs and HVHs for RP vary by race. The effect of race on in-hospital mortality and LOS is attenuated to an extent by differential use of HVSs and HVHs, among other factors. These findings may identify a quality gap and some of its consequences. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e31-e32 Peer Review Report Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Barocas Nashville, TN More articles by this author Darryl Gray Rockville, MD More articles by this author Jay Fowke Nashville, TN More articles by this author Stephen Kappa Nashville, TN More articles by this author Jeffrey Blume Nashville, TN More articles by this author Nathaniel Mercaldo Nashville, TN More articles by this author Sam Chang Nashville, TN More articles by this author Michael Cookson Nashville, TN More articles by this author Joseph A. Smith Nashville, TN More articles by this author David Penson Nashville, TN More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

441 RACIAL VARIATION IN THE QUALITY OF CARE AMONG PATIENTS UNDERGOING CYSTECTOMY FOR BLADDER CANCER

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness1 Apr 2011441 RACIAL VARIATION IN THE QUALITY OF CARE AMONG PATIENTS UNDERGOING CYSTECTOMY FOR BLADDER CANCER Daniel Barocas, Darryl Gray, Jay Fowke, Sam Chang, Michael Cookson, Joseph A. Smith, and David Penson Daniel BarocasDaniel Barocas Nashville, TN More articles by this author , Darryl GrayDarryl Gray Rockville, MD More articles by this author , Jay FowkeJay Fowke Nashville, TN More articles by this author , Sam ChangSam Chang Nashville, TN More articles by this author , Michael CooksonMichael Cookson Nashville, TN More articles by this author , Joseph A. SmithJoseph A. Smith Nashville, TN More articles by this author , and David PensonDavid Penson Nashville, TN More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.532AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Differences in quality of care may contribute to racial variation in outcomes of bladder cancer (BC). Quality indicators in patients undergoing surgery for BC include use of high-volume surgeons (HVSs) and hospitals (HVHs), receipt of pelvic lymphadenectomy (PLND) and undergoing radical cystectomy (RC) instead of partial cystectomy (PC) when clinically indicated. We compared these quality indicators in African-American (AA) and Caucasian patients with BC. METHODS We used public-access versions of the Healthcare Cost and Utilization Project's non-federal State Inpatient Databases, selecting NY, FL, and MD (1996–2007), because they consistently included race, surgeon and hospital identifiers. PC and RC cases among BC patients were identified by ICD-9-CM codes. Surgeon and hospital volume were defined as the number of RCs+PCs performed within a calendar year, with quartiles defined by state and year (highest quartile was considered high-volume.) Quality indicators were compared across racial groups using mixed-effects logistic regression, adjusting for age, Elixhauser comorbidity sum, insurance, and year of surgery, with random effects for state. Use of RC vs. PC was compared in all patients; use of other quality indicators was compared in the sub-group who underwent RC. RESULTS There were 16,631 cases, 13,917 (83.7%) RCs and 2,713 (16.3%) PCs. The cohort was 87.0% Caucasian, 5.3% African-American and 7.8% Other. Compared with Whites, AA patients were younger (65.3 SD [11.6] vs. 69.4 [10.3] years, p<0.001), were more commonly on Medicaid (13.0% vs. 2.4%, p<0.001), and had higher comorbidity counts (26.4% vs. 21.9% with 3 or more comorbidities, p=0.014). AA patients had markedly lower utilization of high-quality surgical services for BC (table.) Surgical Quality of Care Indicators by Racial Group Quality Indicator Yes No Univariate Multivariate⁎⁎ N(%) N(%) Chi-square p value OR 95% CI p value Radical Cystectomy(vs. Partial) White 12,154(84.1) 2,307(15.9) 1.0(referent) African-American 714(81.4) 163(18.6) 0.039 0.71 0.59–0.85 <0.001 Pelvic Lymphadenectomy⁎ White 6,809(56.0) 5,345(44.0) 1.0(referent) African-American 302(42.3) 412(57.7) <0.001 0.55 0.47–0.65 <0.001 Use of High-Volume Surgeon⁎ White 6,991(59.9) 4,684(40.1) 1.0(referent) African-American 335(48.7) 353(51.3) <0.001 0.61 0.52–0.71 <0.001 Use of High-Volume Hospital⁎ White 8,453(69.6) 3,701(30.5) 1.0(referent) African-American 420(58.8) 294(41.2) <0.001 0.61 0.52–0.72 <0.001 ⁎ Pertains to patients who underwent radical cystectomy; ⁎⁎ Mixed-effects logistic regression models, adjusting for age, Elixhauser comorbidity sum, insurance, and year of surgery, with random effects for state. CONCLUSIONS As indicators of healthcare quality among patients undergoing surgery for bladder cancer, utilization of radical compared to partial cystectomy, and use of PLND, HVSs and HVHs among patients undergoing radical cystectomy, varied by race in our sample. Assuming that these findings do not reflect differences in surgical indications among study patients, they may identify a quality gap in the surgical care of bladder cancer patients, which could in turn influence important healthcare outcomes. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e179-e180 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Barocas Nashville, TN More articles by this author Darryl Gray Rockville, MD More articles by this author Jay Fowke Nashville, TN More articles by this author Sam Chang Nashville, TN More articles by this author Michael Cookson Nashville, TN More articles by this author Joseph A. Smith Nashville, TN More articles by this author David Penson Nashville, TN More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Disparities in Utilization of High-Volume Hospitals for Cancer Surgery: Results of a Korean Population-Based Study

Referral to high-volume hospitals has been recommended for cancer procedures with a demonstrated volume-outcome relationship. However, little is known about the factors associated with use of high-volume hospitals for cancer procedures. The purpose of this study was to determine patient characteristics associated with receipt of oncologic surgery at high-volume hospitals. Data were obtained from claims submitted to the Korean National Health Insurance System. We identified patients who underwent the following procedures between 2002 and 2005: esophagectomy, pancreatectomy, gastrectomy, colectomy, lung resection, mastectomy, and cystectomy. Each hospital volume was divided into tertiles. Patient demographic, socioeconomic, and clinical variables were investigated as factors that may affect use of high- or low-volume hospitals. A total of 49,897 patients received one of the seven procedures. Trends toward lower operative risks at high-volume hospitals were observed for all procedures. Patients who were older [odds ratio (OR), 0.60-0.69], lived in a rural area (OR, 0.79), had emergent surgeries (OR, 0.39-0.85), and had lower Charlson score were less likely to go to high-volume hospitals. For all procedures, patients having the lowest income level were significantly less likely to be treated at high-volume hospitals, compared with patients having the highest income level (OR, 0.45-0.58). We identified substantial demographic and socioeconomic disparities in use of high-volume hospitals for the seven procedures examined. The policy for selective referral to high-volume hospitals should include explicit efforts to identify patient and system factors required to reduce current inequities.

Racial and Ethnic Differences in the Use of High-Volume Hospitals and Surgeons

To examine racial/ethnic differences in the use of high-volume hospitals and surgeons for 10 surgical procedures with documented associations between volume and mortality. Cross-sectional regression analysis. New York City area hospital discharge data, 2001-2004. Adults from 4 racial/ethnic categories (white, black, Asian, and Hispanic) who underwent surgery for cancer (breast, colorectal, gastric, lung, or pancreatic resection), cardiovascular disease (coronary artery bypass graft, coronary angioplasty, abdominal aortic aneurysm repair, or carotid endarterectomy), or orthopedic conditions (total hip replacement). Treatment by a high-volume surgeon at a high-volume hospital. There were 133 821 patients who underwent 1 of the 10 procedures. For 9 of the 10 procedures, black patients were significantly (P < .05) less likely (after adjustment for sociodemographic characteristics, insurance type, proximity to high-volume providers, and comorbidities) to be operated on by a high-volume surgeon at a high-volume hospital and more likely to be operated on by a low-volume surgeon at a low-volume hospital. Asian and Hispanic patients, respectively, were significantly less likely to use high-volume surgeons at high-volume hospitals for 5 and 4 of the 10 procedures and more likely to use low-volume surgeons at low-volume hospitals for 3 and 5 of the 10 procedures. Minority patients in New York City are doubly disadvantaged in their surgical care; they are substantially less likely to use both high-volume hospitals and surgeons for procedures with an established volume-mortality association. Better information is needed about which providers minority patients have access to and how they select them.

Racial and Ethnic Disparities in the Use of High-Volume Hospitals

Differences in the source of care could contribute to racial and ethnic disparities in health status. This study looks at a major metropolitan area and examines racial and ethnic differences in the use of high-volume hospitals for 17 services for which there is a documented positive volume-outcome relationship. Focusing on the hospitalizations of New York City area residents in the periods 1995-1996 and 2001-2002, we found, after controlling for socioeconomic characteristics, insurance coverage, proximity of residence to a high-volume hospital, and paths to hospitalization, that minority patients were significantly less likely than whites to be treated at high-volume hospitals for most volume-sensitive services. The largest disparities were between blacks and whites for cancer surgeries and cardiovascular procedures.

Assessing Changes in High-Volume Hospital Use

The relationship between higher procedure volumes and medical outcomes has generated recommendations for greater use of high-volume hospitals, with research and advocacy on this issue intensifying during the 1990s. Despite this interest, the trends presented here showed only limited changes between 1995 and 2002. For a number of services, less than half of patients received care at high-volume hospitals, and for several services, there was a surprising decline in the proportion at high-volume hospitals. Trends in the rate of high-volume hospital use appeared to be associated with trends in aggregate volume, at the same time that there were only modest changes in either patient use of high-volume hospitals or the number of hospitals offering these services. These trends suggested the importance of research on factors that affect patient choices, hospital decisions, and payer incentives concerning hospital use, especially in the context of declining aggregate procedure volumes.

Regionalization of Hepatic Resections Is Associated with Increasing Disparities among Some Patient Populations in Use of High-Volume Providers

The goal of our study was to determine the temporal trends in provider volume for liver resection procedures. The Nationwide Inpatient Sample database for 1988 through 2003 was used to determine temporal trends in hospital and surgeon volume of liver resection procedures. We also examined whether these trends in provider volume were associated with any changes in postoperative outcomes or in patients' access to high-volume providers. Regionalization of liver resection procedures to high-volume surgeons and hospitals has been occurring since 1988 and, in the most recent time period assessed, 25.8% of patients underwent hepatic resection by high-volume surgeons (> or = 17 procedures per year) and 29.9% of patients underwent resection in high-volume hospitals (> or = 45 procedures per year). Unadjusted mortality data suggest that these trends might be associated with a strengthening of the inverse relationship between hospital volume of hepatic resection and postoperative mortality and with an increasing disparity for some patient populations in use of high-volume hospitals. Regionalization of liver resections is occurring at both the level of the individual surgeon and the hospitals where these procedures are performed. These trends in provider volume might be associated with increasing discrepancies in outcomes and patient demographics among different volume categories of hospitals.

Disparities in the Utilization of High-Volume Hospitals for Complex Surgery

Referral to high-volume hospitals has been recommended for operations with a demonstrated volume-outcome relationship. The characteristics of patients who receive care at low-volume hospitals may be different from those of patients who receive care at high-volume hospitals. These differences may limit their ability to access or receive care at a high-volume hospital. To identify patient characteristics associated with the use of high-volume hospitals, using California's Office of Statewide Health Planning and Development patient discharge database. Retrospective study of Californians receiving the following inpatient operations from 2000 through 2004: elective abdominal aortic aneurysm repair, coronary artery bypass grafting, carotid endarterectomy, esophageal cancer resection, hip fracture repair, lung cancer resection, cardiac valve replacement, coronary angioplasty, pancreatic cancer resection, and total knee replacement. Patient race/ethnicity and insurance status in high-volume (highest 20% of patients by mean annual volume) and in low-volume (lowest 20%) hospitals. A total of 719,608 patients received 1 of the 10 operations. Overall, nonwhites, Medicaid patients, and uninsured patients were less likely to receive care at high-volume hospitals and more likely to receive care at low-volume hospitals when controlling for other patient-level characteristics. Blacks were significantly (P<.05) less likely than whites to receive care at high-volume hospitals for 6 of the 10 operations (relative risk [RR] range, 0.40-0.72), while Asians and Hispanics were significantly less likely to receive care at high-volume hospitals for 5 (RR range, 0.60-0.91) and 9 (RR range, 0.46-0.88), respectively. Medicaid patients were significantly less likely than Medicare patients to receive care at high-volume hospitals for 7 of the operations (RR range, 0.22-0.66), while uninsured patients were less likely to be treated at high-volume hospitals for 9 (RR range, 0.20-0.81). There are substantial disparities in the characteristics of patients receiving care at high-volume hospitals. The interest in selective referral to high-volume hospitals should include explicit efforts to identify the patient and system factors required to reduce current inequities regarding their use.