Is There an Association Between the Quality of In-Hospital Cardiac Care and Proportion of Low Income Patients? Steven D. Culler, PhD1 Linda Schieb, MSPH2 Michele Casper, PhD2 Isaac Nwaise, MA2 Paula Yoon, PhD, MPH2 Affiliations:1Rollins School of Public Health, Emory University. 2Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention.
Background: Health Disparities & Quality of Care • Financial strength has deteriorated for selected hospitals, especially those with an adverse socio-economic patient mix. • Quality of care improvement initiatives require financial investments and potentially higher operating costs. • The quality of care provided in hospitals may be associated with the socio-economic mix of the hospital’s patients.
Study Objective To examine if there is an association between a hospital’s proportion of low-income patients and a hospital’s average compliance with quality of care process measures for Acute Myocardial Infarction (AMI) and Congestive Heart Failure (CHF) patients.
Methods: Study Period and Data Sources Study period: • January 1, 2005 to December 31, 2006. Data Sources: • Hospital Quality Alliance (HQA) File provides information on compliance to quality of care process measures for AMI and CHF patients treated during 2005 and 2006. • CMS’s Payment Impact File provides information on each hospital’s proportion of disproportionate share patients for fiscal year 2005 and 2006. • 2005 American Hospital Associations Annual Survey provides selected hospital characteristics.
Methods: Study Population Unit of Analysis: • The hospital. Inclusion Criteria: • All hospitals that reported AMI and CHF data to the HQA in both 2005 and 2006. Exclusion Criteria: • A hospital not treating 26 patients annually for the four most common AMI quality process measures, or • A hospital not treating 26 patients annually for each of the CHF quality process measures. Final Sample: 1,979 Hospitals
Methods: Quality of Care Process Measures • AMI Measures: • Aspirin prescription at admission and discharge • -blocker prescription at admission and discharge • ACE inhibitor or ARB prescription at discharge for left ventricular systolic dysfunction • Adult smoking cessation counseling for smokers • CHF Measures: • Documentation of an evaluation of left ventricular systolic function • ACE inhibitor or ARB prescription at discharge for left ventricular systolic dysfunction • Adult smoking cessation counseling for smokers • Discharge instructions
Methods: Analytical Approach Multivariate RegressionModelwas used to examine the association between a hospital’s percentage of low income patients and its performance level for selected quality care process measures, after controlling for selected hospital factors.
Results: Regression – AMI Estimated Coefficient for disproportionate share variable: After controlling for all other hospital factors
Results: Regression-CHF Estimated coefficient for disproportionate share variable After controlling for all other hospital factors
Summary: • On average, US hospitals are in better compliance with the AMI quality measures than with the CHF quality measures. • 6-item AMI score = 94.0% vs. 4-item CHF score = 81.4% • Compliance rates exceeded 90% for five of AMI quality measures but for only one of the CHF quality measures • Multivariate regression analysis found a negative and significant correlation between compliance with quality care measures and the percentage of disproportionate share patients after controlling for selected hospital characteristics.
Limitations • Quality measures are self-reported by hospitals. • Reported compliance with quality of care measures depends on how well hospitals report both the numerator (number of patients in compliance with quality measure) and the denominator (exclusion of patients not meeting the inclusion criteria for measure). • Our data does not allow us to determine if patients received different quality of care based on their income levels.
Conclusions Overall quality of care for AMI and CHF patients is lower in hospitals treating a higher proportion of low income patients.
Future Research Future research needs to examine why having a higher proportion of low income patients results in lower quality of cardiac care.