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Romana Hasnain-Wynia, PhD Director, Center for Healthcare Equity Associate Professor

Disparities Within and Between Hospitals for Inpatient Quality of Care: Targeting Resources to Close the Gap. Romana Hasnain-Wynia, PhD Director, Center for Healthcare Equity Associate Professor Institute for Health Care Studies Division of General Internal Medicine

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Romana Hasnain-Wynia, PhD Director, Center for Healthcare Equity Associate Professor

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  1. Disparities Within and Between Hospitals for Inpatient Quality of Care: Targeting Resources to Close the Gap Romana Hasnain-Wynia, PhD Director, Center for Healthcare Equity Associate Professor Institute for Health Care Studies Division of General Internal Medicine Northwestern University, Feinberg School of Medicine The authors acknowledge the assistance of the IFQHC and the Centers for Medicare and Medicaid Services (CMS) in providing data which made this research possible. The conclusions prescribed are solely those of the author(s) and do not represent those of IFQHC or CMS. The study was funded by the Commonwealth Fund and the Robert Wood Johnson Foundation’s Changes in Health Care Financing and Organization (HCFO) Initiative

  2. Co-Authors Raymond Kang Mary Beth Landrum Christine Vogeli David W. Baker Joel S. Weissman

  3. Background • Racial and ethnic disparities in quality of care persist • Studies suggest that factors related to patient-physician encounter such as miscommunication, cultural misunderstanding, racism, and bias contribute to disparities • Other studies suggest that differential quality in treatment settings contribute to disparities

  4. Question Where You Go?: Quality differences in various settings Who You Are?: Patient-Centered Care

  5. Disparities in Health Care Are Driven by Where Minority Patients Seek Care Examination of Hospital Quality Alliance Measures Disparities in Health Care Are Driven by Where Minority Patients Seek Care Examination of Hospital Quality Alliance Measures “… hospitals that were lower performers tended to serve a larger proportion of minority patients…” Hasnain-Wynia R, Baker DW, Nerenz, D, et al. Archives of Internal Medicine, June 2007

  6. Bottom performing hospitals had a much higher percentages of minority patients compared with top performing hospitals Hasnain-Wynia, R., Baker, DW, Nerenz, DR, et al. “Are Disparities Driven by Who You Are or Where You Go: An Examination of the Hospital Quality Alliance Measures: Archives of Internal Medicine June 25, 2007 627:1233-1239..

  7. Limitations of Previous Studies • Looked only at Medicare patients • Focused only on one condition such as AMI • Examined only hospital level variables such as proportion of minorities treated, without examining if disparities existed • Examined quality in teaching hospitals only • Limited to comparisons with larger groups (Blacks, Hispanics).

  8. Current HQA Study • Previously unavailable, patient-level HQA database obtained from CMS • Expanded list of measures • n = 19 • All U.S. acute care hospitals • n > 4000 hospitals • n > 2 million patients

  9. Groups by Race/Ethnicity • Black • Hispanic • Asian • American Indian/Alaska Native • Native Hawaiian/Pacific Islander • White

  10. Methods • Multivariate models • Model 1: unadjusted • Model 2: adjusted for individual characteristics, including co-morbidities, payer, age, gender (Total Disparity) • Model 3: Model 2 + adjusted for organizational effects ( random effects, between hospital variation)

  11. Results

  12. Within and Between Disparities Depend on the Quality Metric and Racial/Ethnic Group • Constructed 95 disparities measures • Clinically and statistically significant disparities in 37 measures • Disparity eliminated when adjusting for site of care: 11 measures • Magnitude of disparity reduced when adjusting for site of care : 26 measures

  13. HF-Smoking Cessation *** P<.001 ** P<.01 * P<.05

  14. HF Discharge Instructions *** P<.001 ** P<.01 * P<.05

  15. AMI-PCI *** P<.001 ** P<.01 * P<.05

  16. PN-PN Vaccination *** P<.001 ** P<.01 * P<.05

  17. Place-Based Disparities: Policy Implications • Disparities are multi-factorial—who you are and where you go • Continued segregation in health care • Under-resourced institutions serve minority communities • Focus incentives toward institutions serving a large % of minority patients. • Target resources to areas of greatest impact

  18. Policy Implications • Risks of unintended consequences of forcing action through P4P and public reporting • Need protections of vulnerable populations • Pay for improvement • Pay for disparity reductions

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