Low-Quality, High-Cost Hospitals, Mainly In South, Care For Sharply Higher Shares Of Elderly Black, Hispanic, And Medicaid Patients

Harvard School of Public Health, in Boston, Massachusetts, USA.
Health Affairs (Impact Factor: 4.97). 10/2011; 30(10):1904-11. DOI: 10.1377/hlthaff.2011.0027
Source: PubMed


As policy makers design national programs aimed at managing the quality and costs of health care, it is important to understand the potential impact on minority and poor patients and the hospitals that provide most of their care. We analyzed a range of hospital data and assigned hospitals to various categories, including "best"-high-quality, low-cost institutions-and "worst"-where quality is low and costs high. We found that the "worst" hospitals-typically small public or for-profit institutions in the South-care for double the proportion (15 percent versus 7 percent) of elderly black patients as the "best" hospitals-typically nonprofit institutions in the Northeast. Similarly, elderly Hispanic and Medicaid patients accounted for 1 percent and 15 percent, respectively, of the patient population at the best hospitals, while at the worst hospitals, these groups represented 4 percent and 23 percent of the patients. Patients with acute myocardial infarction at the worst hospitals had 7-10 percent higher odds of death compared to patients with those conditions admitted to the best hospitals. Our findings have important implications for Medicare's forthcoming value-based purchasing program. The worst institutions in particular will have to improve on both costs and quality to avoid incurring financial penalties and exacerbating disparities in care.

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Available from: Ashish K Jha,
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    • "To reduce latter type of racial disparities, interventions to improve performance of particular hospitals which served disproportionately high concentrations of minority patients but provided suboptimal quality of care are needed. These interventions could involve system-level quality initiatives such as pay for performance to incentivize quality improvement in low-quality black-serving hospitals [49,54]. "
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    ABSTRACT: Racial disparities in healthcare in the United States are widespread and have been well documented. However, it is unknown whether racial disparities exist in the use of blood transfusion for patients undergoing major surgery. We used the University HealthSystem Consortium database (2009-2011) to examine racial disparities in perioperative red blood cells (RBCs) transfusion in patients undergoing coronary artery bypass surgery (CABG), total hip replacement (THR), and colectomy. We estimated multivariable logistic regressions to examine whether black patients are more likely than white patients to receive perioperative RBC transfusion, and to investigate potential sources of racial disparities. After adjusting for patient-level factors, black patients were more likely to receive RBC transfusions for CABG (AOR = 1.41, 95% CI: [1.13, 1.76], p = 0.002) and THR (AOR = 1.39, 95% CI: [1.20, 1.62], p < 0.001), but not for colectomy (AOR = 1.08, 95% CI: [0.90, 1.30], p = 0.40). Black-white disparities in blood transfusion persisted after controlling for patient insurance and hospital effects (CABG: AOR = 1.42, 95% CI: [1.30, 1.56], p < 0.001; THR: AOR = 1.43, 95% CI: [1.29, 1.58], p < 0.001). We detected racial disparities in the use of blood transfusion for CABG and THR (black patients tended to receive more transfusions compared with whites), but not for colectomy. Reporting racial disparities in contemporary transfusion practices may help reduce potentially unnecessary blood transfusions in minority patients.
    BMC Health Services Research 03/2014; 14(1):121. DOI:10.1186/1472-6963-14-121 · 1.71 Impact Factor
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    • "In this study we aim to take the analysis a step further and introduce treatment quality in the model. Previous research has shown that quality – measured as the absence of complications – may be among the most important cost drivers for hospitals [6-8]. These analyses define quality by various measures of negative outcomes available in existing registers. "
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    ABSTRACT: An increasing focus on hospital productivity has rendered a need for more thorough knowledge of cost drivers in hospitals, including a need for quantification of the impact of age, case-mix and other characteristics of patients, as well as establishment of the cost-quality relationship.The aim of this study is to identify cost drivers for vascular surgery in Danish hospitals with a specific view to quality of the treatment: Is higher quality associated with increased costs, when all other cost drivers are accounted for?We analyse cost drivers in a register-based study, using patient level data from three sources: The Vascular Register, the hospital cost database, and the National Patient Register with added DRG-information. The analysis follows a multilevel set-up, where cost drivers at patient level are analysed in a set of general linear regression models including complications and mortality as quality measures. At the hospital level of the analysis, we analyse deviations of observed costs from risk-adjusted costs and compare these to deviations of observed quality from risk-adjusted quality.We find, not surprisingly, that a number of patient characteristics, including case-mix and severity, have a major impact on treatment costs. At patient level, both complications and mortality are associated with increased costs. At hospital department level, results are not straightforward, but could indicate a U-shaped association.We conclude that the relation between costs and quality is not straightforward, at least not at department level. Our results indicate, albeit vaguely, a U-shaped relation between quality, in terms of fewer surgical complications than expected, and costs at department level, since our results suggest that increasing costs for vascular departments are associated with increased quality when costs are high and decreased quality when costs are low. For mortality however, we have not been able to establish a clear relation to costs.
    10/2013; 3(1):22. DOI:10.1186/2191-1991-3-22
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    • "The association between hospital characteristics and quality of care was assessed previously using 10 of the reported measures by Hospital Quality Alliance [19]. Jha and colleagues recently found that the “worst” hospitals cared for disproportionately higher numbers of Medicaid and black elderly patients than the “best” hospitals [20]. Lehrman et al. identified key hospital characteristics that determine whether the hospital will perform in the top quartile on both CPC and patient satisfaction measures [21]. "
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    ABSTRACT: Medicare hospital Value-based purchasing (VBP) program that links Medicare payments to quality of care will become effective from 2013. It is unclear whether specific hospital characteristics are associated with a hospital’s VBP score, and consequently incentive payments. The objective of the study was to assess the association of hospital characteristics with (i) the mean VBP score, and (ii) specific percentiles of the VBP score distribution. The secondary objective was to quantify the associations of hospital characteristics with the VBP score components: clinical process of care (CPC) score and patient satisfaction score. Observational analysis that used data from three sources: Medicare Hospital Compare Database, American Hospital Association 2010 Annual Survey and Medicare Impact File. The final study sample included 2,491 U.S. acute care hospitals eligible for the VBP program. The association of hospital characteristics with the mean VBP score and specific VBP score percentiles were assessed by ordinary least square (OLS) regression and quantile regression (QR), respectively. VBP score had substantial variations, with mean score of 30 and 60 in the first and fourth quartiles of the VBP score distribution. For-profit status (vs. non-profit), smaller bed size (vs. 100–199 beds), East South Central region (vs. New England region) and the report of specific CPC measures (discharge instructions, timely provision of antibiotics and beta blockers, and serum glucose controls in cardiac surgery patients) were positively associated with mean VBP scores (p<0.01 in all). Total number of CPC measures reported, bed size of 400–499 (vs. 100–199 beds), a few geographic regions (Mid-Atlantic, West North Central, Mountain and Pacific) compared to the New England region were negatively associated with mean VBP score (p<0.01 in all). Disproportionate share index, proportion of Medicare and Medicaid days to total inpatient days had significant (p<0.01) but small effects. QR results indicate evidence of differential effects of some of the hospital characteristics across low-, medium- and high-quality providers. Although hospitals serving the poor and the elderly are more likely to score lower under the VBP program, the correlation appears small. Profit status, geographic regions, number and type of CPC measures reported explain the most variation among scores.
    BMC Health Services Research 12/2012; 12(1):464. DOI:10.1186/1472-6963-12-464 · 1.71 Impact Factor
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