Disparities in the utilization of high-volume hospitals for complex surgery.

Center for Surgical Outcomes and Quality, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, Calif, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 30.39). 10/2006; 296(16):1973-80. DOI: 10.1001/jama.296.16.1973
Source: PubMed

ABSTRACT 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.

  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Traditional narratives about fat experiences often exclude tangible, lived experiences in favor of examining fatness as a social and interpersonal symbol. In order to expand considerations of what it means to literally be fat, I use information from interviews, personal journals, and ethnographic research to explore how fat persons experience and navigate their daily, spatial worlds. Key to my analysis is an exploration of the concept of spatial discrimination, or experiencing the physical and emotional effects of living in a world designed with smaller bodies in mind. I propose spatial discrimination as a form of microaggression, a type of discrimination that implicitly, and through a myriad small words and examples, derides the physicalities and identities of marginalized persons. Finally, I explore three common, social psychological methods of coping with spatial discrimination: withdrawal, invisibility, and disembodiment, all of which illustrate fat persons’ adaptations to moving through physical spaces that implicitly exclude them.
    Feminism &amp Psychology 07/2012; 22(3):290-306. DOI:10.1177/0959353512445360 · 0.58 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Objectives. Retroperitoneal lymph node dissection (RPLND) outcomes for testis cancer originate mostly from single-center series. We characterized population-based utilization, costs, and outcomes and assessed whether higher volume affects outcomes. Methods and Materials. Using the US Nationwide Inpatient Sample from 2001-2008, we identified 993 RPLND and used propensity score methods to assess utilization, costs, and inpatient outcomes based on hospital surgical volume. Results. 51.6% of RPLND were performed at hospitals where there were two or fewer cases per year. RPLND was more commonly performed at large urban teaching hospitals, where men were younger, more likely to be white and earning incomes exceeding the 50th percentile (all P ≤ .05). Higher hospital volumes were associated with fewer complications and more routine home discharges (all P ≤ .047). However, higher volume hospitals had more transfusions (P = .004) and incurred $1,435 more in median costs (P < .001). Limitations include inability to adjust for tumor characteristics and absence of outpatient outcomes. Conclusions. Sociodemographic differences exist between high versus low volume RPLND hospitals. Although higher volume hospitals had more transfusions and higher costs, perhaps due to more complex cases, they experienced fewer complications. However, most RPLND are performed at hospitals where there were two or fewer cases per year.
    Advances in Urology 04/2012; 2012:189823. DOI:10.1155/2012/189823
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: We analyzed the association between ethnicity and outcomes among prostate cancer patients across hospital and surgeon volume groups. In this retrospective cohort study using SEER-Medicare databases for the period between 1995 and 2003, prostate cancer cases were identified and retrospectively followed for one year pre- and up to eight years post-diagnosis. Based on volume, hospitals and surgeons were divided into three groups each. For each group, we fitted separate models to analyze the association between ethnicity and outcomes such as complications, eight-year mortality and cost, adjusting for covariates. Poisson (zero inflation), generalized linear model (log-link), and Cox regression models were used. African American ethnicity was associated with 30-day complications among medium volume hospital group. African American patients receiving care at medium volume hospitals and from medium volume surgeons had higher costs. Hispanic patients receiving care at low and medium volume hospitals had lower cost compared to white patients. Hispanic patients receiving care from a high-volume surgeon experienced increased hazard of long-term mortality. Association between ethnicity and outcomes varies across hospital and surgeon volume groups. Thus, volume based policy measures may need further exploration for understanding the interaction between structure, process, volume and outcomes.
    Health Policy 02/2011; 99(2):97-106. DOI:10.1016/j.healthpol.2010.07.014 · 1.73 Impact Factor


Available from