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

ArticleinArchives of surgery (Chicago, Ill.: 1960) 145(2):179-86 · February 2010with3 Reads
DOI: 10.1001/archsurg.2009.268 · Source: PubMed
Abstract
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.
    • "They found that black patients were more likely than white patients to be referred to surgeons with the highest risk-adjusted mortality rates in comparison with white patients. A separate study by Epstein et al. [37] found that for nine of ten major surgical procedures black patients were less likely to be operated on by a high-volume surgeon at a high-volume center, the best case scenario reflected in the best outcomes. Compared to whites, blacks were more likely to have surgery performed by a lowvolume surgeon at a low-volume hospital—the worst case scenario in terms of procedural outcomes. "
    Article · Sep 2014
    • "Patient-related difference is important in the volume-outcome relationship study. Some studies revealed the minority, older, and low SES patients are more likely to be treated at low-volume hospitals [20,21]. And there is a negative association between SES and cancer survival rate [22,23,24]. "
    [Show abstract] [Hide abstract] ABSTRACT: The influence of different hospital and surgeon volumes on short-term survival after hepatic resection is not clearly clarified. By taking the known prognostic factors into account, the purpose of this study is to assess the combined effects of hospital and surgeon volume on short-term survival after hepatic resection. 13,159 patients who underwent hepatic resection between 2002 and 2006 were identified in the Taiwan National Health Insurance Research Database. Data were extracted from it and short-term survivals were confirmed through 2006. The Cox proportional hazards model was used to assess the relationship between survival and different hospital, surgeon volume and caseload combinations. High-volume surgeons in high-volume hospitals had the highest short-term survivals, following by high-volume surgeons in low-volume hospitals, low-volume surgeons in high-volume hospitals and low-volume surgeons in low-volume hospitals. Based on Cox proportional hazard models, although high-volume hospitals and surgeons both showed significant lower risks of short-term mortality at hospital and surgeon level analysis, after combining hospital and surgeon volume into account, high-volume surgeons in high-volume hospitals had significantly better outcomes; the hazard ratio of other three caseload combinations ranging from 1.66 to 2.08 (p<0.001) in 3-month mortality, and 1.28 to 1.58 (p<0.01) in 1-year mortality. The combined effects of hospital and surgeon volume influenced the short-term survival after hepatic resection largely. After adjusting for the prognostic factors in the case mix, high-volume surgeons in high-volume hospitals had better short-term survivals. Centralization of hepatic resection to few surgeons and hospitals might improve patients' prognosis.
    Full-text · Article · Jan 2014
    • "Our data indicate, in our population of younger, predominantly employed patients (75%), household income was far more predictive of outcome than minority status. Epstein et al. [19] reported minority patients were less likely to go to surgeons at high-volume hospitals. This finding was confirmed by Cai et al. [11] Table 4. Adjusted odds ratio of socioeconomic factors significantly associated with outcomes of interest using forward stepwise multiple logistic regression (total n = 661) who reported black patients were more likely to receive care in low-volume hospitals. "
    [Show abstract] [Hide abstract] ABSTRACT: BACKGROUND: Few data exist regarding the impact of socioeconomic factors on results of current TKA in young patients. Predictors of TKA outcomes have focused primarily on surgical technique, implant details, and individual patient clinical factors. The relative importance of these factors compared to patient socioeconomic status is not known. QUESTIONS/PURPOSES: We determined whether (1) socioeconomic factors, (2) demographic factors, or (3) implant factors were associated with satisfaction and functional outcomes after TKA in young patients. METHODS: We surveyed 661 patients (average age, 54 years; range, 18-60 years; 61% female) 1 to 4 years after undergoing modern primary TKA for noninflammatory arthritis at five orthopaedic centers. Data were collected by an independent third party with expertise in collecting healthcare data for state and federal agencies. We examined specific questions regarding satisfaction, pain, and function after TKA and socioeconomic (household income, education, employment) and demographic (sex, minority status) factors. Multivariable analysis was conducted to examine the relative importance of these factors for each outcome of interest. RESULTS: Patients reporting incomes of less than USD 25,000 were less likely to be satisfied with TKA outcomes and more likely to have functional limitations after TKA than patients with higher incomes; no other socioeconomic factors were associated with satisfaction. Women were less likely to be satisfied and more likely to have functional limitations than men, and minority patients were more likely to have functional limitations than nonminority patients. Implants were not associated with outcomes after surgery. CONCLUSIONS: Socioeconomic factors, in particular low income, are more strongly associated with satisfaction and functional outcomes in young patients after TKA than demographic or implant factors. Future studies should be directed to determining the causes of this association, and studies of clinical results after TKA should consider stratifying patients by socioeconomic status. LEVEL OF EVIDENCE: Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
    Full-text · Article · Apr 2013
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