Trends in racial disparities for injured patients admitted to trauma centers.
ABSTRACT: To determine whether outcome disparities between black and white trauma patients have decreased over the last 10 years.Pennsylvania Trauma Outcome Study.We performed an observational cohort study on 191,887 patients admitted to 28 Level 1 and Level II trauma centers. The main outcomes of interest were (1) death, (2) death or major complication, and (3) failure-to-rescue. Hospitals were categorized according to the proportion of black patients. Multivariate regression models were used to estimate trends in racial disparities and to assess whether the source of racial disparities was within or between hospitals.Trauma patients admitted to hospitals with high concentrations of blacks (>20 percent) had a 45 percent higher odds of death (adj OR: 1.45, 95 percent CI: 1.09-1.92) and a 73 percent higher odds of death or major complication (adj OR: 1.73, 95 percent CI: 1.42-2.11) compared with patients admitted to hospitals treating low proportions of blacks. Blacks and whites admitted to the same hospitals had no difference in mortality (adj OR: 1.05, 95 percent CI: 0.87, 1.27) or death or major complications (adj OR: 1.01; 95 percent CI: 0.90, 1.13). The odds of overall mortality, and death or major complications have been reduced by 32 percent (adj OR: 0.68; 95 percent CI: 0.54-0.86) and 28 percent (adj OR: 0.72; 95 percent CI: 0.60-0.85) between 2000 and 2009, respectively. Racial disparities did not change over 10 years.Despite the overall improvement in outcomes, the gap in quality of care between black and white trauma patients in Pennsylvania has not narrowed over the last 10 years. Racial disparities in trauma are due to the fact that black patients are more likely to be treated in lower quality hospitals compared with whites.
Project description:Background:Understanding racial differences in outcomes for atrial fibrillation (AF) may guide interventions to diminish health inequities. Methods and Results:In a retrospective, cross-sectional study of adults hospitalized with a principal diagnosis of AF using the 2001-2012 National Inpatient Sample, we assessed racial differences for in-hospital. We accounted for case-mix and clustering by race within hospitals to estimate odds ratios (OR) for death associated with individual patient race and hospital racial composition. We identified 676,567 hospitalizations (mean age 71.8 years, 53.6% women) with principal diagnosis of AF (84.2% White, 7.1% Black, 5.0% Hispanic). Black (vs. White) race was associated with 1.63-fold (95% CI, 1.50-1.78) risk of death. Other races had similar risk of death as Whites. Risk of death for Blacks (vs. Whites) declined over time [2001: OR 1.78(95% CI 1.31-2.43); 2012: OR 1.23(95% CI 0.92-1.64)]. Racial differences in deaths within hospitals narrowed, while hospitals with larger proportions of Blacks had persistently worse outcomes than hospitals with fewer Blacks (OR 1.08 per 10% increase in Blacks in 2001 and 2012). Conclusion:Black patients with a principal diagnosis of AF were more likely to suffer in-hospital death than Whites. Our findings suggest racial disparities based upon individual patients' race improved over time, but outcomes were persistently worse at hospitals with higher proportions of Black patients, regardless of patients' races.
Project description:Racial disparities in acute myocardial infarction treatment may be due to differences in admitting hospitals. Little is known about factors associated with hospital selection for black and white acute myocardial infarction patients.We identified black and white Medicare beneficiaries with acute myocardial infarction in 63 hospital referral regions with at least 50 black admissions during 2005 (n=65,633). We calculated distance from patient home to hospital referral region hospitals using ZIP code centroids. We assessed hospital quality using a composite score made up of hospital risk-adjusted 30-day mortality and acute myocardial infarction performance measures. Hospitals with a score in the top 20% were categorized as high quality, and those in the lowest 20% as low quality. We used conditional multinomial logit models to examine differences in hospital selection for blacks and whites. On average, blacks lived closer to revascularization hospitals (mean, 3.8 versus 6.8 miles; P<0.001) and to high-quality hospitals (mean, 5.6 versus 9.7 miles; P<0.001). After distance was accounted for, blacks were relatively less likely (P<0.001) to be admitted to revascularization hospitals (risk ratio [RR], 0.87; 95% confidence interval [CI], 0.80 to 0.95) and to high-quality hospitals (RR, 0.88; 95% CI, 0.801 to 0.95) but more likely (P<0.001) to be admitted to low-quality hospitals (RR, 1.17; 95% CI, 1.05 to 1.29). In analyses matched by home ZIP code, differences in admissions to revascularization (RR, 0.92; 95% CI, 0.80 to 1.05), high-quality (RR, 0.94; 95% CI, 0.81 to 1.07), and low-quality (RR, 1.15; 95% CI, 0.94 to 1.35) hospitals were not significant.Differences in admissions to revascularization and high-quality hospitals may contribute to disparities in acute myocardial infarction care. These differences may be due in part to residential ZIP code characteristics.
Project description:OBJECTIVE. : To determine whether racial/ethnic disparities in colonoscopy use vary by physician availability. DATA SOURCE. : We used 100 percent Texas Medicare claims data for 2003-2007. STUDY DESIGN. : We identified beneficiaries aged 66-79 in 2007, examined racial/ethnic differences in colonoscopy use from 2003 to 2007, and estimated the percentage of white, black, and Hispanic beneficiaries who underwent colonoscopy by level of physician availability and area income. PRINCIPAL FINDINGS. : For the 974,879 beneficiaries, colonoscopy use was higher in whites (40.7 percent) compared to blacks (35.0 percent) and Hispanics (28.7 percent, p< .001). For whites, increasing availability of colonoscopists and primary care physicians (PCPs) was associated with higher colonoscopy use. For blacks and Hispanics, colonoscopy use was unchanged or decreased with increases in colonoscopist and PCP availability. In multilevel models, the odds of colonoscopy were 20 percent lower for blacks (OR 0.80, 95 percent CI 0.79-0.82) and 32 percent lower for Hispanics (OR 0.68, 95 percent CI 0.66-0.69) compared to whites; adjusting for availability of colonoscopists or PCPs did not attenuate racial/ethnic disparities. We found greater racial/ethnic disparities in areas with greater colonoscopist and PCP availability. CONCLUSIONS. : Greater area availability of colonoscopists and PCPs is associated with increased use of colonoscopy in whites but decreased use in minorities, resulting in larger racial/ethnic disparities.
Project description:OBJECTIVE:To examine experiences of racial discrimination among black adults in the United States, which broadly contribute to their poor health outcomes. DATA SOURCE AND STUDY DESIGN:Data come from a nationally representative, probability-based telephone survey including 802 non-Hispanic black and a comparison group of 902 non-Hispanic white US adults, conducted January-April 2017. METHODS:We calculated the percent of blacks reporting discrimination in several domains, including health care. We used logistic regression to compare the black-white difference in odds of discrimination, and among blacks only to examine variation by socioeconomic status, gender, and neighborhood racial composition. PRINCIPAL FINDINGS:About one-third of blacks (32 percent) reported experiencing discrimination in clinical encounters, while 22 percent avoided seeking health care for themselves or family members due to anticipated discrimination. A majority of black adults reported experiencing discrimination in employment (57 percent in obtaining equal pay/promotions; 56 percent in applying for jobs), police interactions (60 percent reported being stopped/unfairly treated by police), and hearing microaggressions (52 percent) and racial slurs (51 percent). In adjusted models, blacks had significantly higher odds than whites of reporting discrimination in every domain. Among blacks, having a college degree was associated with higher odds of experiencing overall institutional discrimination. CONCLUSIONS:The extent of reported discrimination across several areas of life suggests a broad pattern of discrimination against blacks in America, beyond isolated experiences. Black-white disparities exist on nearly all dimensions of experiences with public and private institutions, including health care and the police. Evidence of systemic discrimination suggests a need for more active institutional interventions to address racism in policy and practice.
Project description:This study investigated whether emergency department crowding affects blacks more than their white counterparts and the mechanisms behind which this might occur. Using a nonpublic database of patients in California with acute myocardial infarction between 2001 and 2011 and hospital-level data on ambulance diversion, we found that hospitals treating a high share of black patients with acute myocardial infarction were more likely to experience diversion and that black patients fared worse compared to white patients experiencing the same level of emergency department crowding as measured by ambulance diversion. The ninety-day and one-year mortality rates among blacks exposed to high diversion levels were 2.88 and 3.09 percentage points higher, respectively, relative to whites, representing a relative increase of 19 percent and 14 percent for ninety-day and one-year death, respectively. Interventions that decrease the need for diversion in hospitals serving a high volume of blacks could reduce these disparities.
Project description:To examine racial/ethnic disparities in quality of schizophrenia care and assess the size of observed disparities across states and over time.Medicaid claims data from CA, FL, NY, and NC.Observational repeated cross-sectional panel cohort study of white, black, and Latino fee-for-service adult beneficiaries with schizophrenia. Main outcome was the relationship of race/ethnicity and year with a composite measure of quality of schizophrenia care derived from 14 evidence-based quality indicators.Quality was assessed for 325,373 twelve-month person-episodes between 2002 and 2008, corresponding to 123,496 Medicaid beneficiaries. In 2002, quality was lowest for blacks in all states. With the exception of FL, quality was lower for Latinos than whites. In CA, blacks had about 43 percent of the individual indicators met compared to 58 percent for whites. Quality improved annually for all groups in CA, NY, and NC. While in CA the improvement was slightly larger for Latinos, in FL quality improved for blacks but declined for Latinos and whites.Quality of schizophrenia care is poor and racial/ethnic disparities exist among Medicaid beneficiaries from four states. The size of the disparities varied across the states, and most of the initial disparities were unchanged by 2008.
Project description:BACKGROUND:Thirty-day readmission penalties implemented with the Hospital Readmission Reduction Program (HRRP) place a larger burden on safety-net hospitals which treat a disproportionate share of racial minorities, leading to concerns that already large racial disparities in readmissions could widen. OBJECTIVE:To examine whether there were changes in Black-White disparities in 30-day readmissions for acute myocardial infarction (AMI), congestive heart failure (CHF), or pneumonia following the passage and implementation of HRRP, and to compare disparities across safety-net and non-safety-net hospitals. DESIGN:Repeated cross-sectional analysis, stratified by safety-net status. SUBJECTS:1,745,686 Medicare patients over 65 discharged alive from hospitals in 5 US states: NY, FL, NE, WA, and AR. MAIN MEASURES:Odds ratios comparing 30-day readmission rates following an index admission for AMI, CHF, or pneumonia for Black and White patients between 2007 and 2014. KEY RESULTS:Prior to the passage of HRRP in 2010, Black and White readmission rates and disparities in readmissions were decreasing. These reductions were largest at safety-net hospitals. In 2007, Blacks had 13% higher odds of readmission if treated in safety-net hospitals, compared with 5% higher odds in 2010 (P?<?0.05). These trends continued following the passage of HRRP. CONCLUSIONS:Prior to HRRP, there were large reductions in Black-White disparities in readmissions at safety-net hospitals. Although HRRP tends to assess higher penalties for safety-net hospitals, improvements in readmissions have not reversed following the implementation of HRRP. In contrast, disparities continue to persist at non-safety-net hospitals which face much lower penalties.
Project description:<h4>Background</h4>The COVID-19 pandemic has magnified existing health disparities for marginalized populations in the United States (U.S.), particularly among Black Americans. Social determinants of health are powerful drivers of health outcomes that could influence COVID-19 racial disparities.<h4>Methods</h4>We collected data from publicly available databases on COVID-19 death rates through October 28, 2020, clinical covariates, and social determinants of health indicators at the U.S. county level. We utilized negative binomial regression to assess the association between social determinants of health and COVID-19 mortality focusing on racial disparities in mortality.<h4>Results</h4>Counties with higher death rates had a higher proportion of Black residents and greater levels of adverse social determinants of health. A one percentage point increase in percent Black residents, percent uninsured adults, percent low birthweight, percent adults without high school diploma, incarceration rate, and percent households without internet in a county increased COVID-19 death rates by 0.9% (95% CI 0.5%-1.3%), 1.9% (95% CI 1.1%-2.7%), 7.6% (95% CI 4.4%-11.0%), 3.5% (95% CI 2.5%-4.5%), 5.4% (95% CI 1.3%-9.7%), and 3.4% (95% CI 2.5%-4.2%), respectively. Counties in the lowest quintile of a measure of economic privilege had an increased COVID-19 death rates of 67.5% (95% CI 35.9%-106.6%). Multivariate regression and subgroup analyses suggested that adverse social determinants of health may partially explain racial disparities in COVID-19 mortality.<h4>Conclusions</h4>This study demonstrates that social determinants of health contribute to COVID-19 mortality for Black Americans at the county level, highlighting the need for public health policies that address racial disparities in health outcomes.
Project description:To examine whether hospitals where patients obtain care explain racial/ethnic differences in treatment delay.Surveillance, Epidemiology, and End Results data linked with Medicare claims.We examined delays in adjuvant chemotherapy or radiation for women diagnosed with stage I-III breast cancer during 1992-2007. We used multivariable logistic regression to assess the probability of delay by race/ethnicity and included hospital fixed effects to assess whether hospitals explained disparities.Among 54,592 women, black (11.9 percent) and Hispanic (9.9 percent) women had more delays than whites (7.8 percent, p < .0001). After adjustment, black (vs. white) women had higher odds of delay (odds ratio = 1.25, 95 percent confidence interval = 1.10-1.42), attenuated somewhat by including hospital fixed effects (OR = 1.17, 95 percent CI = 1.02-1.33).Hospitals are the important contributors to racial disparities in treatment delay.
Project description:OBJECTIVE: To estimate racial differences in mortality at 30 days and up to 2 years following a hospital admission for the elderly with common medical conditions. DATA SOURCES: The Medicare Provider Analysis and Review File and the VA Patient Treatment File from 1998 to 2002 were used to extract patients 65 or older admitted with a principal diagnosis of acute myocardial infarction, stroke, hip fracture, gastrointestinal bleeding, congestive heart failure, or pneumonia. STUDY DESIGN: A retrospective analysis of risk-adjusted mortality after hospital admission for blacks and whites by medical condition and in different hospital settings. PRINCIPAL FINDINGS: Black Medicare patients had consistently lower adjusted 30-day mortality than white Medicare patients, but the initial survival advantage observed among blacks dissipated beyond 30 days and reversed by 2 years. For VA hospitalizations similar patterns were observed, but the initial survival advantage for blacks dissipated at a slower rate. CONCLUSIONS: Racial disparities in health are more likely to be generated in the posthospital phase of the process of care delivery rather than during the hospital stay. The slower rate of increase in relative mortality among black VA patients suggests an integrated health care delivery system like the VA may attenuate racial disparities in health.