Hospital-Level Racial and Ethnic Segregation Among Medicare Beneficiaries Undergoing Common Surgical Procedures

Bonner, Sidra N.; Kunnath, Nicholas; Dimick, Justin B.; Ibrahim, Andrew M.

doi:10.1001/jamasurg.2022.3135

Cited by 16 publications

(27 citation statements)

References 7 publications

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“…[42][43][44] At the system level, racial residential and hospital level segregation in conjunction with modern health care system financing such as insurance price discrimination has contributed to the concentration of racial and ethnic minority groups at lower volume and lower quality hospitals for their surgical care. 8,13,[45][46][47][48][49] For instance, the significantly higher payment in services from private health insurers compared with Medicare and Medicaid, creates incentives for hospitals to provide care to populations that are with larger shares of privately insured patients. 26 This has…”

Section: Societal Inequities In Resource Allocation Contribute To Ine...mentioning

confidence: 99%

“…This has implications for racial and ethnic inequities in care given that non-Hispanic Black and Hispanic patient populations are disproportionately enrolled in Medicaid, whose access to surgical services, particularly surgical subspeciality care, may be limited given lower reimbursement 49 . Furthermore, recent analysis has demonstrated that <25% of hospitals in the United States perform 90% of surgeries for American Indian/Native Americans, Asian and Pacific Islander, Hispanic, and non-Hispanic Black patients with those hospitals having worse outcomes 13 …”

Section: Definitions and Mechanisms Of Racial And Ethnic Inequities I...mentioning

confidence: 99%

“…49 Furthermore, recent analysis has demonstrated that <25% of hospitals in the United States perform 90% of surgeries for American Indian/Native Americans, Asian and Pacific Islander, Hispanic, and non-Hispanic Black patients with those hospitals having worse outcomes. 13 Discriminatory Beliefs, Negative Stereotypes, and Surgical Inequities…”

Section: Biasmentioning

confidence: 99%

“…Racial and ethnic inequities in access, delivery, quality, and outcomes in surgical care are well documented across surgical specialties 1–13 . These inequities have significant implications for the wellbeing and health of patients, their families, and communities in addition to being associated with higher costs to health care systems and lost productivity within society 14 .…”

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confidence: 99%

“…The underlying mechanisms contributing to persistent disparities have been described at the patient, provider, community, health care system, and societal levels. For instance, prior research has identified higher levels of individual and community socioeconomic disadvantage, provider bias, differential access to surgeon specialties, hospital and health care system segregation, and historic federal and state policies as contributing mechanisms to persistent racial and ethnic inequities in surgical care in the United States 7–13 …”

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confidence: 99%

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Surgical Care for Racial and Ethnic Minorities and Interventions to Address Inequities

et al. 2023

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Objective: Racial and ethnic inequities in surgical care in the United States are well documented. Less is understood about evidence-based interventions that improve surgical care and reduce or eliminate inequities. In this review, we discuss effective patient, surgeon, community, health care system, policy, and multi-level interventions to reduce inequities and identifying gaps in intervention-based research. Background: Evidenced-based interventions to reduce racial and ethnic inequities in surgical care are key to achieving surgical equity. Surgeons, surgical trainees, researchers, and policy makers should be aware of the evidence-based interventions known to reduce racial and ethnic disparities in surgical care for prioritization of resource allocation and implementation. Future research is needed to assess interventions effectiveness in the reduction of disparities and patient-reported measures. Methods: We searched PubMed database for English-language studies published from January 2012 through June 2022 to assess interventions to reduce or eliminate racial and ethnic disparities in surgical care. A narrative review of existing literature was performed identifying interventions that have been associated with reduction in racial and ethnic disparities in surgical care. Results and Conclusions: Achieving surgical equity will require implementing evidenced-based interventions to improve quality for racial and ethnic minorities. Moving beyond description toward elimination of racial and ethnic inequities in surgical care will require prioritizing funding of intervention-based research, utilization of implementation science and community based-participatory research methodology, and principles of learning health systems.

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Section: Societal Inequities In Resource Allocation Contribute To Ine...mentioning

confidence: 99%

Section: Definitions and Mechanisms Of Racial And Ethnic Inequities I...mentioning

confidence: 99%

Section: Biasmentioning

confidence: 99%

mentioning

confidence: 99%

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confidence: 99%

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Surgical Care for Racial and Ethnic Minorities and Interventions to Address Inequities

et al. 2023

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Segregated Patterns of Hospital Care Delivery and Health Outcomes

Lin,

Hammond,

Esposito

et al. 2023

JAMA Health Forum

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ImportanceResidential segregation has been shown to be a root cause of racial inequities in health outcomes, yet little is known about current patterns of racial segregation in where patients receive hospital care or whether hospital segregation is associated with health outcomes. Filling this knowledge gap is critical to implementing policies that improve racial equity in health care.ObjectiveTo characterize contemporary patterns of racial segregation in hospital care delivery, identify market-level correlates, and determine the association between hospital segregation and health outcomes.Design, Setting, and ParticipantsThis cross-sectional study of US hospital referral regions (HRRs) used 2018 Medicare claims, American Community Survey, and Agency for Healthcare Research and Quality Social Determinants of Health data. Hospitalization patterns for all non-Hispanic Black or non-Hispanic White Medicare fee-for-service beneficiaries with at least 1 inpatient hospitalization in an eligible hospital were evaluated for hospital segregation and associated health outcomes at the HRR level. The data analysis was performed between August 10, 2022, and September 6, 2023.ExposuresDissimilarity index and isolation index for HRRs.Main Outcomes and MeasuresHealth outcomes were measured using Prevention Quality Indicator (PQI) acute and chronic composites per 100 000 Medicare beneficiaries, and total deaths related to heart disease and stroke per 100 000 residents were calculated for individuals aged 74 years or younger. Correlation coefficients were used to compare residential and hospital dissimilarity and residential and hospital isolation. Linear regression was used to examine the association between hospital segregation and health outcomes.ResultsThis study included 280 HRRs containing data for 4386 short-term acute care and critical access hospitals. Black and White patients tended to receive care at different hospitals, with a mean (SD) dissimilarity index of 23 (11) and mean (SD) isolation index of 13 (13), indicating substantial variation in segregation across HRRs. Hospital segregation was correlated with residential segregation (correlation coefficients, 0.58 and 0.90 for dissimilarity and isolation, respectively). For Black patients, a 1-SD increase in the hospital isolation index was associated with 204 (95% CI, 154-254) more acute PQI hospitalizations per 100 000 Medicare beneficiaries (28% increase from the median), 684 (95% CI, 488-880) more chronic PQI hospitalizations per 100 000 Medicare beneficiaries (15% increase), and 6 (95% CI, 2-9) additional deaths per 100 000 residents (6% increase) compared with 68 (95% CI, 24-113; 6% increase), 202 (95% CI, 131-274; 8% increase), and 2 (95% CI, 0 to 4; 3% increase), respectively, for White patients.Conclusions and RelevanceThis cross-sectional study found that higher segregation of hospital care was associated with poorer health outcomes for both Black and White Medicare beneficiaries, with significantly greater negative health outcomes for Black populations, supporting racial segregation as a root cause of health disparities. Policymakers and clinical leaders could address this important public health issue through payment reform efforts and expansion of health insurance coverage, in addition to supporting upstream efforts to reduce racial segregation in hospital care and residential settings.

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Emergency Department Pediatric Readiness and Disparities in Mortality Based on Race and Ethnicity

Jenkins,

Lin,

Ames

et al. 2023

JAMA Netw Open

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ImportancePresentation to emergency departments (EDs) with high levels of pediatric readiness is associated with improved pediatric survival. However, it is unclear whether children of all races and ethnicities benefit equitably from increased levels of such readiness.ObjectiveTo evaluate the association of ED pediatric readiness with in-hospital mortality among children of different races and ethnicities with traumatic injuries or acute medical emergencies.Design, Setting, and ParticipantsThis cohort study of children requiring emergency care in 586 EDs across 11 states was conducted from January 1, 2012, through December 31, 2017. Eligible participants included children younger than 18 years who were hospitalized for an acute medical emergency or traumatic injury. Data analysis was conducted between November 2022 and April 2023.ExposureHospitalization for acute medical emergency or traumatic injury.Main Outcomes and MeasuresThe primary outcome was in-hospital mortality. ED pediatric readiness was measured through the weighted Pediatric Readiness Score (wPRS) from the 2013 National Pediatric Readiness Project assessment and categorized by quartile. Multivariable, hierarchical, mixed-effects logistic regression was used to evaluate the association of race and ethnicity with in-hospital mortality.ResultsThe cohort included 633 536 children (median [IQR] age 4 [0-12] years]). There were 557 537 children (98 504 Black [17.7%], 167 838 Hispanic [30.1%], 311 157 White [55.8%], and 147 876 children of other races or ethnicities [26.5%]) who were hospitalized for acute medical emergencies, of whom 5158 (0.9%) died; 75 999 children (12 727 Black [16.7%], 21 604 Hispanic [28.4%], 44 203 White [58.2%]; and 21 609 of other races and ethnicities [27.7%]) were hospitalized for traumatic injuries, of whom 1339 (1.8%) died. Adjusted mortality of Black children with acute medical emergencies was significantly greater than that of Hispanic children, White children, and of children of other races and ethnicities (odds ratio [OR], 1.69; 95% CI, 1.59-1.79) across all quartile levels of ED pediatric readiness; but there were no racial or ethnic disparities in mortality when comparing Black children with traumatic injuries with Hispanic children, White children, and children of other races and ethnicities with traumatic injuries (OR 1.01; 95% CI, 0.89-1.15). When compared with hospitals in the lowest quartile of ED pediatric readiness, children who were treated at hospitals in the highest quartile had significantly lower mortality in both the acute medical emergency cohort (OR 0.24; 95% CI, 0.16-0.36) and traumatic injury cohort (OR, 0.39; 95% CI, 0.25-0.61). The greatest survival advantage associated with high pediatric readiness was experienced for Black children in the acute medical emergency cohort.Conclusions and RelevanceIn this study, racial and ethnic disparities in mortality existed among children treated for acute medical emergencies but not traumatic injuries. Increased ED pediatric readiness was associated with reduced disparities; it was estimated that increasing the ED pediatric readiness levels of hospitals in the 3 lowest quartiles would result in an estimated 3-fold reduction in disparity for pediatric mortality. However, increased pediatric readiness did not eliminate disparities, indicating that organizations and initiatives dedicated to increasing ED pediatric readiness should consider formal integration of health equity into efforts to improve pediatric emergency care.

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Hospital-Level Racial and Ethnic Segregation Among Medicare Beneficiaries Undergoing Common Surgical Procedures

Abstract: This cohort study uses Medicare fee-for-service claims data to assess hospital-level racial and ethnic segregation among beneficiaries undergoing common surgical procedures.

Cited by 16 publications

References 7 publications

Surgical Care for Racial and Ethnic Minorities and Interventions to Address Inequities

Surgical Care for Racial and Ethnic Minorities and Interventions to Address Inequities

Segregated Patterns of Hospital Care Delivery and Health Outcomes

Emergency Department Pediatric Readiness and Disparities in Mortality Based on Race and Ethnicity

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