Segregated Patterns of Hospital Care Delivery and Health Outcomes

Abstract

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.

Measuring Local-Area Racial Segregation for Medicare Hospital Admissions

“…There is considerable evidence that residential segregation drives variation in hospital racial composition, with several recent studies showing poor hospital quality in residentially segregated areas . This, in part, reflects the lower quality of hospitals located in largely Black communities.…”

“…This measure is the mean of the absolute value of the LHS index across the region, weighted by the size of the hospital. Following the Dissimilarity Index, 14 this measure is the percentage of all hospitalizations in a region who must be moved across hospitals to achieve evenness or representativeness, but where the total number of hospitalizations at each hospital is held constant 8 (eAppendix in Supplement 1 ). We adopt the Dartmouth Atlas hospital referral region (HRR) as our measure of regional markets.…”

“…Racial inequities in health outcomes can be, in part, attributed to disparities in treatment and utilization arising from geographic variation in clinical practices, historical and systemic racism, implicit bias, social determinants of health, and poor access to care . There has been increasing attention to the role of lower-quality care in segregated communities leading to poor health outcomes . In the case of Black patients, it is less well understood whether higher rates of patient admissions occur because hospitals’ markets comprise segregated communities, or because patients from the same communities are admitted to different hospitals.…”

“…Local patient sorting could be positive if patients disproportionately seek care at hospitals providing more affirming care, such as that captured in an index of hospital inclusivity . Differential patterns of admissions could also lead to poorer overall health care quality if patients forgo higher-quality hospitals primarily serving White patients because of historical segregation or negative perception . And while several efforts have been made recently to capture inclusivity, to our knowledge, there is no measure of hospital sorting within hospital-level markets that is both distinct from traditional measures of segregation and predetermined, hence insulated from hospital efforts to attract or avoid certain patients.…”

“… 4 , 5 , 6 , 7 There has been increasing attention to the role of lower-quality care in segregated communities leading to poor health outcomes. 8 , 9 In the case of Black patients, it is less well understood whether higher rates of patient admissions occur because hospitals’ markets comprise segregated communities, or because patients from the same communities are admitted to different hospitals. Local patient sorting could be positive if patients disproportionately seek care at hospitals providing more affirming care, such as that captured in an index of hospital inclusivity.…”