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| Health economist Amitabh Chandra
used Medicare data on heart attack patients to study the connection
between race, geography, and hospital quality. |
Posted
December 1, 2004
Hospital Geography Helps Account for Racial Disparities
in Health Care, Economist Argues
African-Americans may get poorer medical treatment because they
are more likely to go to bad hospitals, said Dartmouth economics
professor Amitabh Chandra at a Nov. 19 talk sponsored by the Sadie
Lewis Webb Program in Law and Biomedicine.
Chandra’s assertion that geographic variations in care explain
most racial disparities in treatment offers an alternate explanation
to an Institute of Medicine report that placed more blame on physician-based
discrimination. “Instead of pushing the physician-discrimination
story, we’re going to push a differences-in-hospital-quality
story,” he said. The IOM lambasted southern hospitals in
particular, but Chandra charged that racial disparities are a “local
phenomenon,” with problems in northern hospitals as well.
He based his arguments on a series of papers he and others authored
on the topic.
“The key fact that comes from [the literature on race and
health care] is that African-Americans, once you’ve controlled
for all the clinical characteristics at the time of presentation,
appear to get less—so it could be less of kidney dialysis,
it could be less of renal transplantation, it could be less of
bypass surgery,” he explained.
Chandra studied the results of heart attacks in Medicare beneficiaries
across the country and found wide variations in treatment depending
on the hospital. Many measures that good hospitals take—providing
beta blockers when a heart attack patient first arrives at the
hospital, for example—are not necessarily expensive. Forty
trials published in the Journal of the American Medical Association trumpet
giving beta blockers to heart attack patients, yet many hospitals
have not made the practice standard for all patients.
In charting hospital quality on a map of the United States, Chandra
and co-author Katherine Baicker found that many low-quality hospitals
were in fact in the South, but they were also in New Jersey and
California. Top states for health care included New Hampshire,
Maine, Vermont, North Dakota, Utah, Iowa, Wisconsin, and Colorado.
Part of what drives quality, they found, was the composition of
the physician mix—there were a high number of specialists
in low-quality states, suggesting that physicians were not getting
a good overall picture of patients’ health.
Chandra also looked at the geography of hospital referral regions—where
people actually go to get care, even if it’s across state
lines. While some have argued that there are simply dumb doctors
in some regions, Chandra said one scholar who studied the five
leading academic medical centers in Boston found significant variations
in how they treat heart attacks and strokes, suggesting that regional
differences are not as important to care as individual hospital
differences.
From 1998-2001, 4,690 hospitals treated heart attacks; 1,000 hospitals
account for almost 80 percent of all African-American patients,
but only 35 percent of white patients.
“If I go after the first 40 hospitals, I can improve outcomes
for 20 percent of blacks,” he said.
About 2,000 hospitals didn’t see a single African-American
patient. Although Chandra was not allowed to tell the ranking of
hospitals regarding heart attacks due to Medicare regulations,
he is writing a paper that will name the 40 worst hospitals for
treating African-Americans.
A model of the 30-day mortality rate shows that “mortality
goes up for both blacks and whites” in hospitals that treat
more African-American patients. Hospitals that saw no blacks were
also low-quality centers. All-white hospitals tend to be located
in Appalachia—eastern Kentucky, eastern Tennessee, and West
Virginia. Forty percent of the white population is treated by small
regional hospitals.
“The one thing we know, in terms of markers of quality,
is that hospitals which have big volume are better,” he said,
perhaps because they attract better physicians or because they
learn more from the volume of patients.
Overall, blacks are about 12 percent more likely to die 90 days
after a heart attack, when adjusting for gender and age. Some doctors
have told Chandra that African-American patients have more severe
illnesses in general. “They are much sicker, I don’t
dispute that, but it’s not driving the outcome,” Chandra
said.
That 12 percent falls to about 10 percent when hospital characteristics
are accounted for, and just 5 percent when considering the actual
hospital. “I can explain 60 percent of the racial disparity
in care by controlling for the kind of hospital that you go to,” he
said. Thus physician discrimination may account for 40 percent
of the white-black mortality gap, but 60 percent is due to geography.
Whites treated in hospitals that care for a disproportionate number
of African-Americans have a 30 percent lower survival rate after
90 days, while blacks treated at the same hospital have a 17 percent
lower survival rate in comparison to those treated at top hospitals.
While Chandra’s data on heart attack patients provides a
clear picture because the outcome of bad treatment is premature
death, racial disparities in regards to other medical problems
are not as easy to assign to geography, as hospitals have strengths
in different subspecialties. “There really are no clean,
simple answers,” Chandra said. He plans to write similar
papers on hip fractures and strokes, as soon as the data is compiled,
which may take three to four years.
He suggested that hospitals could help matters by focusing on
the rates of procedures, such as heart catheterization, for whites
and blacks. On average, there is a 9 percent gap between whites
and blacks in receiving heart catheterizations, although catheterization
rates as a whole vary regionally.
“The policy prescription is….you want to match the
rate at which a procedure is being done to inform preferences for
that procedure,” he said.
Chandra said data suggests that Hispanics are also going to lousy
hospitals and are likewise suffering from poor treatment, but Medicare’s
race coding for Hispanics is less reliable when you compare it
to Census reports. “The race field in the Medicare data is
populated by Social Security Administration data,” entered
in the 1940s and 1950s, when classifications for Hispanics were
less likely to be used. “I think there’s more work
to be done on Hispanics.”
• Reported by M. Wood
