Deep-Pocket Whites More Likely to Get High-Quality Surgical Care

LOS ANGELES, Oct. 25 -- Race and the ability to pay appear to be major determinants of the quality of complex surgical care that patients receive in California hospitals, researchers here have found.

Access to high-volume hospitals, and, presumably, superior care may be easier for patients who are white and privately insured, reported Clifford Y. Ko, M.D., M.S., and colleagues at the University of California at Los Angeles, in the Oct. 25 issue of Journal of the American Medical Association.

"Overall, the study showed that non-whites, Medicaid, and uninsured patients were less likely to receive care at high-volume hospitals and more likely to receive care at low-volume hospitals," said co-author David S. Zingmond, M.D., also of UCLA.

"Since there is significant interest among health care policy experts in improving quality of care by directing patients to high-volume facilities, we hope that addressing key disparities may broaden receipt of care for more patients at these facilities," said Dr. Ko.

The investigators reviewed discharge data on 719,608 patients who underwent one of 10 procedures linked to better outcomes in high volume hospitals.

The procedures were:

• Elective abdominal aortic aneurysm repair
• Coronary artery bypass grafting
• Carotid endarterectomy
• Esophageal cancer resection
• Hip fracture repair
• Lung cancer resection
• Cardiac valve replacement
• Coronary angioplasty
• Pancreatic cancer resection
• Total knee replacement.

The authors compared patient race/ethnicity and insurance status in patients who underwent surgery in the highest fifth of hospitals for patient volume, vs. those who underwent surgery in the lowest fifth.

They found that after controlling for other patient-level characteristics such as gender and distance traveled for care, nonwhites (blacks, Asians, and Hispanics), Medicaid patients, and uninsured patients were less likely to receive care at high-volume hospitals and more likely to receive care at low-volume hospitals.

Hispanic patients were significantly less likely than whites (P<0.05) to receive care at high-volume hospitals for all but one of the 10 procedures; only esophageal cancer resection rates were similar between high- and low-volume institutions for this group. Hispanic patients were least likely to have pancreatic cancer resection at a high-throughput establishment, with a relative risk compared with whites of 0.46 (95% confidence interval, 0.32-0.68, P<0.05).

Similarly blacks were significantly less likely than whites to receive care at high-volume hospitals for six of the 10 operations (P<0.05). For example, African Americans were 60% less likely than whites to have pancreatic cancer resection at a high-volume hospital (relative risk 0.40, 95% confidence interval, 0.21-0.67, P<0.05), and 30% less likely to have a carotid enterectomy in a hospital that does them by the thousands (relative risk 0.70, 95% CI, 0.60-0.83, P<0.05).

Other procedures blacks were more likely to receive in low volume institutions included hip fracture repair, knee replacement, lung cancer resection, and abdominal aortic aneurysm repair.

Asians were more likely to receive care at low-volume hospitals for five of the 10 procedures. Asians as a whole were 40% less likely to get carotid endarterectomies in high-volume facilities (relative risk 0.60, 95% CI, 0.52-0.70, P <0.05). Patients of Asian background were also less likely to be treated at high-volume hospitals for CABG, coronary angioplasty, hip fracture or knee replacement.

When the authors turned their attention to insurance, they found that Medicaid patients were significantly less likely than Medicare patients to receive care at high-volume hospitals for seven of the operations (all but AAA repair, esophageal cancer resection, and pancreatic cancer resection, relative risk range vs. privately insured patients, 0.22-0.66).

Uninsured patients were significantly more likely to receive every procedure except esophageal cancer resection at a low-volume center. For example, patients without insurance were 80% less likely to get valve-replacement surgery from seasoned surgical centers than from less experienced centers (relative risk 0.20, 95% CI, 0.15-0.25, P<0.05).

"Our study demonstrates significant differences among patients receiving care at high- and low-volume hospitals in the large, ethnically diverse population of California," said Dr. Ko. "More study needs to be done to see if the findings are similar nationwide."

But in an accompanying editorial, surgeon Samuel R. G. Finlayson, M.D., of Dartmouth Medical School in Hanover, N.H., suggested that patient preference may account for a substantial proportion of the racial and economic disparities in care between low- and high-volume hospitals.

"Just as shoppers do not all choose to shop at the stores with the best values, some patients may not choose to receive care at hospitals that health care experts believe deliver the highest-quality care," Dr. Finlayson wrote.

"To some, the desirability of a hospital may be driven more by familiarity, ethnic or cultural makeup of hospital staff and patients, or other factors related to social comfort," he continued. "Because of racial discrimination, ethnic minorities may be more inclined to seek care at hospitals where they already feel comfortable. Among the poor who live on the social margins, there may be a greater desire to avoid moving from a familiar hospital to an unfamiliar one. The popular appeal of what is referred to as 'high-quality; care is probably grossly overestimated, while the strength of patients' preferences for 'lower-quality' hospitals where they may feel socially more at ease is probably underestimated."

Calling volume-based referrals a "lazy" approach to quality improvement, he instead advocated directing health-care quality research efforts toward determining specific factors that would allow high-quality care to be provided across difference social and economic settings, a sentiment echoed by Dr. Ko and colleagues.

"While there is significant interest among health care policy experts in improving quality by directing patients to high-volume hospitals, policy development should include explicit efforts to identify the patient and system factors required to reduce current inequities in the receipt of care at such hospitals," they wrote.