Hospital Safety:
Do race and ethnicity matter?
Ernest Moy, MD, MPH
Elizabeth Dayton, MA
Roxanne Andrews, PhD
The Agency for Healthcare Research and Quality
The National Healthcare Quality and Disparities Reports
• The NHDR is an
annual report to
Congress.
• It includes a
comprehensive set of
measures for healthcare
quality and access.
• It analyzes disparities
by race, ethnicity, and
socioeconomic status,
and for priority
populations.
Patient Safety Today
 44 - 98,000 American lives lost annually
 Lost incomes, disability, and health care
expenditures attributable to medical
errors cost a projected $29 billion
Institute of Medicine, 2000
 Limited research examines racial and
ethnic variation in adverse events
Romano, Geppert, Davies, et al., Health Affairs, 2003
Coffey, Andrews, Moy, Medical Care, 2005
Patient Safety Datasources
 HCUP SID Disparities Analytic File:
Patient Safety Indicators (PSIs)
 Medicare Patient Safety Monitoring
System: Adverse Events
 Quality Improvement Organization
Program: Surgical Infection Prophylaxis
 Medical Expenditure Panel Survey:
Inappropriate Medications
HCUP SID Disparities
Analytic File
 Patient safety indicators from all-payer





hospital discharge abstract data
Adjusted for age, gender, age-gender
interaction, DRG, and co-morbidities
Sample from 23 HCUP-SID states* with
“good” racial/ethnic data
Missing data imputed
Data weighted to produce national
estimates
Sample size: about 14.5 million records
from about 1700 hospitals
* AZ, CA, CO, CT, FL, GA, HI, KS, MD, MA, MI, MO, NH, NJ, NY, PA, RI, SC, TN, TX,
VA, VT, WI
Medicare Patient Safety
Monitoring System
 Adverse events from charts
 Randomly-selected, nationwide subset
of inpatient medical records of Medicare
beneficiaries
 Data weighted to produce national
estimates
 Sample size: about 26,000 charts
– 5,500 surgical cases
– 4,000 central venous catheter insertions
Quality Improvement
Organization Program
 Quality of surgical infection prophylaxis
from charts
 Randomly-selected, nationwide subset
of inpatient medical records of Medicare
beneficiaries
 Sample size: about 21,000 surgical
cases
Postoperative Complication Rates
Relative to Whites, HCUP 2003
Wound
dehiscence
Sepsis
1.17
1.50
1.54
PE/DVT
Black
Hispanic
API
0.83
1.18
1.17
Respiratory
failure
1.32
1.38
Metabolic
derangement
2.05
1.22
Hemorrhage
1.30
0.0
0.5
1.0
1.5
2.0
2.5
3.0
Bars with numbers included meet our statistical (p<0.05) and
magnitude (>10% relative difference) criteria for significance
Obstetric Complication Rates
Relative to Whites, HCUP 2003
0.85
0.77
OB trauma,
vaginal delivery
0.78
0.83
OB trauma,
instruments
Black
Hispanic
API
OB trauma,
Cesarean
0.79
1.44
1.12
Birth trauma
0.86
0.0
0.5
1.0
1.5
2.0
2.5
3.0
Bars with numbers included meet our statistical (p<0.05) and
magnitude (>10% relative difference) criteria for significance
Other Complication Rates
Relative to Whites, HCUP 2003
Laceration
1.42
Infections
Pneumothorax
0.78
Black
Hispanic
API
Foreign body
1.54
Bedsores
0.84
0.75
0.75
Anesthesia
Failure to
rescue
1.17
0.0
0.5
1.0
1.5
2.0
2.5
3.0
Bars with numbers included meet our statistical (p<0.05) and
magnitude (>10% relative difference) criteria for significance
Summary of PSIs Relative to
Whites (Better-Same-Worse)
Black
Hispanic
API
Postop
0–1–5
0–3–3
1–3–2
Obstetric
2–1–1
4–0–0
0–3–1
Other
1–4–2
2–5–0
1–5–1
Total
3–6–8
6–8–3
2 – 11 – 4
Black Postoperative Complication Rates
Relative to Whites, MPSMS 2003
UTI
PE/DVT
Pneumonia
Composite
1.66
0.0
0.5
1.0
1.5
2.0
2.5
3.0
Bars with numbers included meet our statistical (p<0.05) and
magnitude (>10% relative difference) criteria for significance
Black CVC-Associated Complication Rates
Relative to Whites, MPSMS 2003
BSI
Mechanical
event
Insertion site
infection
Composite
0.0
0.5
1.0
1.5
2.0
2.5
3.0
Bars with numbers included meet our statistical (p<0.05) and
magnitude (>10% relative difference) criteria for significance
Appropriate Surgical Infection Prophylaxis
Relative to Whites, QIO 2004
1.20
Not received
within 1 hr
0.78
Black
Hispanic
API
AI/AN
1.24
Not stopped
within 24 hrs
1.27
1.22
0.0
0.5
1.0
1.5
2.0
2.5
3.0
Bars with numbers included meet our statistical (p<0.05) and
magnitude (>10% relative difference) criteria for significance
Summary:
Disparities in Hospital Safety
 HCUP-SID: Disparities exist
– Blacks and Hispanics have higher rates of
postoperative complications
– Hispanics have lower rates of obstetric
complications
– But fewer disparities related to other complications
 MPSMS: Blacks have higher rates of
postoperative but not CVC-associated
complications
 QIO: Surgical infection prophylaxis varies by
race/ethnicity
“Complication-Related” Death Rates
Per 1000 Discharge With Complications
by Race/Ethnicity, HCUP 2001-2003
180
170
Total
White
Black
Hispanic
API
160
150
140
130
120
2001
2002
2003
Note: “Complication-related” death rate = “failure to rescue”
Postoperative and CVC Complication
Rates (%) by Race, MPSMS 2002-2003
12
10
8
2002
2003
6
4
2
0
Total
White
Black
Postoperative Composite
Total
White
Black
CVC Composite
Summary: Trends in
Hospital Safety Disparities
 HCUP-SID: Disparities not narrowing
 MPSMS: Black-white differences in
CVC-associated complications
narrowing but not postoperative
complications
 QIO: No data (yet)
Next Steps:
Why do these disparities exist?
 Minorities go to different hospitals or
providers?
 Minorities are sicker when they are
hospitalized?
 Minorities have more comorbidities?
 Procedures are harder to perform on
minorities?
Contact Information
Ernest Moy, MD, MPH
National Healthcare Quality and Disparities Reports
Center for Quality Improvement and Patient Safety
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD, 20850
301-427-1329 (voice)
301-427-1341 (fax)
Ernest.Moy@ahrq.hhs.gov