Are There Racial/Ethnic Disparities
in Mortality Rates and Surgical
Procedure Use in the Veterans
Health Administration?
Stephanie Shimada, PhD
Amy K. Rosen, PhD
Priscilla Chew, MPH
Ann M. Borzecki, MD MPH
VA HSR&D QUERI SDP05-006
AcademyHealth ARM, June 2009
Rationale
Racial disparities in quality continue to be
a significant problem.
The AHRQ Inpatient Quality Indicators
(IQIs) are a measure of inpatient quality of
care based on administrative data.
– The National Healthcare Disparities Report
has shown disparities in some IQIs outside
the VA.
Stephanie Shimada, AcademyHealth
ARM June 2009
What are the Inpatient Quality
Indicators (IQIs)?
Volume Indicators
e.g., Pancreatic resection volume
Mortality Indicators for Inpatient
Procedures
e.g., Abdominal aortic aneurysm rate
Mortality Indicators for Inpatient Conditions
e.g., Congestive heart failure mortality rate
Utilization Indicators
e.g., Cesarean delivery rate
Stephanie Shimada, AcademyHealth
ARM June 2009
How are IQIs defined?
IQIs are generated by applying AHRQ software
to administrative discharge data to determine
which hospitalizations are in the denominator or
numerator for a given IQI.
– Denominator=All discharges at risk
– Numerator=All discharges in denominator with ICD-9CM codes indicating the event occurred.
– IQI Mortality or Utilization
Rate=Numerator/Denominator
Stephanie Shimada, AcademyHealth
ARM June 2009
Research Question
Do IQI mortality rates and utilization rates
vary by racial/ethnic group in VA?
– Previous research has found fewer racial
disparities in other measures of quality in VA.
Stephanie Shimada, AcademyHealth
ARM June 2009
Methods
Data Sources:
– VA Medical SAS Inpatient Data Files (Patient
Treatment Files) for Fiscal Years 2004-2007
(October 1, 2003-September 30, 2007)
Sample: Veterans receiving inpatient care at
one of 123 VA acute-care hospitals between
FY2004 and FY2007
– N= 2,272,894 hospitalizations
– N= 1,024,406 unique individuals
Stephanie Shimada, AcademyHealth
ARM June 2009
Analyses
Combined and created racial/ethnic groups
using inpatient data sources.
– Racial groups : White, African-American, Latino,
Asian/Pacific Islander, American Indian, Unknown
Applied AHRQ IQI software (v 3.1a) to VA
discharge data to obtain IQI indicators and
obtain risk-adjusted IQI rates and IQI
composites by race.
Logistic Regression controlling for age, sex, and
the 29 comorbidities in the AHRQ Comorbidities
Software, and adjusting for clustering at the
VISN (hospital region) level.
Stephanie Shimada, AcademyHealth
ARM June 2009
Number of Deaths by Procedure
White
Black
Unknown
Latino
Asian PI
American Indian
600
# Deaths
500
400
300
200
100
0
om
ct
re
rte
da
En
id
ot
t
ar
C
en
A
em
TC lac
P
ep
R y
m
ip
H oto
ni
ra
C
n
G ir
t io
B
A pa ec
C
s
n
e
R R e t io
c
AA ic se
A ea t
e
cr al R
an
P age
ph
so
E
y
IQI
Stephanie Shimada, AcademyHealth
ARM June 2009
Number of In-Hospital Deaths
# Deaths
White
Black
Unknown
Latino
Asian PI
American Indian
5000
4500
4000
3500
3000
2500
2000
1500
1000
500
0
ia
on
um
ne
re
P
tu
ac
e
Fr
ag
rh
or
ip
H
r
fe
ns
tra
em
ke
tr o
F
IH
G
S
H
C
I
o
In
M
M
A
A
IQIs
Stephanie Shimada, AcademyHealth
ARM June 2009
Risk-Adjusted Mortality Rates per 100
Discharges for CHF
CHF Mortality Rates (IQI16)
7
6
5
4.4
4
3.7
3
2
1
0
All VA
White
Black
Latino
Asian PI
Stephanie Shimada, AcademyHealth
ARM June 2009
American
Indian
Unknown
Risk-Adjusted Mortality Rates per 100
Discharges for Pneumonia
Pneumonia Mortality (IQI20)
9
8
7
6.4
6
6.9
6.7
5
4.5
4
3
2
1
0
All VA
White
Black
Latino
Asian PI
Stephanie Shimada, AcademyHealth
ARM June 2009
American
Indian
Unknown
Risk-Adjusted Rates per 100 Cholecystectomies
Laparascopic Cholecystectomy
(IQI23)
90
80
79.6
70
65.1
60
64.2
58.3
50
40
30
20
10
0
All VA
White
Black
Latino
Asian PI
Stephanie Shimada, AcademyHealth
ARM June 2009
American
Indian
Unknown
Risk-Adjusted Rate of Incidental
Appendectomy per 100 Abdominal Surgeries
Incidental Appendectomy
in the Elderly (IQI24)
6
5
4
3
2
1.4
1
0.8
0.8
0
All VA
White
Black
Latino
Asian PI
Stephanie Shimada, AcademyHealth
ARM June 2009
American
Indian
Unknow n
Risk-Adjusted Rate of Bilateral Catheterization
per 100 Cardiac Catheterizations
Bilateral Cardiac Catheterization
(IQI25)
14
12
10
9.7
8
7.6
8.2
6
5.9
4
2
0
All VA
White
Black
Latino
Asian PI American Unknown
Indian
Stephanie Shimada, AcademyHealth
ARM June 2009
Mortality for Selected Procedures
IQI Composite 1
2.5
2
1.6
1.5
1.3
1.3
1
1.2
1.0
1.0
0.5
0
White
Black
Latino
Asian /
Pacific
Islander
Stephanie Shimada, AcademyHealth
ARM June 2009
American
Indian
Unknown
Mortality for Selected Conditions
IQI Composite 2
1.4
1.2
1
0.8
1.0
0.9
0.9
1.0
1.0
American
Indian
Unknown
0.8
0.6
0.4
0.2
0
White
Black
Latino
Asian /
Pacific
Islander
Stephanie Shimada, AcademyHealth
ARM June 2009
Results: In-Hospital Mortality Rates
IQI Name (IQI Number)
Odds Ratios
African-American
vs. White
AMI Mortality Rate (15)
AMI Mortality Rate, w/o transfer (32)
CHF Mortality Rate (16)
Acute Stroke Mortality Rate (17)
GI Hemorrhage Mortality Rate (18)
Hip Fracture Mortality Rate (19)
Other Minority vs.
White
1.06
1.01
***0.72
1.01
0.97
*0.78
0.87
0.82
0.90
1.02
0.86
0.86
*1.15
**0.68
Pneumonia Mortality Rate (20)
Stephanie Shimada, AcademyHealth
ARM June 2009
Results: Utilization Rates
IQI Name (IQI Number)
Odds Ratios
AfricanAmerican vs.
White
Laparascopic Cholecystectomy Rate (23)
Incidental Appendectomy in the Elderly Rate (24)
Bilateral Cardiac Catheterization Rate (25)
Stephanie Shimada, AcademyHealth
ARM June 2009
0.93
**0.58
1.18
Other
Minority vs.
White
1.36
0.53
1.16
Conclusions
We found few racial disparities in IQI
rates.
– There were no significant racial differences in
risk-adjusted IQI rates for 12 of 18 IQIs.
– Differences found showed that minorities
were at higher risk for some IQIs but at lower
risk for others.
– No significant differences in mortality
composites.
Stephanie Shimada, AcademyHealth
ARM June 2009
Implications
There was large variation in laparascopic
cholecystectomy utilization.
Underuse of this procedure amongst American
Indian vets should be addressed.
VA should address all differences found
through research and target with QI
interventions as needed.
Stephanie Shimada, AcademyHealth
ARM June 2009
Thank You
Stephanie Shimada, PhD
stephanie.shimada@va.gov
shimada@bu.edu
Results – Patient Race
All discharge records
(N=2,272,894)
Frequency
Percent
1,433,546
63.1%
434,941
19.14%
Latino
32,605
1.59%
Asian/Pacific
Islander
19,519
0.86%
American
Indian
12,386
0.54%
Unknown
336,297
14.8%
White
AfricanAmerican
Stephanie Shimada, AcademyHealth
ARM June 2009