1 2
Dan P. Ly
Dan P L 1, 2
Co‐authors: Lenny Lopez3, Thomas Isaac4, and Ashish K. Jha5, 6
F di Funding: none disclosed
di l d
1Harvard Kennedy School; y
; 2Weill Cornell Medical College; g ; 3 Mongan Institute for Health g
Policy, Massachusetts General Hospital; 4Department of General Medicine and Primary Care, Beth Israel Deaconess Medical Center; 5 VA Boston Healthcare System; 6 Department of Health Policy and Management, Harvard School of Public Health. Why do disparities exist?
 Care concentrated among a small number of providers  Suggests that site of care matters
 May explain some part of the disparities gap
Patient Safety Indicators (PSIs)
y
(
)
 Rates of adverse events in hospitals
 Increasingly used for P4P and public reporting:
 The Premier Hospital Quality Improvement Demonstration
 National Quality Forum
N i
l Q li F
 HealthGrades
Q
Questions
 Do minority serving hospitals have higher rates of adverse events?
 Are higher rates, if they exist, concentrated among all A hi h if h i d ll patients or primarily among black patients?
Methods
 13 PSIs, including:
 Iatrogenic pneumothorax
I t
i th
 Catheter‐related infections
 Post‐op PE
P
PE
 Post‐op DVT
 Examined hospitals in top 10% of proportion of black dh
l
% f
f bl k
patients served
 Examined other cut‐points in sensitivity analyses
d h
l
 Calculated PSI rates for whites, blacks separately
Results— Hospital Characteristics
Minority-Serving Hospitals
N=450
4 0
Non-Minority-Serving Hospitals
N=4,038
4 038
<100
100-400
>400
Region *
33
47
21
49
42
9
Northeast
Midwest
South
West
Ownership *
11
16
68
5
13
32
35
20
For-profit
Private nonprofit
Public
Urban *
Teaching *
20
50
30
79
19
15
61
24
74
5
Hospital Size *
Mean
Percent Medicare *
Percent Medicaid *
*p-value <0.05 Nurse-staffing ratio *
44
23
5.9
49
16
7.1
k d
d
Risk‐adjusted regressions
Minority-Serving Hospitals
Non-Minority-Serving Hospitals
1.5
1.7
Pressure ulcer
57.1*
30.1
Death among surgical patients
160*
112
Iatrogenic pneumothorax
0.4
0.4
Catheter-related bloodstream infection
2.0*
1.3
Postop hip fracture
0.5
0.5
Postop hemorrhage or hematoma
2.5
2.3
18
1.8
08
0.8
Postop respiratory failure
27.6*
16.8
Postopp PE or DVT
18.6*
11.2
Postop sepsis
30.8*
14.3
Postop wound dehiscence
4.0
4.3
Accidental puncture or laceration
1 4*
1.4
19
1.9
Death in low-mortality DRGs
Postop physiologic and metabolic
derangement
*p-value <0.05
Race‐stratified analyses‐‐whites
y
Minority-Serving Hospitals
Non-Minority-Serving Hospitals
20
2.0
17
1.7
Pressure ulcer
45.1*
28.6
Death among surgical patients
154*
110
Iatrogenic pneumothorax
0.5
0.4
Catheter-related bloodstream infection
1.7*
1.2
Postop hip fracture
0.6
0.5
Postop hemorrhage or hematoma
2.0
2.2
Postop physiologic and metabolic
derangement
1.0
0.8
Postop respiratory failure
27.1*
16.5
P
Postop
PE or DVT
17.0*
11.0
Postop sepsis
27.2*
13.7
Postop wound dehiscence
4.2
4.4
Accidental puncture or laceration
16
1.6
19
1.9
Death in low-mortalityy DRGs
*p-value <0.05
Race‐stratified analyses‐‐blacks
y
Minority-Serving Hospitals
Non-Minority-Serving Hospitals
12
1.2
21
2.1
Pressure ulcer
72.8*
58.6
Death among surgical patients
155*
110
Iatrogenic pneumothorax
0 3*
0.3*
05
0.5
Catheter-related bloodstream infection
2.3
2.0
Postop hip fracture
0.3
0.4
g or hematoma
Postopp hemorrhage
3.2
2.9
Postop physiologic and metabolic
derangement
2.0
1.7
Postop respiratory failure
33.6*
22.4
Postop PE or DVT
22.8
21.3
Postop sepsis
27.9*
16.2
Postop wound dehiscence
4.7
3.4
Accidental puncture or laceration
1.1*
2.1
Death in low-mortality
low mortality DRGs
*p-value <0.05
Conclusions
 Minority‐serving hospitals perform worse on many safety indicators
 Rates for both whites and blacks worse in high R
f b h hi d bl k i hi h minority‐serving hospitals
Limitations
 Only use Medicare data  Therefore, could only calculate rates for elderly
Th f
ld l l l t t f ld l
 PSIs may not accurately reflect underlying safety
PSI l fl d l i f
 Could only examine small set of hospital characteristics
Implications
p
 Minority‐serving hospitals are likely to:
 Appear to be poor performers in public reporting efforts
A
t b f
i bli ti ff t
 Be at risk of being financially penalized in P4P efforts
 Potential impact of public reporting or P4P:
 Minority‐serving hospitals might:


Improve performance by putting greater focus on safety F ll f th b hi d if Fall further behind if penalties are significant
lti i ifi
t