黑人病人比白人病人更可能住在病人安全状况更差的医院.docx

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1、HEALTH POLICY CENTER:URBAN INSTITUTEBlack Patients Are More Likely Than White Patients to Be in Hospitals with Worse Patient Safety ConditionsAnuj GangopadhyayaMarch 2021Black and white patients receive different standards of care in the United States. This was true when the Institute of Medicine pu

2、blished Unequal Treatment in 2003, identifying differences in care by patient race and laying out policy proposals and guidelines aimed at narrowing these differences (Institute of Medicine 2003),1 and this remains true today. In the 2019 Agency for Healthcare Research and Quality (AHRQ) disparities

3、 report, an annual assessment on disparities in medical care quality and access, Black patients received significantly worse quality of care relative to white patients in 82 out of 202 (or 40 percent of) quality measures (Agency for Healthcare Research and Quality 2020).Identifying and reducing raci

4、al disparities in the quality of health care is a necessary (if insufficient) step toward reversing the effects of systemic racism on racial health inequities in America. This brief assesses the state of racial disparities in the quality of inpatient care using 11 AHRQ-developed patient safety quali

5、ty indicators that measure rates of adverse patient safety events or hospital- acquired illnesses or injuries. Four of these measures center on general patient safety, and seven are related to risk of adverse events surrounding surgical procedures. This study investigates differences in Black and wh

6、ite patient safety measures using complete hospital discharge records from 26 states in 2017 and further examines whether some of these differences in patient safety quality between Black and white patients can be attributed to the hospitals into which they are admitted.Key FindingsJ For 6 out of 11

7、 patient safety indicators, including 5 out of 7 surgery-related patient safety indicators, Black patients experienced significantly worse quality of care relative to white patients in 2017 across the 26 states in this analysis. White patients experienced significantlyTABLE 3Differences in Black and

8、 White Admission Rates into High-Quality HospitalsShare of Black patients (%)Share of white patients (%)Difference (percentage points)Adjusted difference (percentage points)Adjusted difference (% change relative to white patients)General patient safety indicatorsPressure ulcer rate15.321.2-5.9-6,8*-

9、31.9%*Iatrogenic pneumothorax rate25.232.1-6.9-7.3*-22.8%*Central venous catheter-related blood stream infection rate44.854.4-9.6-9,5*-17.5%*In hospital fall with hip fracture rate54.052.41.61.22.3%Surgery-related patient safety indicatorsPerioperative hemorrhage or hematoma rate17.723.7-6.0-5.9*-25

10、.0%*Postoperative acute kidney injury requiring dialysis31.037.7-6.7-7,0*-18.5%*Postoperative respiratory failure rate31.042.5-11.5-10.8*-25.5%*Perioperative pulmonary embolism or deep vein thrombosis rate17.430.1-12.7-12.6*-41.7%*Postoperative sepsis rate21.330.9-9.7-9.6*-30.9%*Postoperative wound

11、dehiscence rate46.850.3-3.5-3.7-7.3%Abdominopelvic accidental puncture or laceration rate27.433.0-5.6-5.8*-17.4%*Source： 2017 SID discharges from AK, AR, AZ, CO, DC, DE, FL, GA, KS, KY, MAZ MDZ MI, MS, NC, NJ, NM, NV, OR, RI, SDZ UT, VT, WA, WI, WV. Quality measures calculated using AHRQ SAS QI soft

12、ware version 2020.Notes： High-quality hospitals have patient safety indicator rates below the median hospital rate across all hospitals for each measure. Discharges restricted to patients ages 19 or older. Adjusted differences include controls for patient age-group and gender. Standard errors are cl

13、ustered at the hospital-level.* Differences are statistically significant at the p 0.05 level.BLACK PATIENTS MORE LIKELY TO BE IN HOSPITALS WITH WORSE SAFETY CONDITIONSFigure 1 describes the likelihood of being admitted into high-quality hospitals by race among the four general patient safety indica

14、tors. For three of the four measures, white patients (yellow bars) are more likely to be admitted into high-quality hospitals relative to Black patients (blue bars), Table 3 shows that Black patients are 5.9, 6.9, and 9.6 percentage points less likely to be admitted into hospitals that are best at p

15、reventing pressure ulcers, iatrogenic pneumothorax, and catheter-related blood stream infections, respectively. Accounting for differences in patient age and gender has almost no impact on these differences, and each of these differences is statistically significant. Moreover, these differences are

16、large, with Black patients 31.9 and 22.8 percent less likely to be admitted into hospitals that are considered high quality in terms of preventing pressure ulcers and iatrogenic pneumothorax, respectively, relative to white patients. Although Black patients are slightly more likely to be admitted to

17、 hospitals that are better at preventing in-hospital falls with hip fracture relative to white patients, the estimated difference is not statistically significant.FIGURE 1Share of Black and White Patients Admitted into High-Quality Hospitals among General PatientSafety Indicators Black patients Whit

18、e patients54.4%Pressure ulcer rate Iatrogenic pneumothorax rate Central venous catheter- In-hospital fall with hip related blood stream infection fracture rate rateURBAN INSTITUTESource: 2017 SID discharges from AK, AR, AZ, CO, DC, DE, FL, GA, KS, KY, MA, MD, MI, MS, NC, NJ, NM, NV, OR, RI, SD, UT,

19、VT, WA, WI, WV. Quality measures calculated using AHRQ SAS QI software version 2020.Notes： High-quality hospitals have patient safety indicator rates at or below the median hospital rate across all hospitals for each measure. Discharges restricted to patients ages 19 or older. Bars represent share o

20、f patient population admitted into high- quality hospitals for each measure.BLACK PATIENTS MORE LIKELY TO BE IN HOSPITALS WITH WORSE SAFETY CONDITIONSFIGURE 2Share of Black and White Patients Admitted into High-Quality Hospitals Among Surgery-RelatedPatient Safety Indicators Black patients White pat

21、ientshematoma rate injury requiring failure rate embolism ordehiscence rate puncture ordialysisdeep veinlaceration ratethrombosis rateURBAN INSTITUTESource: 2017 SID discharges from AK, AR, A乙 CO, DC, DE, FL, GA, KSZ KY, MA, MD, MI, MS, NC, NJ, NM, NV, OR, RIZ SO, UT, VT, WA, WI, WV. Quality measure

22、s calculated using AHRQ SAS QI software version 2020.Notes： High-quality hospitals have patient safety indicator rates at or below the median hospital rate across all hospitals for each measure. Discharges restricted to patients ages 19 or older. Bars represent share of patient population admitted i

23、nto high- quality hospitals for each measure.Figure 2 presents differences in the likelihood of being admitted into high-quality hospitals by race among the seven surgery-related patient safety indicators. Patterns across all measures present essentially the same result: relative to white patients,

24、Black patients are less able to access hospitals that are best at minimizing avoidable illness and injuries acquired during or after surgery.Table 3 shows that six out of seven of the adjusted differences in admission rates to high-quality hospitals for surgery-related measures are statistically sig

25、nificant, with only the likelihood of admission into hospitals best at preventing postoperative wound dehiscence being statistically similar between Black and white patients. Several of these differences are very large. Black patients are 25.5 percent and 41.7 percent less likely to be admitted into

26、 hospitals effective at preventing postoperative respiratory failure and perioperative pulmonary embolism relative to white patients. They are 30.9 percent less likely than white patients to be admitted into hospitals that are effective at preventing postoperative sepsis infections. Black patients a

27、re 7.0 and 5.8 percentage points (18.5 and 17.4 percent) less likely to be admitted into hospitals effective at preventing postoperative kidney injuries requiring dialysis and abdominopelvic accidental punctures, which is noteworthy because high-quality hospitals can virtually eliminate patient risk

28、s for these measures, as seen in table 2.TABLE 4Sensitivity Analysis for Differences in Black and White Admission Rates into High-Quality HospitalsBlack-white adjusted difference in admission rates into high-quality hospitals (percentage points)Main estimates from table 3Among Medicare patients only

29、Adjusting for state of residenceGeneral patient safety indicatorsPressure ulcer rate-6,8*-7.0*-5.4*Iatrogenic pneumothorax rate-7,3*-7.1*-3.5*Central venous catheter-related blood stream infection rate-9.5*-9.1*-5.0*In hospital fall with hip fracture rate1.21.32.6Surgery-related patient safety indic

30、atorsPerioperative hemorrhage or hematoma rate-5.9*-5.8*-1.4Postoperative acute kidney injury requiring dialysis-7.0*-7.8*-1.1Postoperative respiratory failure rate-10.8*-9.9*-3.7*Perioperative pulmonary embolism or deep vein thrombosis rate-12.6*-12.7*-4,8*Postoperative sepsis rate-9.6*-9,9*-4.4*Po

31、stoperative wound dehiscence rate-3.7-3.9-1.6Abdominopelvic accidental puncture or laceration rate-5,8*-5,6*-0.5Source： 2017 SID discharges from AK, AR, AZ, CO, DC, DE, FL, GA, KS, KY, MA, MD, MI, MS, NC, NJ, NM, NV, OR, RI, SD, UT, VT, WA, WI, WV. Quality measures calculated using AHRQ SAS QI softw

32、are version 2020.Notes： High-quality hospitals have patient safety indicator rates below the median hospital rate across all hospitals for each measure. Discharges restricted to patients ages 19 or older with Medicare coverage. Shares and difference estimates in the main specification (first column)

33、 are adjusted for patient age-group and gender. Adjusted differences in the second column use the same specification of the main model but restrict analysis to patients with Medicare coverage. Adjusted differences in the third column use all patients and adjusts for patient age-group, gender, and st

34、ate of residence. Standard errors are clustered at the hospital-level.* Differences are statistically significant at the p 0.05 level.1313BLACK PATIENTS MORE LIKELY TO BE IN HOSPITALS WITH WORSE SAFETY CONDITIONSTable 4 assesses whether the main results in table 3 are sensitive to two separate chang

35、es. First, discharges are restricted to Black and white patients with Medicare coverage. Differences in admission rates between Black and white patients may be driven in part by systematic differences in payer type and or differences in network sizes, Thus, restricting the sample to those with Medic

36、are coverage helps narrow (but does not eliminate) differences in these potential drivers. Second, the main model is augmented to adjust for patient state of residence, restricting comparisons to differences in Black and white admission rates among those living in the same state. Black-white differe

37、nces in admission rates to high- and low-quality hospitals may be smaller in local areas. Specifically, high- or low-quality hospitals may be concentrated in certain states, and therefore Black and white differences in admission rates to high-quality hospitals among patients living in the same state

38、 could be more muted (e,g.z if all hospitals in a state have similar rates of adverse events, and if Black and white patients received inpatient care within state borders, we would observe no differences in Black-white admission rates to high- or low-quality hospitals in that state).Table 4 demonstr

39、ates that even after limiting to Medicare-covered patients, major differences remain in the types of hospitals Black and white patients access, and Black-white differences in admission to high-quality hospitals are largely unaffected by restricting the analysis to patients with this coverage type. F

40、or example, where Black patients were estimated to be 6.8 percentage points less likely than white patients to be admitted into a high-quality hospital that prevents pressure ulcers, Black patients with Medicare are 7.0 percentage points less likely than white patients with Medicare to be admitted i

41、nto these hospitals.Important differences emerge when adjusting differences for patient state of residence. Relative to the main estimates in the first column of table 4, the inclusion of state controls (column three) leads to no change in the direction of these estimates. However, most estimates ar

42、e smaller in magnitude, and six of these estimates are statistically significant (relative to nine statistically significant estimates in the main analysis). When comparing among patients residing in the same state, Black-white differences in admission rates to hospitals classified as high quality i

43、n preventing perioperative hemorrhage and postoperative acute kidney injury are statistically insignificant. Still, Black-white differences in admission rates to high-quality hospitals persist on many measures even when making comparisons among patients in the same state. Altogether, this suggests t

44、hat some of the Black-white differences in admissions to high-quality hospitals stem from the lack of availability of high-quality hospitals in states where greater shares of Black patients live.Hospitals classified as high quality for one patient safety indicator may be low quality for other measur

45、es, so these findings on differences in admissions into high-quality versus low-quality hospitals for individual patient safety measures may not generalize to differences in admissions into hospitals that are generally considered unsafe across several indicators. This issue may be particularly true

46、of patient safety measures with low numbers of total adverse events, because a single adverse event for one measure could drive a hospital from a high-quality to a low-quality classification. To address this, table 5 assesses differences in the Black-white admission rates to hospitals that are class

47、ified as high-quality hospitals across several patient safety indicators (i.e., those that achieved rates of adverse patient safety events below the median rate on multiple measures).TABLE 5Differences in Black and White Admission Rates into Hospitals Designated as High Quality Across Multiple Patie

48、nt Safety IndicatorsNumber of hospitalsShare of hospitals (%)Adjusted Black-white difference in admission rates (percentage points)General patient safety indicatorsHigh-quality hospital in at least 1 general patient safety indicator2,09793-0.4High-quality hospital in at least 2 general patient safety indicators1,84982-9.1*High-quality hospital in at least 3 general patient safety indicatorslz52167-8.9*High-quali