Compared to white patients, black, Asian and Hispanic patients and those who are uninsured are less likely to undergo complex surgery at high-volume hospitals, which have been associated with better outcomes, according to a study in the October 25 issue of JAMA.
Efforts to improve the quality of surgical care in the United States have led many organizations to advocate the use of high-volume hospitals for certain procedures, since a number of studies have reported of a direct volume-outcome relationship for certain procedures, with patients at high-volume hospitals consistently having better outcomes. It appears there are important differences in the racial and socioeconomic status of patients who receive care at high- and low-volume hospitals, according to background information in the article. These differences may affect the ability to access or receive care at a high-volume hospital.
Jerome H. Liu, M.D., M.S.H.S., of the David Geffen School of Medicine at the University of California-Los Angeles, and colleagues conducted a study to determine whether the use of high-volume hospitals varies by race/ethnicity or insurance status in a broad population of patients undergoing complex surgical care. The researchers examined patient characteristics and use of high-volume hospitals across 10 hospital-based procedures with known volume-outcome relationships among Californians during a 5-year period (2000-2004), collecting data from California's Office of Statewide Health Planning and Development patient discharge database.
The procedures included 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, and total knee replacement.
According to this database, a total of 719,608 patients received 1 of the 10 operations. The researchers found that "in general, blacks, Asians, Hispanics, patients with Medicaid, and uninsured patients were less likely to go to high-volume hospitals for complex surgical procedures but more likely to go to low-volume hospitals, when compared with whites and patients with Medicare. Furthermore, patients with private insurance were significantly more likely to go to high-volume hospitals for 3 of the surgical procedures."
For all 10 operations, black patients were significantly less likely to receive care at high-volume hospitals in 6 of the operations, Asians less likely in 5, and Hispanics less likely in 9.
Medicaid patients were significantly less likely than Medicare patients to receive care at high-volume hospitals for 7 of the operations, while uninsured patients were less likely to be treated at high-volume hospitals for 9.
" … our study demonstrates robust findings in a large (12 percent of the U.S. population), ethnically diverse population that includes all patients undergoing the selected procedures without restrictions based on demographics, insurance, or sampling. 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," the authors conclude.
(JAMA. 2006;296:1973-1980. Available pre-embargo to the media at www.jamamedia.org.)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
Editorial: Delivering Quality to Patients
In an accompanying editorial, Samuel R. G. Finlayson, M.D., M.P.H., of Dartmouth Medical School, Hanover, N.H., comments on the findings of Liu and colleagues.
"In a sense, volume-based referral policies are an 'end run' around the issue of quality: they neither require that the essential components of quality be identified (they just measure volume as a proxy for quality), nor do they require that quality is improved at hospitals (they simply direct the patient to specific centers that already meet that standard). The central focus of quality improvement should be the task of delivering quality care to patients, not the other way around.
Granted, there probably is a role for volume-based referral for the few procedures for which the volume-outcome association is particularly strong (e.g., pancreatic surgery). However, an approach that simultaneously sidesteps the task of improving quality and ignores the vast majority of surgical procedures should not be the crown jewel of the surgical quality movement."
(JAMA. 2006;296:2026-2027. Available pre-embargo to the media at www.jamamedia.org.)
Editor's Note: Financial disclosures – none reported.
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