Disparities may limit patient access to surgical procedures at high-volume hospitals

UCLA researchers report that race/ethnicity and insurance disparities may limit patient access to complex surgical procedures at high-volume California hospitals.

Published in the Oct. 25 edition of the Journal of the American Medical Association, the study examined patient characteristics and the use of high-volume hospitals for 10 surgical procedures.

Hospitals that perform large numbers of a procedure are considered high-volume. Previous quality studies have suggested better patient outcomes at high-volume medical centers compared to low-volume hospitals.

"Since there is significant interest among health care policy experts in improving quality of care by directing patients to high-volume facilities, we hope that addressing key disparities may broaden receipt of care for more patients at these facilities," said Dr. Clifford Ko, senior author, professor of surgery and director of the UCLA Center for Surgical Outcomes and Quality.

Ko adds that helping patients access high-volume hospitals is just one of several strategies being pursued by health organizations and policy experts to improve surgical quality of care. Other programs focus on accreditation of surgical programs, outcomes evaluation and feedback, and improving the process and delivery of care.

For the study, researchers used patient discharge data from California's Office of Statewide Health Planning and Development to identify 719,608 patients during a five-year period from 2000 to 2004. Researchers controlled for clinical and demographic variants such as sex, age and additional medical conditions.

Patients received one of 10 operations known for having a positive volume-outcome relationship such as abdominal aortic aneurysm repair, coronary artery bypass, esophagus removal, coronary angioplasty, knee replacement and pancreatic resection.

"Overall, the study showed that non-whites, Medicaid and uninsured patients were less likely to receive care at high-volume hospitals and more likely to receive care at low-volume hospitals," said Dr. David Zingmond, study author, assistant professor of medicine, and deputy director of the UCLA Center for Surgical Outcomes and Quality.

Ethnicity impacted findings. Blacks were less likely than whites to receive care at high-volume hospitals for six of the 10 operations. For example, among patients undergoing elective abdominal aortic aneurysm repair, blacks were only 71 percent as likely as whites to be treated at a high-volume hospital.

Asians and Hispanics were less likely to receive care at high-volume hospitals for five and nine of the procedures respectively compared with whites.

The type of medical insurance also affected findings. Medicaid patients were significantly less likely than Medicare patients to receive care at high-volume hospitals for seven of the operations, while uninsured patients were less likely to be treated at high-volume hospitals for nine of the procedures.

For example, for total knee replacement, the percentage of patients with private insurance was higher for patients going to a high-volume hospital (28 - 34 percent) compared with a low-volume facility (14 - 29 percent), while the percentage of patients without insurance was lower for patients going to a high-volume (1 -3 percent) compared with a low-volume (2-6 percent) facility.

"Our study demonstrates significant differences among patients receiving care at high- and low- volume hospitals in the large, ethnically diverse population of California," said Ko. "More study needs to be done to see if the findings are similar nationwide."

Ko also notes that for policy makers, looking at a single difference such as race alone may not be enough to impact the issue. The study found for example that non-white populations receiving care at low-volume hospitals generally had lower rates of private insurance and higher uninsured rates.

"Our study provides insight into identifying patient factors that may help improve the quality of surgical care at high-volume facilities," said Ko.


Programs pursuing other types of quality of surgical care strategies such as accreditation and outcome review include the Surgical Care Improvement Program, the National Surgical Quality Improvement Program, the Society of Thoracic Surgery Database and the American College of Surgeons Bariatric Accreditation Program.

Study funding was provided by a Veterans Administration/UCLA Multicampus Ambulatory Healthcare Fellowship, a National Institute on Aging Mentored Clinical Scientist Award and the UCLA Robert Wood Johnson Clinical Scholars Program.

Additional authors include: Dr. Jerome H. Liu, Dr. Marcia L. McGory, Dr. Nelson F. SooHoo, Susan L. Ettner, Ph.D., and Dr. Robert H. Brook. Affiliations include the Center for Surgical Outcomes and Quality, UCLA Department of Surgery; UCLA Division of General Internal Medicine and Health Services Research; UCLA Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA; UCLA School of Public health; RAND Corporation, and the Greater Los Angeles VA.

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