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Where do black veterans receive hospital care? Variability in disparities within the VA healthcare system

Jha AK, Stone RA, Lave JR, Chen H, Klusaritz H, Volpp KG. Where do black veterans receive hospital care? Variability in disparities within the VA healthcare system. Paper presented at: VA HSR&D National Meeting; 2007 Feb 22; Arlington, VA.


Objectives: Racial disparities in care are well documented although their reasons are not fully understood. Research in non-VA settings suggests higher mortality rates in hospitals with a large proportion of black patients. We sought to determine whether mortality rates or racial disparities in outcomes were also higher in VA hospitals that disproportionately cared for black veterans. Methods: We ranked VA hospitals by the number of Blacks discharged in 2002 and identified hospitals that cumulatively cared for 25% and 75% of all black veterans. We examined the characteristics of hospitals that disproportionately cared for Blacks and determined 30-day mortality rates for six common medical conditions: pneumonia, acute myocardial infarction (AMI), congestive heart failure (CHF), gastrointestinal bleeding, hip fracture, and stroke. We used random effects models to assess the degree of variability in outcomes across hospitals. Results: Just 9 VA hospitals cared for 25% of all hospitalized black veterans in 2002 and 42 facilities (28% of all VA hospitals) cared for 75% of black veterans. These 42 minority-serving facilities were more often major teaching hospitals (83% versus 37%, p < 0.01) and had available advanced procedures such as angioplasty (68% versus 38%, p < 0.01) than other hospitals. Age- and comorbidity adjusted 30-day mortality did not vary by hospital subgroup for any of the six conditions (p > 0.12 for each). For example, AMI mortality rates among veterans > 65 were 15.1% versus 14.9% among minority-serving and non-minority-serving hospitals respectively. Results were similar for black-white differences in mortality across hospitals. For example, elderly Blacks with AMI had 20% lower odds of death in minority-serving hospitals and 18% lower odds of death in non-minority serving hospitals. Implications: Hospital care for black veterans is very concentrated: 28% of hospitals care for 75% of Blacks and 9 hospitals care for 1 in 4 Blacks. The striking lack of variation in overall outcomes and racial disparities across hospitals suggests uniformity in care within the VA not found in the private sector. Impacts: Future programs to improve care for black veterans can focus on a small number of hospitals, although uniformity in care suggests no easy target to better hospital care for our veterans.

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