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Are There Racial/Ethnic Disparities in Mortality Rates and Surgical Procedure Use in the Veterans Health Administration?

Shimada SL, Rosen AK, Chew PW, Borzecki AM. Are There Racial/Ethnic Disparities in Mortality Rates and Surgical Procedure Use in the Veterans Health Administration? Paper presented at: AcademyHealth Annual Research Meeting; 2009 Jun 30; Chicago, IL.

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Research Objectives: Minorities often experience reduced access to care, poorer quality of care, and worse outcomes. The Agency for Healthcare Research and Quality (AHRQ) has developed the Inpatient Quality Indicators (IQIs) to screen for potential inpatient quality problems using discharge data. The IQIs include: a) mortality rates from specific procedures and conditions where high mortality may be associated with poorer care, and b) utilization rates of procedures where concerns exist about over-/under-, or misuse. AHRQ has reported disparities in IQI rates between whites and minorities in the National Healthcare Disparities Report. We examined whether there were racial/ethnic disparities in IQI rates within the Veterans Health Administration (VA). Study Design: We utilized 2004-2007 inpatient discharge data from 123 VA hospitals (N = 2,272,894 hospitalizations) and AHRQ IQI Software Version 3.1 to calculate risk-adjusted IQI rates by race. Population Studied: Veterans who received inpatient care at one of 123 VA hospitals between 2004 and 2007 and met the inclusion criteria for each IQI (N = 388 - 88,874 hospitalizations, depending on the IQI). Principal Findings: There were no significant racial/ethnic differences in risk-adjusted mortality or utilization rates for 17 out of 22 IQIs. The congestive heart failure (CHF) mortality rate was significantly lower for African-Americans (3.7%, 95% CI 3.4-4.0%) than for whites (4.4%, 95% CI 4.2-4.6%). The pneumonia mortality rate was significantly lower for Latinos (4.5%, 95% CI 3.2-6.1%) than for whites (6.4%, 95% CI 6.2-6.6%), African-Americans (6.9%, 95% CI 6.4-7.4%), or patients of unknown/unreported race (6.7%, 95% CI 6.2-7.1%). Utilization indicators showed that Latinos were significantly more likely (79.6%, 95% CI 73.0-85.6%) and Native Americans were significantly less likely (58.3%, 95% CI 45.5-70.9%) to have a laparascopic cholecystectomy compared with white (65.1%, 95% CI 63.9-66.4%) and African-American (64.2%, 95% CI 61.1-67.3%) patients. Incidental appendectomies were performed at lower rates for African American patients (0.82%, 95% CI 0.55-1.17%) and patients of unknown race (0.83%, 95% CI 0.59-1.13%) than for white patients (1.35%, 95% CI 1.19-1.53%). Bilateral cardiac catheterizations were performed at significantly higher rates among patients of unknown race (9.7%, 95% CI 9.2-10.2%) than for white (7.6%, 95% CI 7.4-7.8%), African-American (8.2%, 95% CI 7.7-8.7%), or Native American (5.9%, 95% CI 3.6-8.9%) patients. Conclusions: We found variation in mortality and utilization rates across racial/ethnic groups, with no one racial/ethnic group consistently having higher or lower rates. There was also large variation between groups in utilization rates for laparascopic cholecystectomy, suggesting significant underuse for Native American veterans. Although we did not find significant differences for many IQIs, small numbers in the denominator for some racial/ethnic groups may have prevented us from detecting some disparities in VA. Implications for Policy, Delivery, or Practice: There is evidence that high mortality from the conditions assessed by the IQIs are associated with poorer quality care. Racial/ethnic disparities in IQI rates suggest that inpatient care quality may not be uniform across all racial/ethnic groups in VA, especially in terms of surgical procedure use. Future research should examine patient-, hospital-, and system-level factors that might explain variation in IQI rates within the VA and between the VA and non-VA settings.

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