Compared with whites, black, Asian, and Hispanic patients are less likely to receive surgery, including interventional procedures, from high-volume providers or hospitals, according to a study of patients in New York City. The findings were published in the February 2010 issue of Archives of Surgery.
Researchers led by Andrew J. Epstein, PhD, of Yale University (New Haven, CT), analyzed use of high-volume hospitals and surgeons by 133,821 patients in the New York City metropolitan area for 10 procedures during the period from 2001 to 2004. Patients from 4 racial/ethnic categories (white, black, Asian, and Hispanic) were included in the study. Cardiovascular procedures in the study included CABG, angioplasty, abdominal aortic aneurysm repair, and carotid endarterectomy. Volume thresholds differed for each procedure.
Clear Patterns Emerge
Although use of high-volume hospitals and surgeons varied greatly across procedures, there was a clear pattern of lower use of high-volume providers by minority patients. White patients were more frequently treated by both high-volume hospitals and surgeons across all 10 procedures than were black, Asian, and Hispanic patients. On average, white patients used both high-volume hospitals and surgeons in 37.6% of cases, while black patients used both in only about 20% of cases. Conversely, while about 30% of white patients used both lower-volume hospitals and surgeons, the rate was nearly two-thirds higher in black patients.
Even after adjustment for demographic, socioeconomic, and insurance characteristics, comorbidity, scheduled admission and transfer statuses, and proximity to higher-volume hospitals and surgeons, the combined use of high-volume hospitals and providers was 11.8% lower for black patients, 8% lower for Asian patients, and 7% lower for Hispanic patients than for white patients.
Dr. Epstein and colleagues say they believe their study is one of the first to examine racial/ethnic patterns in use of high-volume hospitals and high-volume surgeons across a broad range of surgical procedures.
In a telephone interview with TCTMD, Dr. Epstein said although the findings are not necessarily generalizable to the entire country, they highlight the fact that these differences exist even on a fairly level playing ground.
“Our intention by using New York City, which is essentially a small place with a big population, was to minimize differences in geographic distribution of populations by race and ethnicity,” he said. “We were looking at a geographic area where there is good transportation infrastructure and it is possible for anyone, realistically, to get to a high-volume surgeon or hospital within their area. Although I wouldn’t say the findings are generalizable to the entire country, . . . the fact that we found these differences by race and volume suggest they are only going to be exacerbated in places where there is less overall access to high-volume hospitals and surgeons.”
Rising Tide Lifts All Boats
While no single approach is likely to solve the problem of racial disparities in care, according to Formosa Chen, MD, and colleagues from the University of California, Los Angeles (Los Angeles, CA), “many health policy experts believe the focus should be on improving the underlying quality of care by all providers in all settings regardless of procedure volume.” In an invited critique accompanying the study, they point to the Surgical Care Improvement Project, which now includes approximately 4,000 hospitals. The project aims to identify basic process measures that reduce complications such as infection and thromboembolism. According to Dr. Chen and colleagues, adherence to the measures has risen substantially among hospitals in the project. In addition, another effort, the National Surgical Quality Improvement Program, has demonstrated improved surgical outcomes in both high- and low-volume facilities.
“Recommendations based on the volume-outcomes relationship have long concentrated on increasing use of high-volume providers by all patients,” Dr. Chen and colleagues write. “For particular procedures, this strategy is likely appropriate (eg, esophagectomy and pancreatectomy). However, for most surgical procedures, ‘raising the tide to lift all boats’ is probably how we should try to proceed.”
Volume Not the Sole Guide to Quality
In a telephone interview with TCTMD, Tony G. Farah, MD, of Allegheny General Hospital (Pittsburgh, PA), cautioned that while “volume is a good proxy overall for quality, . . . when you look at stent procedures or bypass procedures . . . it can be very different because many interventional cardiologists do not meet the ACC criteria for minimum number to qualify per year as high-volume—although they have in totality enough volume—and [yet] they have good outcomes. The same is true for some operators who work at high-volume hospitals. They have a support structure around them that would lead to good outcomes, so even if they are not considered by the criteria to be high-volume themselves they can have just as good outcomes as someone who meets the criteria. So you can’t make a blanket statement that low volume equals bad outcomes.”
Dr. Farah, speaking on behalf of the Society for Cardiovascular Angiography and Interventions, also pointed out that the referring physician is an important independent variable in the equation because they are usually the ones who either decide or help patients decide where they will go for a procedure.
Dr. Epstein agreed, saying there is a need for better understanding of the formation of referral networks. “There isn’t a lot of information in the literature on how these networks form,” he said. “There are factors such as reimbursement and hospital structure, but ultimately the referring physician is responsible for sending his or her patient to the best provider possible. Of course, ‘best’ is hard to quantify, but I think the point is that with greater availability of performance metrics and so on, the physicians who are referring patients are a good place to start. And, of course, empowering consumers to do their own research and ask questions is important, too.”
Mean annual procedure volumes for each hospital and surgeon were calculated using the full Statewide Planning and Research Cooperative System, which includes all discharges from nongovernmental acute-care hospitals. Other sources of information included the American Hospital Association Annual Survey of Hospitals, the American Medical Association Masterfile, and the 2000 United States Census.
Hospitals and surgeons were categorized as high-volume for a particular procedure if their average volume met or exceeded an evidence-based threshold. Annual hospital volume thresholds established by the Leapfrog Group were used for CABG, coronary angioplasty, abdominal aortic aneurysm repair, and pancreatic cancer surgery.
In addition to the 4 cardiovascular procedures, other procedures analyzed included 5 types of cancer surgery (breast, colorectal, gastric, lung, and pancreatic) and 1 orthopedic procedure (total hip replacement). Procedures were chosen for which the literature had documented significant associations between short-term patient mortality and both hospital and surgeon volume.
2. Chen F, Zingmond D, Ko C. More than size matters. Arch Surg. 2010;145:186.