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16 Geography and Racial Health Disparities
Pages 604-640

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From page 604...
... More recently, racial differences in cardiac surgery were hypothesized to depend on the race of the physician; however, no significant differences were found (Chen et al., 2001)
From page 605...
... It is not surprising that African-American and Hispanic patients tend to see different physicians and are admitted to different hospitals compared to non-Hispanic whites. This is largely the consequence of where people live: there are far fewer African Americans seeking care in eastern Tennessee hospitals than in Mississippi hospitals, and many more Hispanic patients seeking care in hospitals in Florida, Texas, and California than in Maine and New Hampshire.
From page 606...
... It is important to note here that we do not argue against the existence of racial disparities, nor do we argue that they are necessarily mitigated by geographical variation. If African Americans live in regions with poor hospital quality, then that in itself represents a valid source of racial disparities.
From page 607...
... Racial differences arising within a hospital or even within a physician's practice may reasonably be ascribed to differences in underlying health status, patient preferences, financial barriers, provider biases, or some combination of these four factors. Here, however, the insights of the regional variation literature is relevant; it is not the case that the rate of therapeutic interventions for whites should be necessarily viewed as the "correct" or "desired" rate (Tu et al., 1997; Wennberg, 1986)
From page 608...
... , but that ratio never exceeded 12 percent and has fallen as many insurance carriers have dropped the Medicare+Choice option. In some urban regions the ratio of HMO patients in the Medicare population has been higher than the national average, and this has engendered more concern about selection bias.5 The Dartmouth Atlas has divided the United States into 306 Hospital Referral Regions (HRRs)
From page 609...
... 609 are ya ming y y y or 50 perf surger Highw ya w hospital than 249 499 more Boundar Boundar 99 er to to or hospitals ascularv care weF to orf HSA State Interstate Express 50 100 250 500 cardio red. Acute beds Symbols major in Region.
From page 610...
... Figure 16-2 demonstrates that there is substantial variation in Medicare payments for services reimbursed on a fee-for-service basis (including non-risk-bearing health maintenance organizations)
From page 611...
... is often used immediately following a heart attack, or shortly thereafter, or to relieve pain for patients with ischemic heart disease. In 1996 more than 200,000 of these procedures were conducted with an average rate of 7.5 per 1,000 Medicare enrollees.
From page 612...
... (Log Ratio 1.0 Discharge 0.5 Standardized 0.2 y y y y Repair y Bypass afting Bypass Cancer Gr k Surger terectom Colerecetal Fracture ter y for Transluminal Cholecystectomy Ar Replacement Bac Prostatectom Hip Endar y Angioplasty Hip Extrremity Cronar Carotid wer Radical Coronar Lo Colectom Percutaneous FIGURE 16-4 Surgical variation for ten common procedures. Each data point represents an observation for a Hospital Referral Region relative to the U.S.
From page 613...
... One might suspect these variations may be in part the consequence of differences in underlying patterns of cardiovascular disease. Certainly one might expect that HRR-level rates of PTCA should be associated with HRR-level rates of heart attacks (acute myocardial infarctions, or AMIs)
From page 614...
... This is not terribly surprising; clearly, hospitals in Washington, DC, will be more likely utilized by African Americans and Hispanics than those in Minot, South Dakota. To capture this difference, we use a nearly 100 percent sample of Medicare fee-for-service patients who were admitted for a heart attack, or AMI, in 1998-1999; these data come from the National Bureau of Economic Research Medicare claims panel developed by McClellan and Staiger (1999)
From page 615...
... Slightly more than one-fifth of nonblack AMI patients are admitted to hospitals with no black AMI patients. Point A shows that 50 percent of nonblack Medicare patients are admitted to hospitals that account for just 9 percent of black patients.
From page 616...
... .9 A story similar to racial differences in the hospitals where minorities seek care holds for physicians. In a recent study, Harrison and Thurston (2001)
From page 617...
... utilizes data on heart attack treatments assembled by researchers at Dartmouth College and Stanford University to examine state-level differences in treatment patterns. Figure 16-6 uses these data to provide measures of angioplasty use for several selected states during 1990-1995 using a sample of fee-for-service Medicare patients admitted to hospital for AMI.10 In addition, the U.S.
From page 618...
... . Note also the considerable degree of variation across states, so that the PTCA rates for black Medicare patients in California (13.9 percent)
From page 619...
... From a policy viewpoint it is useful to decompose that 35 percent difference into two parts: that part attributable to within-state differences (15 percent) and the remaining 20 percent that is caused by African Americans being more likely to live in a state where everyone experiences higher cardiovascular mortality rates.
From page 620...
... 95 % Beta Blocker = 74.9 - 0.32 x {% Black}, t-stat. = -2.3, R2= 0.08 90 Receiving 85 80 Patients 75 Discharge 70 at 65 Appropriate 60 Blocker of 55 Beta 50 45 0.00 5.00 10.00 15.00 20.00 25.00 30.00 35.00 40.00 Percentage Percentage of African Americans in State FIGURE 16-7 Percentage of appropriate AMI patients treated with beta blockers at discharge and percentage African American, by state.
From page 621...
... In other words, it is not simply the large African-American population in Mississippi that leads to such low compliance with the use of beta blockers where appropriate; it would appear that white AMI patients in Mississippi are not getting beta blockers either.13 Nonetheless, this example illustrates the risks of making inferences about individual behavior based on aggregated data. This problem is generally referred to as "ecological fallacy" and is well known in both the public health literature and in the political science literature (King, 1997; Susser, 1994a, 1994b)
From page 622...
... . The second point is that this pattern is replicated in other studies showing a correlation between outcomes and percentage African American (Deaton and Lubotsky, 2001)
From page 623...
... .17 Although the Dartmouth Atlas' use of HRR attempts to circumvent these problems by using zip code location and migration data to assign individuals to hospitals, even these measures likely understate true differences across HRRs in utilization variability.18 We next consider the statistical issues at a more general level: how specification of risk adjusters and geography can dramatically affect the bias in estimated regression coefficients. To illustrate the importance of geography and focus the discussion, we simplify the analysis and assume that high-quality data have been obtained which avoids problems with unmeasured confounding variables; any errors in measuring the "true" relationship arises because of model specification.
From page 624...
... Here, African Americans have worse outcomes even within the same hospitals. This correct race difference is 2 (the distance between the lines for blacks and whites at the same level of quality, or within the same geographical unit)
From page 625...
... Here, African Americans have worse outcomes even within the same hospitals. This correct race difference is 2 (the distance between the lines for blacks and whites at the same level of quality, or within the same geographical unit)
From page 626...
... Here, African Americans have worse outcomes even within the same hospitals and the race difference grows in worse hospitals. This correct race differential is 1 Quality + 2.
From page 627...
... First, as noted earlier, the presumption is that racial differences are the same across regions (as in Figure 16-9b) , a finding that does not appear to be true in practice.
From page 628...
... (The critical assumption in using nonblack mortality rates as a measure of quality is that the authors can adjust for differences in underlying health status for nonblacks living in largely black areas compared to nonblacks living in largely white areas.) This focus on identifying the degree to which the observed racial disparities are explained by hospital quality alone has the strength of not being contaminated by other potentially important factors, such as provider-patient interactions and patient preferences.
From page 629...
... If whites were to be admitted to the same hospitals as African Americans in this simple example, mortality rates would be predicted to rise by 1.1 percent, or the difference between 18.7 percent and 17.6 percent. in explaining outcomes, but notes the striking degree to which whites and blacks who are seen at similar hospitals tend to have similar outcomes.
From page 630...
... These studies taken together suggest an additional focus for improving quality of care among the black elderly population. If African Americans are more likely to be seen at low-quality hospitals, public policies that attempt to improve hospital quality would disproportionately benefit African Americans.
From page 631...
... For example, a cursory examination of the medical and social science literature on racial disparities in outcomes reveals that for nearly every study, the white treatment rate is seen as the "gold standard" against which to evaluate black outcomes. This may or may not be the right approach: For economists interested in the study of the racial wage gap, for example, it makes sense to view white wages or white test scores as the standard against which black outcomes should be measured (Chandra, 2000, 2002)
From page 632...
... and PTCA; for PTCA inappropriate rates were 24 percent in California, 14 percent in Pennsylvania, 8 percent in Georgia, and 12 percent in Alabama. These regional differences clearly have implications for the percentage of Hispanics and African Americans receiving inappropriate care.
From page 633...
... This is true for two reasons: First, statistical pitfalls can trip up otherwise careful and valid empirical research documenting the existence and prevalence of disparities. Second, the policy solutions to racial disparities that occur because African Americans and Hispanics tend to live in different places from non-Hispanic whites are quite different from the more obvious sources of racial differences in treatment within a hospital or provider group.
From page 634...
... A significant proportion of care, however, is provided by referral hospitals that serve a larger region. Hospital Referral Regions were defined in the Atlas by documenting where patients were referred for major cardiovascular surgical procedures and for neurosurgery.
From page 635...
... 7. Illness has been controlled for by using age-sex-race-specific mortality and hospitalization rates for five conditions: hip fracture, cancer of the colon or lung treated surgically, gastrointestinal hemorrhage, acute myocardial infarction, or stroke.
From page 636...
... is a nonsurgical procedure performed under X-ray guidance in a cardiac catheterization lab to aid in the diagnosis of coronary artery disease.
From page 637...
... . Racial differ ences in the use of cardiac catheterization after acute myocardial infarction.
From page 638...
... . Racial differences in cardiac revascularization rates: Does "overuse" explain higher rates among white patients?
From page 639...
... . Racial differences in hospital quality for the treatment of acute myocardial infarction: Evidence from the Medicare population (Unpublished)


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