1. Disparities Within and Between Hospitals for Inpatient Quality of Care: Targeting Resources to Close the Gap Romana Hasnain-Wynia, PhD Director, Center for Healthcare Equity Associate Professor Institute for Health Care Studies Division of General Internal Medicine Northwestern University, Feinberg School of Medicine The authors acknowledge the assistance of the IFQHC and the Centers for Medicare and Medicaid Services (CMS) in providing data which made this research possible. The conclusions prescribed are solely those of the author(s) and do not represent those of IFQHC or CMS. The study was funded by the Commonwealth Fund and the Robert Wood Johnson Foundation’s Changes in Health Care Financing and Organization (HCFO) Initiative

2. Co-Authors Raymond Kang Mary Beth Landrum Christine Vogeli David W. Baker Joel S. Weissman

3. Background Racial and ethnic disparities in quality of care persist Racial and ethnic disparities in quality of care persist Studies suggest that factors related to patient-physician encounter such as miscommunication, cultural misunderstanding, racism, and bias contribute to disparities Studies suggest that factors related to patient-physician encounter such as miscommunication, cultural misunderstanding, racism, and bias contribute to disparities Other studies suggest that differential quality in treatment settings contribute to disparities Other studies suggest that differential quality in treatment settings contribute to disparities

4. Question Who You Are?: Patient-Centered Care Where You Go?: Quality differences in various settings

6. “… hospitals that were lower performers tended to serve a larger proportion of minority patients…” Hasnain-Wynia R, Baker DW, Nerenz, D, et al. Archives of Internal Medicine, June 2007 Disparities in Health Care Are Driven by Where Minority Patients Seek Care Examination of Hospital Quality Alliance Measures Disparities in Health Care Are Driven by Where Minority Patients Seek Care Examination of Hospital Quality Alliance Measures

7. Bottom performing hospitals had a much higher percentages of minority patients compared with top performing hospitals Hasnain-Wynia, R., Baker, DW, Nerenz, DR, et al. “Are Disparities Driven by Who You Are or Where You Go: An Examination of the Hospital Quality Alliance Measures: Archives of Internal Medicine June 25, 2007 627:1233-1239..

8. Limitations of Previous Studies Looked only at Medicare patients Looked only at Medicare patients Focused only on one condition such as AMI Focused only on one condition such as AMI Examined only hospital level variables such as proportion of minorities treated, without examining if disparities existed Examined only hospital level variables such as proportion of minorities treated, without examining if disparities existed Examined quality in teaching hospitals only Examined quality in teaching hospitals only Limited to comparisons with larger groups (Blacks, Hispanics). Limited to comparisons with larger groups (Blacks, Hispanics).

9. Current HQA Study Previously unavailable, patient-level HQA database obtained from CMS Previously unavailable, patient-level HQA database obtained from CMS Expanded list of measures Expanded list of measures n = 19 n = 19 All U.S. acute care hospitals All U.S. acute care hospitals n > 4000 hospitals n > 4000 hospitals n > 2 million patients n > 2 million patients

10. Groups by Race/Ethnicity Black Black Hispanic Hispanic Asian Asian American Indian/Alaska Native American Indian/Alaska Native Native Hawaiian/Pacific Islander Native Hawaiian/Pacific Islander White White

11. Methods Multivariate models Multivariate models Model 1: unadjusted Model 1: unadjusted Model 2: adjusted for individual characteristics, including co-morbidities, payer, age, gender (Total Disparity) Model 2: adjusted for individual characteristics, including co-morbidities, payer, age, gender (Total Disparity) Model 3: Model 2 + adjusted for organizational effects ( random effects, between hospital variation) Model 3: Model 2 + adjusted for organizational effects ( random effects, between hospital variation)

12. Results

13. Within and Between Disparities Depend on the Quality Metric and Racial/Ethnic Group Constructed 95 disparities measures Clinically and statistically significant disparities in 37 measures Disparity eliminated when adjusting for site of care: 11 measures Magnitude of disparity reduced when adjusting for site of care : 26 measures

14. HF-Smoking Cessation *** P<.001 ** P<.01 * P<.05

15. HF Discharge Instructions *** P<.001 ** P<.01 * P<.05

16. AMI-PCI *** P<.001 ** P<.01 * P<.05

17. PN-PN Vaccination *** P<.001 ** P<.01 * P<.05

18. Place-Based Disparities: Policy Implications Disparities are multi-factorial—who you are and where you go Disparities are multi-factorial—who you are and where you go Continued segregation in health care Continued segregation in health care Under-resourced institutions serve minority communities Under-resourced institutions serve minority communities Focus incentives toward institutions serving a large % of minority patients. Focus incentives toward institutions serving a large % of minority patients. Target resources to areas of greatest impact Target resources to areas of greatest impact

19. Policy Implications Risks of unintended consequences of forcing action through P4P and public reporting Risks of unintended consequences of forcing action through P4P and public reporting Need protections of vulnerable populations Need protections of vulnerable populations Pay for improvement Pay for improvement Pay for disparity reductions Pay for disparity reductions