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November 27, 1996

Racial Variation in Predicted and Observed In-Hospital Death: A Regional Analysis

Author Affiliations

From the Program in Health Care Research, Division of General Internal Medicine, Department of Medicine, Cleveland Veterans Affairs Medical Center, Case Western Reserve University School of Medicine (Drs Gordon and Rosenthal), and Cleveland Health Quality Choice Coalition (Dr Harper), Cleveland, Ohio. Dr Gordon is now with the Houston Center for Quality of Care and Utilization Studies: A VA HSR&D Field Program and Baylor College of Medicine, Houston, Tex.

JAMA. 1996;276(20):1639-1644. doi:10.1001/jama.1996.03540200025026

Objective.  —To compare observed, predicted, and risk-adjusted hospital mortality rates in white and African-American patients and to determine whether, as prior studies suggest, African-American patients would have higher predicted risks of death and similar or higher risk-adjusted mortality.

Design.  —Retrospective cohort study.

Setting.  —Thirty hospitals in northeast Ohio.

Patients.  —A total of 88 205 eligible patients consecutively discharged in the years 1991 through 1993 with the following 6 diagnoses: acute myocardial infarction, congestive heart failure, obstructive airways disease, gastrointestinal hemorrhage, pneumonia, and stroke.

Methods.  —We measured predicted risks of death at admission for each diagnosis using validated multivariable models based on standard clinical data abstracted from patients' medical records. We then adjusted in-hospital mortality rates in white and African-American patients for predicted risk of death and other covariates using logistic regression analysis.

Main Outcome Measures.  —Predicted risk of death at admission and observed hospital mortality in white and African-American patients.

Results.  —Predicted risks of death were lower (P<.001) in African Americans for 4 of the 6 diagnoses. Adjusted odds of hospital death were lower (P<.01) in African Americans for 2 of the 6 diagnoses (congestive heart failure and obstructive airways disease) and similar for the other 4 diagnoses. For all diagnoses, in aggregate, the adjusted odds of hospital death were 13% lower in African-American compared with white patients (multivariable odds ratio, 0.87; 95% confidence interval, 0.80-0.94). Findings were similar if further adjustments were made for differences in length of stay, site of hospitalization, or discharge triage practices.

Conclusion.  —Contrary to our a priori hypotheses, predicted risks of death and risk-adjusted mortality rates were generally lower in African-American patients. Our finding of lower predicted risk may reflect racial differences in hospital admission practices or in access to outpatient care. However, our findings suggest that, once hospitalized, African-American patients attained similar or better outcomes, as measured by an important measure—hospital mortality.