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Original Investigation
June 11, 2007

Concentration and Quality of Hospitals That Care for Elderly Black Patients

Author Affiliations

Author Affiliations: Department of Health Policy and Management, Harvard School of Public Health (Drs Jha and Epstein and Ms Li), Division of General Medicine, Brigham and Women's Hospital (Drs Jha, Orav, and Epstein), and the Veterans Administration Boston Healthcare System (Dr Jha), Boston, Mass.

Arch Intern Med. 2007;167(11):1177-1182. doi:10.1001/archinte.167.11.1177

Background  The reasons for racial differences in health care are not well known, but the characteristics of hospitals where people receive care may be an important factor in the quality of care that patients receive. Therefore, we sought to determine the proportion and volume of elderly black vs white patients treated at hospitals and examine the characteristics and performances of hospitals that care for disproportionately high volumes of black patients.

Methods  We used 2004 Medicare data to calculate, for each hospital in our study, the volume and proportion of black patients discharged. We then examined the hospitals' structural characteristics and performances according to quality measures for patients with acute myocardial infarction, congestive heart failure, and pneumonia.

Results  The 5% of hospitals with the highest volume of black patients cared for nearly half of all elderly black patients, and the hospitals in the top quartile by volume of patients cared for nearly 90% of elderly black patients. Hospitals with a high volume of black patients were larger and were more often teaching hospitals located in the southern United States (P<.001 for each comparison) than those with a low volume of black patients. Hospitals with a high proportion of black patients had comparable characteristics. After adjusting for hospital characteristics, hospitals that treated a high vs low volume of black patients had worse performance summary scores for acute myocardial infarction (89.0 vs 90.7; P = .002) and pneumonia measures (76.9 vs 79.4; P<.001). Adjusting for hospital referral region eliminated the gap in performance scores for acute myocardial infarction but not for pneumonia. There were comparable differences in performance scores for hospitals that treated a high vs low proportion of black patients.

Conclusions  Hospital care for black patients in the United States is remarkably concentrated in a small percentage of hospitals, although the hospitals that care for a high proportion of black patients have only marginally worse quality of care than those that care for a low proportion of black patients. The level of concentration of black patients provides a fresh opportunity to improve care for black patients by targeting efforts toward a small group of hospitals.