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March 2018

Choice of Hospital as a Source of Racial/Ethnic Disparities in Neonatal Mortality and Morbidity Rates

Author Affiliations
  • 1Health Economics Resource Center and Center for Implementation to Innovation, Veterans Affairs Palo Alto Healthcare System, Menlo Park, California
  • 2Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
  • 3Division of Neonatology, Department of Pediatrics, The Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 4Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania, Philadelphia
JAMA Pediatr. 2018;172(3):221-223. doi:10.1001/jamapediatrics.2017.4917

The study by Howell et al1 in this issue of JAMA Pediatrics is a carefully done, methodologically sound examination of the racial/ethnic disparities in the outcomes for very preterm infants in New York City. The authors partitioned the racial/ethnic differences in a combined morbidity and mortality index into those attributable to maternal and infant factors present at delivery, those attributable to which hospital cared for each infant, and other unexplained factors. Not surprisingly, infant health risks, such as gestational age at delivery, explained most of the large racial/ethnic disparities in neonatal outcomes. What is concerning about the results is that differences in where care was provided explained 40% of the black-white disparity and 30% of the Hispanic-white disparity in mortality/morbidity rates. In these New York City data there was a very large range in risk-adjusted mortality/morbidity rates across the study hospitals (9.7% to 57.7%). Looking at the results (see eFigure 1 in the article’s Supplement1) shows there were no racial/ethnic differences in access to the best-performing hospitals (the top 2 quintiles). However, black and Hispanic patients were, on average, more likely to receive care at hospitals within the lower 3 quintiles. It was notable that almost no white patients were cared for in the lowest performing quintile of hospitals. One encouraging finding from this article is that the authors did not find any within-hospital disparities in outcomes. Previous studies looking at this topic in perinatal medicine yielded mixed results, with some studies finding no difference in hospital care between infants of different racial/ethnic status while others found significant differences in access to high-quality hospitals.2-5 Similar to this work, racial/ethnic disparities in access to high-quality care have been noted in the hospitalized care of adult patients6 and access to outpatient services.7 Because the data are only from New York City, we cannot assume that the disparity patterns found by Howell et al1 apply to the rest of the country. But, if it were to apply to the rest of the country, these results would point to an alarming driver of disparities in perinatal outcomes by race/ethnicity.

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