Customize your JAMA Network experience by selecting one or more topics from the list below.
Bonner SN, Kunnath N, Dimick JB, Ibrahim AM. Hospital-Level Racial and Ethnic Segregation Among Medicare Beneficiaries Undergoing Common Surgical Procedures. JAMA Surg. 2022;157(10):961–964. doi:10.1001/jamasurg.2022.3135
Recently, the US Senate identified health care segregation, the concentration of racial and ethnic groups within specific hospitals, as a key barrier to achieving health equity in medical care.1 Previous research found that racial and ethnic minority patients were more likely to undergo surgery at low-volume, low-quality hospitals compared with White patients, contributing to persistent racial and ethnic disparities in surgical outcomes.2,3 However, to date, the extent and effect of hospital-level segregation in US surgical care is unknown.
This cohort study used 100% Medicare fee-for-service claims to assess hospital-level racial and ethnic segregation among beneficiaries aged 65 to 99 years who underwent appendectomy, colectomy, hernia repair, or cholecystectomy from January 2014 to December 2018. The University of Michigan institutional review board exempted the study and waived informed consent because this was a secondary analysis and data were deidentified. We followed the STROBE guideline.
Multivariable logistic regression analyses compared surgical outcomes at the top 10% of hospitals by volume of racial and ethnic minority beneficiaries served with those at hospitals serving a lower volume of minority beneficiaries. Outcomes included 30-day mortality, 30-day readmissions, complications (based on ICD-9-CM and ICD-10-CM codes using validated methods4), and serious complications (requiring length of stay greater than the 75th percentile for each operation). Covariates included comorbidities, admission type (elective, emergent, or urgent), and operation. We used 27 Elixhauser comorbidities as in prior evaluations of surgical cohorts using Medicare claims.5 Medicare beneficiary race and ethnicity data were captured through Social Security data with categories designated by the Office of Management and Budget. We used American Indian/Native American, Asian and Pacific Islander, Hispanic, non-Hispanic Black, and non-Hispanic White racial and ethnic categories. Data were analyzed from January to February 2022 using Stata/MP, version 17. Two-sided P < .05 was significant.
Of 1 580 359 patients (mean [SD] age, 75.3 [7.3] years), 0.5% were American Indian/Native American; 1.5%, Asian; 2.3%, Hispanic; 8.2%, non-Hispanic Black; and 85.9%, non-Hispanic White. Of all hospitals, 12.6%, 19.0%, 18.6%, and 25.9% performed 90% of surgeries for American Indian/Native American, Asian and Pacific Islander, Hispanic, and non-Hispanic Black beneficiaries, respectively (Figure). Compared with hospitals serving lower volumes of minority patients, the top 10% of hospitals serving the largest volumes of minority patients had higher rates of 30-day mortality (6.64% vs 6.07%; odds ratio [OR], 1.08; 95% CI, 1.08-1.08; P < .001), complications (30.30% vs 28.06%; OR, 1.14; 95% CI, 1.14-1.14; P < .001), serious complications (15.96% vs 14.49%; OR, 1.13; 95% CI, 1.13-1.13; P < .001), and 30-day readmissions (14.90% vs 14.49%; OR, 1.03; 95% CI, 1.03-1.03; P < .001) (Table).
Our findings showed that a small percentage of hospitals provided a disproportionate amount of surgical care to racial and ethnic minority Medicare beneficiaries with inferior surgical outcomes, suggesting that ongoing concentration of racial and ethnic minorities within certain hospitals may contribute to surgical disparities. Our results suggest that resource allocation for quality improvement, community-hospital partnerships, and delivery model innovation to hospitals that disproportionately provide surgical care to racial and ethnic minority groups is important to mitigate disparities.6
A limitation is inclusion of only Medicare fee-for-service beneficiaries, which may limit generalizability to all surgical patients in the US, including those with Medicare Advantage Plans. However, Medicare fee-for-service claims represent a geographically inclusive data source, with all hospitals performing common surgical procedures and most serving Medicare beneficiaries. Medicare claims have been used in prior assessments of hospital segregation, and Medicare is invested in reducing racial inequities in care.4 Our results suggest that ensuring high-quality surgical care for racial and ethnic minority patients will require surgeons, surgical societies, and policy makers to prioritize hospitals providing most of the surgical care to these patients. Future work should explore how hospital factors, including admission and transfer policies and price discrimination, interact with patient characteristics such as insurance, geographic residence, barriers to access, and patient site-of-care preferences to contribute to hospital-level segregation among surgical cohorts.
Accepted for Publication: April 13, 2022.
Published Online: August 3, 2022. doi:10.1001/jamasurg.2022.3135
Corresponding Author: Sidra N. Bonner, MD, MPH, Department of Surgery, University of Michigan, 2101 Taubman Center, 1500 E Medical Center Dr, Ann Arbor, MI 48109 (firstname.lastname@example.org).
Author Contributions: Dr Bonner had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Bonner, Dimick, Ibrahim.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Bonner, Ibrahim.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Kunnath.
Obtained funding: Dimick.
Administrative, technical, or material support: Dimick.
Supervision: Dimick, Ibrahim.
Conflict of Interest Disclosures: Dr Bonner reported receiving grant funding from the National Institutes of Health (NIH) T32 Multidisciplinary Research Training Program in Lung Diseases at the University of Michigan and personal fees from JAMA Network for serving as a visual abstract editor. Dr Dimick reported receiving grant funding from the NIH and being an equity owner of ArborMetrix, Inc outside the submitted work. Dr Ibrahim reported receiving personal fees from HOK for architectural consulting and design and from JAMA Network for serving as a visual abstract editor outside the submitted work. No other disclosures were reported.
Disclaimer: Justin B. Dimick, MD, MPH, is Surgical Innovation Editor of JAMA Surgery, but he was not involved in any of the decisions regarding review of the manuscript or its acceptance.