Racial and Ethnic Differences in the Use of High-Volume Hospitals and Surgeons | Oncology | JAMA Surgery | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
Smedley  BDStith  AYNelson  ARthe Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, eds Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.  Washington, DC: National Academy Press; 2002:1-562
Bach  PBPham  HHSchrag  DTate  RCHargraves  JL Primary care physicians who treat blacks and whites.  N Engl J Med 2004;351 (6) 575- 584PubMedGoogle ScholarCrossref
Bradley  EHHerrin  JWang  Y  et al.  Racial and ethnic differences in time to acute reperfusion therapy for patients hospitalized with myocardial infarction.  JAMA 2004;292 (13) 1563- 1572PubMedGoogle ScholarCrossref
Barnato  AELucas  FLStaiger  DWennberg  DEChandra  A Hospital-level racial disparities in acute myocardial infarction treatment and outcomes.  Med Care 2005;43 (4) 308- 319PubMedGoogle ScholarCrossref
Groeneveld  PWLaufer  SWGarber  AM Technology diffusion, hospital variation, and racial disparities among elderly Medicare beneficiaries, 1989-2000.  Med Care 2005;43 (4) 320- 329PubMedGoogle ScholarCrossref
Skinner  JChandra  AStaiger  DLee  JMcClellan  M Mortality after acute myocardial infarction in hospitals that disproportionately treat black patients.  Circulation 2005;112 (17) 2634- 2641PubMedGoogle ScholarCrossref
Hasnain-Wynia  RBaker  DWNerenz  D  et al.  Disparities in health care are driven by where minority patients seek care: examination of the Hospital Quality Alliance Measures.  Arch Intern Med 2007;167 (12) 1233- 1239PubMedGoogle ScholarCrossref
Jha  AKOrav  EJZheng  JEpstein  AM The characteristics and performance of hospitals that care for elderly Hispanic Americans.  Health Aff (Millwood) 2008;27 (2) 528- 537PubMedGoogle ScholarCrossref
Schulman  KABerlin  JAHarless  W  et al.  The effect of race and sex on physicians' recommendations for cardiac catheterizations.  N Engl J Med 1999;340 (8) 618- 626PubMedGoogle ScholarCrossref
Balsa  AIMcGuire  TGMeredith  LS Testing for statistical discrimination in health care.  Health Serv Res 2005;40 (1) 227- 252PubMedGoogle ScholarCrossref
Green  ARCarney  DRPallin  DJ  et al.  Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients.  J Gen Intern Med 2007;22 (9) 1231- 1238PubMedGoogle ScholarCrossref
Kaiser Family Foundation and Agency for Healthcare Research and Quality National Survey on Consumers' Experiences With Patient Safety and Quality Information.  Menlo Park, CA: Kaiser Family Foundation: November 2004. http://www.kff.org/kaiserpolls/pomr111704pkg.cfm. Accessed November 30, 2008
Liu  JHZingmond  DZMcGory  ML  et al.  Disparities in the utilization of high-volume hospitals for complex surgery.  JAMA 2006;296 (16) 1973- 1980PubMedGoogle ScholarCrossref
Trivedi  ANSequist  TDAyanian  JZ Impact of hospital volume on racial disparities in cardiovascular procedure mortality.  J Am Coll Cardiol 2006;47 (2) 417- 424PubMedGoogle ScholarCrossref
Neighbors  CJRogers  MLShenassa  EDSciamanna  CNClark  MANovak  SP Ethnic/racial disparities in hospital procedure volume for lung resection for lung cancer.  Med Care 2007;45 (7) 655- 663PubMedGoogle ScholarCrossref
Mukamel  DBWeimer  DLMushlin  AI Referrals to high-quality cardiac surgeons: patients' race and characteristics of their physicians.  Health Serv Res 2006;41 (4, pt 1) 1276- 1295PubMedGoogle Scholar
Birkmeyer  JDStukel  TASiewers  AEGoodney  PPWennberg  DELucas  FL Surgeon volume and operative mortality in the United States.  N Engl J Med 2003;349 (22) 2117- 2127PubMedGoogle ScholarCrossref
Halm  EALee  CChassin  MR Is volume related to outcomes in health care? a systematic review and methodologic critique of the literature.  Ann Intern Med 2002;137 (6) 511- 520PubMedGoogle ScholarCrossref
Dudley  RAJohansen  KLBrand  RRennie  DJMilstein  A Selective referral to high-volume hospitals: estimating potentially avoidable deaths.  JAMA 2000;283 (9) 1159- 1166PubMedGoogle ScholarCrossref
Gandjour  ABannenberg  ALauterbach  KW Threshold volumes associated with higher survival in health care: a systematic review.  Med Care 2003;41 (10) 1129- 1141PubMedGoogle ScholarCrossref
Birkmeyer  JDDimick  JB Potential benefits of the new Leapfrog standards: effect of process and outcomes measures.  Surgery 2004;135 (6) 569- 575PubMedGoogle ScholarCrossref
Hannan  ELRadzyner  MRubin  DDougherty  JBrennan  MF The influence of hospital and surgeon volume on in-hospital mortality for colectomy, gastrectomy, and lung lobectomy in patients with cancer.  Surgery 2002;131 (1) 6- 15PubMedGoogle ScholarCrossref
Corcoran  CDSenchaudhuri  PMehta  CRPatel  NR Exact inference for categorical data.  In:  Encyclopedia of Biostatistics.2nd ed. Hoboken, NJ: John Wiley and Sons; 2005Google Scholar
Elixhauser  ASteiner  CHarris  DRCoffey  RM Cormorbidity measures for use with administrative data.  Med Care 1998;36 (1) 8- 27PubMedGoogle ScholarCrossref
 AHRQ Comorbidity Software Version 2.1. http://www.hcup-us.ahrq.gov/toolssoftware/comorbidity/comorbidity.jsp. Accessed November 30, 2008
Cook  TD Advanced statistics: up with odds ratios! a case for odds ratios when outcomes are common.  Acad Emerg Med 2002;9 (12) 1430- 1434PubMedGoogle ScholarCrossref
McNutt  LAWu  CXue  XHafner  JP Estimating the relative risk in cohort studies and clinical trials of common outcomes.  Am J Epidemiol 2003;157 (10) 940- 943PubMedGoogle ScholarCrossref
Kleinman  LCNorton  EC What's the risk? a simple approach for estimating adjusted risk measures from nonlinear models including logistic regression.  Health Serv Res 2009;44 (1) 288- 302PubMedGoogle ScholarCrossref
Bartus  T Estimation of marginal effects using margeff.  Stata J 2005;5 (3) 309- 329Google Scholar
Blendon  RJBuhr  TCassidy  EF  et al.  Disparities in physician care: experiences and perceptions of a multi-ethnic America.  Health Aff (Millwood) 2008;27 (2) 507- 517PubMedGoogle ScholarCrossref
Kawachi  IDaniels  NRobinson  DE Health disparities by race and class: why both matter.  Health Aff (Millwood) 2005;24 (2) 343- 352PubMedGoogle ScholarCrossref
Mukamel  DBWeimer  DLBuchmueller  TCLadd  HMushlin  AI Changes in racial disparities in access to coronary artery bypass grafting surgery between the late 1990s and early 2000s.  Med Care 2007;45 (7) 664- 671PubMedGoogle ScholarCrossref
Iceland  JWeinberg  DHSteinmetz  S Racial and Ethnic Residential Segregation in the United States: 1980-2000. U.S. Census Bureau, Series CENSR-3.  Washington, DC: US Government Printing Office; 2000:1-151
Mukamel  DBWeimer  DLZwanziger  JGorthy  SFHMushlin  AI Quality report cards, selection of cardiac surgeons, and racial disparities: a study of the publication of the New York State cardiac surgery reports.  Inquiry 2004-2005;41 (4) 435- 446PubMedGoogle ScholarCrossref
Wilson  CTWoloshin  SSchwartz  LM Choosing where to have major surgery: who makes the decision?  Arch Surg 2007;142 (3) 242- 246PubMedGoogle ScholarCrossref
Blustein  J The reliability of racial classifications in hospital discharge abstract data.  Am J Public Health 1994;84 (6) 1018- 1021PubMedGoogle ScholarCrossref
Sheikh  K Reliability of provider volume and outcome associations for healthcare policy.  Med Care 2003;41 (10) 1111- 1117PubMedGoogle ScholarCrossref
Luft  HS From observing the relationship between volume and outcome to making policy recommendations.  Med Care 2003;41 (10) 1118- 1126PubMedGoogle ScholarCrossref
Sheikh  K Sheikh responds to provider volume-patient outcome association and policy by Luft.  Med Care 2003;41 (10) 1123- 1126Google ScholarCrossref
Original Article
February 2010

Racial and Ethnic Differences in the Use of High-Volume Hospitals and Surgeons

Author Affiliations

Author Affiliations: Division of Health Policy and Administration, School of Public Health, Yale University, New Haven, Connecticut (Drs Epstein and Schlesinger); and Urban Institute, Washington, DC (Dr Gray).

Arch Surg. 2010;145(2):179-186. doi:10.1001/archsurg.2009.268

Objective  To examine racial/ethnic differences in the use of high-volume hospitals and surgeons for 10 surgical procedures with documented associations between volume and mortality.

Design  Cross-sectional regression analysis.

Setting  New York City area hospital discharge data, 2001-2004.

Patients  Adults from 4 racial/ethnic categories (white, black, Asian, and Hispanic) who underwent surgery for cancer (breast, colorectal, gastric, lung, or pancreatic resection), cardiovascular disease (coronary artery bypass graft, coronary angioplasty, abdominal aortic aneurysm repair, or carotid endarterectomy), or orthopedic conditions (total hip replacement).

Main Outcome Measure  Treatment by a high-volume surgeon at a high-volume hospital.

Results  There were 133 821 patients who underwent 1 of the 10 procedures. For 9 of the 10 procedures, black patients were significantly (P < .05) less likely (after adjustment for sociodemographic characteristics, insurance type, proximity to high-volume providers, and comorbidities) to be operated on by a high-volume surgeon at a high-volume hospital and more likely to be operated on by a low-volume surgeon at a low-volume hospital. Asian and Hispanic patients, respectively, were significantly less likely to use high-volume surgeons at high-volume hospitals for 5 and 4 of the 10 procedures and more likely to use low-volume surgeons at low-volume hospitals for 3 and 5 of the 10 procedures.

Conclusions  Minority patients in New York City are doubly disadvantaged in their surgical care; they are substantially less likely to use both high-volume hospitals and surgeons for procedures with an established volume-mortality association. Better information is needed about which providers minority patients have access to and how they select them.