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Original Investigation |

Explaining Racial Disparities in Outcomes After Cardiac Surgery:  The Role of Hospital Quality

Govind Rangrass, MD1; Amir A. Ghaferi, MD1; Justin B. Dimick, MD, MPH1
[+] Author Affiliations
1Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor
JAMA Surg. 2014;149(3):223-227. doi:10.1001/jamasurg.2013.4041.
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Importance  Racial disparities in mortality rates after coronary artery bypass graft (CABG) surgery are well established. We have yet to fully understand how care at high-mortality, low-quality hospitals contributes to racial disparities in surgical outcomes.

Objective  To determine the effects of hospital quality on racial disparities in mortality rates after CABG surgery.

Design, Setting, and Participants  The national Medicare database (2007-2008) was used to identify 173 925 patients undergoing CABG surgery in US hospitals.

Main Outcomes and Measures  Our primary measure of quality was the risk-adjusted mortality rate for each hospital. Logistic regression was used to determine the relationship between race and mortality rates, accounting for patient characteristics, socioeconomic status, and hospital quality.

Results  Nonwhite patients had 33% higher risk-adjusted mortality rates after CABG surgery than white patients (odds ratio [OR], 1.33; 95% CI, 1.23-1.45). In hospitals treating the highest proportion of nonwhite patients (>17.7%), the mortality was 4.8% in nonwhite and 3.8% in white patients. When assessed independently, differences in hospital quality explained 35% of the observed disparity in mortality rates (OR, 1.22; 95% CI, 1.12-1.34). We were able to explain 53% of the observed disparity after adjusting for differences in socioeconomic status and hospital quality. However, even after these factors were taken into account, nonwhite patients had a 16% higher mortality (OR, 1.16; 95% CI, 1.05-1.27).

Conclusions and Relevance  Hospital quality contributes significantly to racial disparities in outcomes after CABG surgery. However, a significant fraction of this racial disparity remains unexplained. Efforts to decrease racial disparities in health care should focus on underperforming centers of care treating disproportionately high numbers of nonwhite patients.

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Differences in Mortality Rates Between White and Nonwhite Patients in Hospitals Stratified by Proportion of Nonwhite Patients Treated

After hospitals were grouped according to proportion of nonwhite patients treated, hospitals in the highest tercile (treating >17.7% nonwhite patients) had the highest risk-adjusted mortality for both white and nonwhite patients (3.8% and 4.8%, respectively), and those in the lowest tercile (treating <2% nonwhite patients) had the lowest (3.2% and 3.7%, respectively).

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