1. Hospital Safety: Do race and ethnicity matter? Ernest Moy, MD, MPH Elizabeth Dayton, MA Roxanne Andrews, PhD The Agency for Healthcare Research and Quality The National Healthcare Quality and Disparities Reports

2. The NHDR is an annual report to Congress. It includes a comprehensive set of measures for healthcare quality and access. It analyzes disparities by race, ethnicity, and socioeconomic status, and for priority populations.

3. Patient Safety Today 44 - 98,000 American lives lost annually 44 - 98,000 American lives lost annually Lost incomes, disability, and health care expenditures attributable to medical errors cost a projected $29 billion Lost incomes, disability, and health care expenditures attributable to medical errors cost a projected $29 billion Institute of Medicine, 2000 Limited research examines racial and ethnic variation in adverse events Limited research examines racial and ethnic variation in adverse events Romano, Geppert, Davies, et al., Health Affairs, 2003 Coffey, Andrews, Moy, Medical Care, 2005

4. Patient Safety Datasources HCUP SID Disparities Analytic File: Patient Safety Indicators (PSIs) HCUP SID Disparities Analytic File: Patient Safety Indicators (PSIs) Medicare Patient Safety Monitoring System: Adverse Events Medicare Patient Safety Monitoring System: Adverse Events Quality Improvement Organization Program: Surgical Infection Prophylaxis Quality Improvement Organization Program: Surgical Infection Prophylaxis Medical Expenditure Panel Survey: Inappropriate Medications Medical Expenditure Panel Survey: Inappropriate Medications

5. HCUP SID Disparities Analytic File Patient safety indicators from all-payer hospital discharge abstract data Patient safety indicators from all-payer hospital discharge abstract data Adjusted for age, gender, age-gender interaction, DRG, and co-morbidities Adjusted for age, gender, age-gender interaction, DRG, and co-morbidities Sample from 23 HCUP-SID states* with “good” racial/ethnic data Sample from 23 HCUP-SID states* with “good” racial/ethnic data Missing data imputed Missing data imputed Data weighted to produce national estimates Data weighted to produce national estimates Sample size: about 14.5 million records from about 1700 hospitals Sample size: about 14.5 million records from about 1700 hospitals * AZ, CA, CO, CT, FL, GA, HI, KS, MD, MA, MI, MO, NH, NJ, NY, PA, RI, SC, TN, TX, VA, VT, WI

6. Medicare Patient Safety Monitoring System Adverse events from charts Adverse events from charts Randomly-selected, nationwide subset of inpatient medical records of Medicare beneficiaries Randomly-selected, nationwide subset of inpatient medical records of Medicare beneficiaries Data weighted to produce national estimates Data weighted to produce national estimates Sample size: about 26,000 charts Sample size: about 26,000 charts – 5,500 surgical cases – 4,000 central venous catheter insertions

7. Quality Improvement Organization Program Quality of surgical infection prophylaxis from charts Quality of surgical infection prophylaxis from charts Randomly-selected, nationwide subset of inpatient medical records of Medicare beneficiaries Randomly-selected, nationwide subset of inpatient medical records of Medicare beneficiaries Sample size: about 21,000 surgical cases Sample size: about 21,000 surgical cases

8. Postoperative Complication Rates Relative to Whites, HCUP 2003 Bars with numbers included meet our statistical (p 10% relative difference) criteria for significance

9. Obstetric Complication Rates Relative to Whites, HCUP 2003 Bars with numbers included meet our statistical (p 10% relative difference) criteria for significance

10. Other Complication Rates Relative to Whites, HCUP 2003 Bars with numbers included meet our statistical (p 10% relative difference) criteria for significance

11. Summary of PSIs Relative to Whites (Better-Same-Worse) BlackHispanicAPI Postop 0 – 1 – 5 0 – 3 – 3 1 – 3 – 2 Obstetric 2 – 1 – 1 4 – 0 – 0 0 – 3 – 1 Other 1 – 4 – 2 2 – 5 – 0 1 – 5 – 1 Total 3 – 6 – 8 6 – 8 – 3 2 – 11 – 4

12. Black Postoperative Complication Rates Relative to Whites, MPSMS 2003 Bars with numbers included meet our statistical (p 10% relative difference) criteria for significance

13. Black CVC-Associated Complication Rates Relative to Whites, MPSMS 2003 Bars with numbers included meet our statistical (p 10% relative difference) criteria for significance

14. Appropriate Surgical Infection Prophylaxis Relative to Whites, QIO 2004 Bars with numbers included meet our statistical (p 10% relative difference) criteria for significance

15. Summary: Disparities in Hospital Safety HCUP-SID: Disparities exist HCUP-SID: Disparities exist – Blacks and Hispanics have higher rates of postoperative complications – Hispanics have lower rates of obstetric complications – But fewer disparities related to other complications MPSMS: Blacks have higher rates of postoperative but not CVC-associated complications MPSMS: Blacks have higher rates of postoperative but not CVC-associated complications QIO: Surgical infection prophylaxis varies by race/ethnicity QIO: Surgical infection prophylaxis varies by race/ethnicity

16. “Complication-Related” Death Rates Per 1000 Discharge With Complications by Race/Ethnicity, HCUP 2001-2003 Note: “Complication-related” death rate = “failure to rescue”

17. Postoperative and CVC Complication Rates (%) by Race, MPSMS 2002-2003 Postoperative CompositeCVC Composite

18. Summary: Trends in Hospital Safety Disparities HCUP-SID: Disparities not narrowing HCUP-SID: Disparities not narrowing MPSMS: Black-white differences in CVC-associated complications narrowing but not postoperative complications MPSMS: Black-white differences in CVC-associated complications narrowing but not postoperative complications QIO: No data (yet) QIO: No data (yet)

19. Next Steps: Why do these disparities exist? Minorities go to different hospitals or providers? Minorities go to different hospitals or providers? Minorities are sicker when they are hospitalized? Minorities are sicker when they are hospitalized? Minorities have more comorbidities? Minorities have more comorbidities? Procedures are harder to perform on minorities? Procedures are harder to perform on minorities?

20. Contact Information Ernest Moy, MD, MPH National Healthcare Quality and Disparities Reports Center for Quality Improvement and Patient Safety Agency for Healthcare Research and Quality 540 Gaither Road Rockville, MD, 20850 301-427-1329 (voice) 301-427-1341 (fax) Ernest.Moy@ahrq.hhs.gov