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CLINICAL RESEARCH: RACE AND HEART DISEASE

Impact of Hospital Volume on Racial Disparities in Cardiovascular Procedure Mortality

Amal N. Trivedi, MD, MPH^_*,, Thomas D. Sequist, MD, MPH^_*, and John Z. Ayanian, MD, MPP^_*,,_*

^_* Department of Medicine, Division of General Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts

Manuscript received April 15, 2005; revised manuscript received August 3, 2005, accepted August 15, 2005.

^_* Reprint requests and correspondence: Dr. John Z. Ayanian, Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, Massachusetts 02115 (Email: ayanian{at}hcp.med.harvard.edu).

OBJECTIVES: We assessed use of low-volume hospitals by race and ethnicity for major cardiovascular procedures and determined whether hospital volume is an important factor explaining racial and ethnic differences in post-procedure mortality.

BACKGROUND: Low hospital volume predicts mortality for cardiovascular procedures and could be a mediator of racial and ethnic differences in procedure outcomes.

METHODS: We analyzed data from 719,679 hospitalizations for cardiac artery bypass grafting (CABG), percutaneous transluminal coronary angioplasty (PTCA), abdominal aortic aneurysm (AAA) repair, and carotid endarterectomy (CEA) from 1998 to 2001 using the Nationwide Inpatient Sample. We used multivariate logistic regression to assess whether race predicts use of low-volume hospitals and the relative contribution of hospital volume to racial disparity in post-procedure in-hospital mortality.

RESULTS: Black and Hispanic patients were more likely than white patients to receive cardiovascular procedures in low-volume hospitals. Black patients had greater risk-adjusted mortality than white patients after elective AAA repair (odds ratio [OR], 1.84; 95% confidence interval [CI], 1.20 to 2.84), CABG (OR, 1.19; 95% CI, 1.06 to 1.33), and CEA (OR, 1.56; 95% CI, 1.07 to 2.27), but not PTCA. Hispanic patients did not have higher risk-adjusted mortality than white patients. Adjusting for hospital volume did not substantially reduce the relative risk of death for black patients compared with white patients.

CONCLUSIONS: Black and Hispanic patients were more likely to receive cardiovascular procedures in low-volume hospitals, but hospital volume did not explain a large proportion of racial differences in post-procedure mortality. Additional research is needed to determine why black patients have increased mortality after cardiovascular procedures and how these mortality rates can be reduced.

Abbreviations and Acronyms   AAA = abdominal aortic aneurysm   AHRQ = Agency for Healthcare Research and Quality   CABG = coronary artery bypass graft   CEA = carotid endarterectomy   CON = certificate of need   ICD-9-CM = International Classification of Diseases-9th edition-Clinical Modification   NIS = Nationwide Inpatient Sample   PTCA = percutaneous transluminal coronary angioplasty

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