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Hopkins Center for Health Disparities Solutions Projects

Disparities in the Quality of Hospital Care: Does Where You Go Matter?

PI: Darrell J. Gaskin, PhD

Co-Investigators: Thomas A. LaVeist, PhD; Gerard F. Anderson, PhD; Christine Spencer, ScD; and Robert Herbert

Disparities in hospital based care have been well documented. There is some empirical evidence suggesting that disparities in the quality of hospital care are due more to variation in quality of care across hospitals than variation in quality of care within hospitals. Stated simply, minority patients receive lower quality care because they are being served by lower quality hospitals. According to prior research, minority and low-income patients are distributed differently across hospitals than white and more affluent patients. Minority and low-income patients are more likely to use safety net hospitals, public hospitals and major teaching hospitals. However, because these hospitals serve higher proportions of minority and low-income patients, they claim to have expertise in providing high quality care to these patients. For example, when Medicaid managed care threatened to shift Medicaid patients from traditional safety net hospitals, advocates for these hospitals claimed that this policy hurt Medicaid patients because it moved them from hospitals that understood the nexus of their health and social problems to hospitals that were unfamiliar with the unique challenges associated with serving these patients. In addition, studies have shown that larger, urban and teaching hospitals provide better quality of care than smaller, rural and non-teaching hospitals. Hence, these advocates would argue that hospitals that serve higher proportions of minority and low-income patients provide better quality of care to them than hospitals that are unfamiliar with them.

The proposed project will explore these competing hypotheses using state inpatient discharge data from 15 states: AZ, CA, CO, FL, IA, MA, MD, MI, NC, NJ, NY, PA, SC, TX and WI. We propose to investigate four research aims which will shed light on the source of disparities in the quality of hospital care. 1) We will assess whether minority and low-income patients tend to use hospitals that provide lower quality care. 2) We will assess the association between the hospital characteristics and the quality of hospital care provided to minority and low-income patients. 3) We will examine the association between hospitals’ financial status and the quality of care hospitals provided to minority and low-income patients. 4) We will visit eight hospitals to identify best practices and barriers to providing these patients high quality care. We will select the case study hospitals based on the level of quality they provide their minority and low income patients and their safety net hospitals status. To measure quality we will use the AHRQ inpatient quality indicators and patient safety indicators. We will use data from the AHA Annual Survey of Hospitals and Medicare Cost Reports for measures of hospital characteristics and financial status.

Our findings will help federal and state policymakers, hospital officials, health plans, employer groups and community leaders to address disparities in the quality of hospital care. For example, if we find minority and low-income patients receive poor quality care when they use under-resourced hospitals, but safety net, public and major teaching hospitals are high performers for these patients when they are financially healthy, this suggests that government subsidies to these hospitals could be used to reduce disparities in the quality of hospital care. Hospital officials can use our findings to identify structural and organizational factors that are related to disparities. Our case studies will identify best practices that other hospitals can use to improve the quality of care to their minority and low income patients. By interviewing low performers, we hope to identify barriers hospitals face to providing high quality care to minority and low-income patients. They can also try to implement best practices in their own facilities. As purchasers of care for minority and low-income patients, health plans and employer groups could use the findings and conclusions from this study to encourage their enrollees to use higher quality hospitals and to encourage low performers to improve.