Black student enrollment in US medical schools

Blacks represent about 12% of the nation's population, but only 6% of the total medical school enrollment, 5% of medical school graduates, 5% of postgraduate trainees, 3% of physicians in practice, and 2% of medical school faculties. Addressing this underrepresentation of blacks in medicine not only is a matter of justice, equity, and national conscience but also has implications for the provision of quality physician care to this nation's minority and medically underserved populations. Black physicians are more likely to understand the cultural and social context of illness and disability among blacks and are also more likely to be able to communicate effectively with black patients. Black physicians are also more likely to practice in communities whose residents lack adequate access to medical care. An approach to addressing the problem of underrepresentation is proposed, consisting of activities at the precollege, college, and medical school levels.     

The excess incidence of diabetic end-stage renal disease among blacks. A population-based study of potential explanatory factors.

OBJECTIVE--To investigate whether the excess incidence of diabetic end-stage renal disease (ESRD) among African Americans could be explained by racial differences in putative ESRD risk factors. DESIGN--Population-based, ecologic study using the 1981 and 1982 Maryland Statewide Household Hypertension Survey for data on risk factor prevalence. PARTICIPANTS--A total of 2.1 million adults residing within the boundaries of the Maryland Regional ESRD Registry, grouped by race and ZIP code into 26 subpopulations. MAIN OUTCOME MEASURE--Incidence rates of treatment for diabetic ESRD between 1980 and 1985 from the Maryland Regional ESRD Registry by subpopulation. RESULTS--Between 1980 and 1985, 442 persons entered treatment for diabetic ESRD. At the level of the subpopulation, diabetic ESRD incidence was positively associated with black race (relative risk [RR], 3.42; 95% confidence interval [CI], 2.84 to 4.13), prevalence of diabetes (RR, 2.35; 95% CI, 1.92 to 2.87), prevalence of poorly controlled hypertension (RR, 1.80; 95% CI, 1.45 to 1.86), lack of a regular source of health care (RR, 1.82; 95% CI, 1.62 to 2.05), and lower socioeconomic status as indicated by lack of college education (RR, 1.41; 95% CI, 1.32 to 1.52) (all, P < .0001). After adjusting for these risk factors, black race remained strongly associated with the overall incidence of diabetic ESRD (RR, 2.70; 95% CI, 1.89 to 3.86; P < .0001). Further analyses suggested that this excess risk among blacks was confined to ESRD related to non-insulin-dependent diabetes (RR, 4.80; 95% CI, 3.09 to 7.46; P < .0001); blacks were at no higher risk than were whites for ESRD related to insulin-dependent diabetes (RR, 0.90; 95% CI, 0.52 to 1.55; P = .70). CONCLUSIONS--These data suggest that the excess incidence of diabetic ESRD among blacks is not fully explained by a higher prevalence of diabetes or hypertension in blacks or by racial differences in age, socioeconomic status, or access to health care. Instead, they suggest an increased susceptibility to ESRD resulting from non-insulin-dependent diabetes among blacks as compared with whites.     

Access to medical care for black and white Americans. A matter of continuing concern

A 1986 national survey of use of health services shows a significant deficit in access to health care among black compared with white Americans. This gap was experienced by all income levels of black Americans. In addition, the study points to significant underuse by blacks of needed medical care. Moreover, blacks compared with whites are less likely to be satisfied with the qualitative ways their physicians treat them when they are ill, more dissatisfied with the care they receive when hospitalized, and more likely to believe that the duration of their hospitalizations is too short.     

Left ventricular hypertrophy in black and white hypertensives. Standard electrocardiographic criteria overestimate racial differences in prevalence.

OBJECTIVE--To assess racial differences in the accuracy of standard electrocardiographic (ECG) criteria in the diagnosis of left ventricular hypertrophy (LVH). DESIGN--The sensitivity and specificity of standard ECG criteria were compared in blacks and whites using echocardiographic LVH as the reference standard. SETTING--Eight worksite-based hypertension clinics in New York, NY. PATIENTS--A sample of 122 black and 148 white hypertensive patients. RESULTS--The prevalence of ECG-LVH was two to six times higher in blacks than in whites, depending on the criteria used (range, 6% to 24% in blacks vs 1% to 7% in whites; P = .0005 to .19 for black-white comparisons). The difference in prevalence of echocardiographic LVH [corrected], however, was less striking and did not attain statistical significance (26% in blacks and 20% in whites; P greater than .2). The sensitivity of the ECG was low (range, 3% to 17%) and did not differ significantly between the two races for any of the conventional criteria; specificity, however, was lower in blacks for all criteria (range, 73% to 94% vs 95% to 100% for whites; P = .0001 to .09). The predictive value of a positive ECG was consistently, although not significantly, lower in the black subjects. Black race was the strongest independent predictor of decreased ECG specificity in multiple logistic regression analysis that also considered age, gender, body mass index, left ventricular mass index, and smoking. CONCLUSIONS--Commonly used ECG criteria for the detection of LVH have a poor sensitivity in both black and white hypertensives and a lower specificity in blacks than in whites; this may lead to a greater number of false-positive diagnoses in black patients, as well as to an overestimation of black-white difference in LVH prevalence.     

Differences in mortality and use of revascularization in black and white patients with acute MI admitted to hospitals with and without revascularization services

Context  Racial differences in the use of coronary revascularization after acute myocardial infarction (AMI) have been widely reported. However, few studies have examined patterns of care for AMI patients admitted to hospitals with and without revascularization services. Objective  To compare rates of hospital transfer, coronary revascularization, and mortality after AMI for black and white patients admitted to hospitals with and without revascularization services. Design, Setting, and Participants  Retrospective cohort study of 1 215 924 black and white Medicare beneficiaries aged 68 years and older, admitted with AMI between January 1, 2000, and June 30, 2005, to 4627 US hospitals with and without revascularization services. Main Outcome Measures  For patients admitted to nonrevascularization hospitals, transfer to another hospital with revascularization services; for all patients, risk-adjusted rates of 30-day coronary revascularization and 1-year mortality. Results  Black patients admitted to hospitals without revascularization were less likely (25.2% vs 31.0%; P<.001) to be transferred. Black patients admitted to hospitals with or without revascularization services were less likely to undergo revascularization than white patients (34.3% vs 50.2% and 18.3% vs 25.9%; P<.001) and had higher 1-year mortality (35.3% vs 30.2% and 39.7% vs 37.6%; P<.001). After adjustment for sociodemographics, comorbidity, and illness severity, blacks remained less likely to be transferred (hazard ratio [HR], 0.78; 95% confidence interval [CI], 0.75-0.81; P<.001) and undergo revascularization (HR, 0.71; 95% CI, 0.69-0.74; P<.001; and HR, 0.68; 95% CI, 0.65-0.70; P<.001 in hospitals with and without revascularization, respectively). Risk-adjusted mortality was lower for blacks during the first 30 days after admission (HR, 0.91; 95% CI, 0.88-0.93; P<.001; and HR, 0.90; 95% CI, 0.87-0.92; P<.001 in hospitals with and without revascularization, respectively) but was higher (P<.001) thereafter. Conclusions  Black patients admitted to hospitals with and without coronary revascularization services are less likely to receive coronary revascularization. The higher long-term mortality of black patients may reflect the lower use of revascularization or other aspects of AMI care.      

The early effect of Medicare's prospective payment system on the use of medical intensive care services in three community hospitals

To assess the impact of Medicare's prospective payment system (PPS) on patient care and outcome from the medical intensive care unit (MICU), we reviewed the medical records of 400 MICU patients from three community hospitals: 200 patients were admitted before the PPS and 200 were admitted after the PPS. We sampled Medicare patients, aged 65 years and over, and non-Medicare comparison patients, aged 50 to 64 years, collecting data on case mix, treatment intensity and discharge disposition, hospital and six-month mortality, length of stay, and number of intensive care unit beds. After the PPS, the number of intensive care unit beds decreased 31%, without changes in MICU patients' illness severity or treatment intensity. Hospital length of stay decreased 15% in the Medicare group and 43% in the comparison group. For both Medicare and comparison patients combined, MICU length of stay decreased 14% and patients after the PPS were less likely to be discharged to go home. There were no significant changes in in-hospital or six-month mortality. Thus, clinically meaningful decreases in length of stay among seriously ill patients did not result in a change in in-hospital or six-month mortality.     

Mortality and locomotion 6 months after hospitalization for hip fracture: risk factors and risk-adjusted hospital outcomes

CONTEXT: Hip fracture is a common clinical problem that leads to considerable mortality and disability. A need exists for a practical means to monitor and improve outcomes, including function, for patients with hip fracture. OBJECTIVES: To identify and compare the importance of significant prefracture predictors of functional status and mortality at 6 months for patients hospitalized with hip fracture and to compare risk-adjusted outcomes for hospitals providing initial care. DESIGN: Prospective study with data obtained from medical records and through structured interviews with patients and proxies. SETTING AND PARTICIPANTS: A total of 571 adults aged 50 years or older with hip fracture who were admitted to 4 New York, NY, metropolitan hospitals between August 1997 and August 1998. MAIN OUTCOME MEASURES: In-hospital and 6-month mortality; locomotion at 6 months; and adverse outcomes at 6 months, defined as death or needing assistance to ambulate, compared by hospital, adjusting for patient risk factors. RESULTS: The in-hospital mortality rate was 1.6%. At 6 months, the mortality rate was 13.5%, and another 12.8% needed total assistance to ambulate. Laboratory values were strong predictors of mortality but were not significantly associated with locomotion. Age and prefracture residence at a nursing home were significant predictors of locomotion (P =.02 for both) but were not significantly associated with mortality. Adjustment for baseline characteristics either substantially augmented or diminished interhospital differences in outcomes. Two hospitals had 1 outcome (functional status or mortality) that was significantly worse than the overall mean while the other outcome was nonsignificantly better than average. CONCLUSIONS: Mortality and functional status ideally should be considered both together and individually to distinguish effects limited to one or the other outcome. Hospital performance for these 2 measures may differ substantially after adjustment, probably because different processes of care are important to each outcome.     

Racial/ethnic variation in perceptions of medical information sources in Durham County, North Carolina

BACKGROUND: Concerns about health and health care disparities have led some groups to promote better communication of medical information as a potential means of empowering patients to overcome barriers to health care and to practice healthy behaviors. We examined the independent effect of race/ethnicity on perceptions of the usefulness of different sources of health information. METHODS: We analyzed data from a cross-sectional telephone survey of black, Latino, and white adults (n = 515) in Durham County North Carolina, in 2002. Respondents rated the usefulness of medical information sources, nonmedical information sources, and media. We used logistic regression to determine the effect of race/ethnicity on ratings of information sources, adjusting for demographic, socioeconomic, and health status factors. RESULTS: Compared to white respondents, Latinos and black respondents were more likely to perceive as useful the local health department, ministers/churches, community centers, television, and radio. Latinos were less likely than white and black respondents to report the pharmacy as a useful source of medical information. LIMITATIONS: Some findings may be particular to Durham County, especially those based on the Latino subgroup. Also, the response rate (43%) suggests that nonresponse bias may have affected our results. Finally perceived usefulness may affect one's intent to act on information but may not correlate with the benefit gained from a particular source. CONCLUSIONS: There are substantial racial/ethnic differences in perceptions of certain medical information sources. Medical information designed for minority populations may be more effective if disseminated through particular sources.     

The need for acute, subacute, and nonacute care at 105 general hospital sites on Ontario

BACKGROUND: Previous studies of hospital utilization have not taken into account the use of acute care beds for subacute care. The authors determined the proportion of patients who required acute, subacute and nonacute care on admission and during their hospital stay in general hospitals in Ontario. From this analysis, they identified areas where the efficiency of care delivery might be improved. METHODS: Ninety-eight of 189 acute care hospitals in Ontario, at 105 sites, participated in a review that used explicit criteria for rating acuity developed by Inter-Qual Inc., Marlborough, Mass. The records of 13,242 patients who were discharged over a 9-month period in 1995 after hospital care for 1 of 8 high-volume, high-variability diagnoses or procedures were randomly selected for review. Patients were categorized on the basis of the level of care (acute, subacute or nonacute) they required on admission and during subsequent days of hospital care. RESULTS: Of all admissions, 62.2% were acute, 19.7% subacute and 18.1% nonacute. The patients most likely to require acute care on admission were those with acute myocardial infarction (96.2% of 1826 patients) or cerebrovascular accident (84.0% of 1596 patients) and those admitted for elective surgery on the day of their procedure (73.4% of 3993 patients). However, 41.1% of patients awaiting hip or knee replacement were admitted the day before surgery so did not require acute care on admission. The proportion of patients who required acute care on admission and during the subsequent hospital stay declined with age; the proportion of patients needing nonacute care did not vary with age. After admission, acute care was needed on 27.5% of subsequent days, subacute care on 40.2% and nonacute care on 32.3%. The need for acute care on admission was a predictor of need for acute care during subsequent hospital stay among patients with medical conditions. The proportion of patients requiring subacute care during the subsequent hospital stay increased with age, decreased with the number of inpatient beds in each hospital and was highest among patients with congestive heart failure, chronic obstructive pulmonary disease and pneumonia. INTERPRETATION: In 1995, inpatients requiring subacute care accounted for a substantial proportion of nonacute care days in Ontario's general hospitals. These findings suggest a need to evaluate the efficiencies that might be achieved by introducing a subacute category of care into the Canadian health care system. Generally, efforts are needed to reduce the proportion of admissions for nonacute care and of in-hospital days for other than acute care.     

Rising incidence of renal cell cancer in the United States

CONTEXT: Clinical surveys have revealed that incidental detection of renal cell carcinoma is rising because of increased use of imaging procedures. OBJECTIVE: To examine incidence, mortality, and survival trends of renal cell and renal pelvis cancers by age, sex, race, and tumor stage at diagnosis. DESIGN: Calculation of age-adjusted incidence and mortality rates, along with 5-year relative survival rates, using data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. SETTING AND PARTICIPANTS: Patients diagnosed as having kidney cancer from 1975 through 1995 in the 9 geographic areas covered by tumor registries in the SEER program, which represent about 10% of the US population. MAIN OUTCOME MEASURES: Incidence, mortality, and 5-year relative survival rates by time periods. RESULTS: The age-adjusted incidence rates for renal cell carcinoma between 1975 and 1995 for white men, white women, black men, and black women were 9.6, 4.4, 11.1, and 4.9 per 100000 person-years, respectively. The corresponding rates for renal pelvis cancer were 1.5, 0.7, 0.8, and 0.5 per 100000 person-years. Renal cell cancer incidence rates increased steadily between 1975 and 1995, by 2.3% annually among white men, 3.1 % among white women, 3.9% among black men, and 4.3% among black women. Increases were greatest for localized tumors but were also seen for more advanced and unstaged tumors. In contrast, the incidence rates for renal pelvis cancer declined among white men and remained stable among white women and blacks. Although 5-year relative survival rates for patients with renal cell cancer improved among whites but not among blacks, kidney cancer mortality rates increased in all race and sex groups. CONCLUSIONS: Increasing detection of presymptomatic tumors by imaging procedures, such as ultrasonography, computed tomography, and magnetic resonance imaging, does not fully explain the upward incidence trends of renal cell carcinoma. Other factors may be contributing to the rapidly increasing incidence of renal cell cancer in the United States, particularly among blacks.     

Access and equity to cancer care in the USA: a review and assessment

Cancer represents a serious threat to the health of women and men living in the USA. As the second leading cause of death, it claims about 500,000 lives annually. Health disparities occur when there are differences in the incidence, prevalence, mortality, and burden of disease among specific sub-populations within a specified region. For decades, disparities have been reported among Americans from racial/ethnic minority groups and those from low income groups. African Americans, the largest racial minority group in the USA, have the highest cancer incidence and mortality rates in the USA; it is about 10% higher in African Americans than in white people. Inequities in insurance status among Americans adversely affect their ability to obtain the entire range of cancer care. Those who are members of ethnic minorities and the working poor are especially apt to have poorer access to care and reduced quality of cancer care services as a result.     

Variations in indicated care of patients with acute coronary syndromes in Queensland hospitals

OBJECTIVE: To identify variation in the rates of use of key evidence-based therapies and in clinical outcomes among patients hospitalised with acute coronary syndromes (ACS). DESIGN: Retrospective analysis of data on care processes and clinical outcomes of representative patient samples recorded by the Queensland Health Cardiac Collaborative registry. SETTING: 18 public hospitals (3 tertiary, 15 non-tertiary) in Queensland, August 2001 to December 2003. STUDY POPULATION: 2156 patients who died or were discharged after troponin-positive ACS. MAIN OUTCOME MEASURES: Comparison of proportions of highly eligible patients receiving indicated care and in-hospital mortality between subgroups categorised by age, sex, comorbidities (diabetes, renal failure, chronic obstructive pulmonary disease and mental disorder), type of admitting hospital (tertiary or non-tertiary), and cardiologist involvement (transfer or non-transfer to cardiology unit). RESULTS: Patients aged > or = 65 years were less likely than younger patients to receive heparin (79% v 87%), beta-blockers (79% v 87%), lipid-lowering agents (78% v 87%), coronary angiography (51% v 66%), and referral to cardiac rehabilitation (17% v 33%). Patients with diabetes were less likely than others to receive coronary angiography (50% v 63%), while those with moderate to severe renal failure were less likely to receive thrombolysis (52% v 84%), heparin (71% v 83%), beta-blockers (69% v 84%), lipid-lowering agents (61% v 84%), in-hospital cardiac counselling (46% v 64%) and referral to cardiac rehabilitation (9% v 25%). Patients admitted to tertiary hospitals were more likely than those admitted to non-tertiary hospitals to receive coronary angiography (85% v 55%) and referral to cardiac rehabilitation (36% v 21%). Risk-adjusted mortality was highest in patients with moderate to severe renal failure (15% v 3%) and older patients (6% v 2%). CONCLUSIONS: Variations exist in the provision of indicated care to patients with ACS according to age, diabetic status, renal function and type of admitting hospital. Excess mortality in elderly patients and in those with advanced renal disease may be partially attributable to failure to use key therapies.     

The incidence and cost of adverse events in Victorian hospitals 2003-04

OBJECTIVES: To determine the incidence of adverse events in patients admitted in the year 2003-04 to selected Victorian hospitals; to identify the main hospital-acquired diagnoses; and to estimate the cost of these complications to the Victorian and Australian health system. DESIGN: The patient-level costing dataset for major Victorian public hospitals, 1 July 2003-30 June 2004, was analysed for adverse events by identifying C-prefixed diagnosis codes denoting complications, preventable or otherwise, arising during the course of hospital treatment. The in-hospital cost of adverse events was estimated using linear regression modelling, adjusting for age and comorbidity. MAIN OUTCOME MEASURES: Cost of each patient admission ("admitted episode"), length of stay and mortality. RESULTS: During the designated timeframe, 979,834 admitted episodes were in the sample, of which 67,435 (6.88%) had at least one adverse event. Patients with adverse events stayed about 10 days longer and had over seven times the risk of in-hospital death than those without complications. After adjusting for age and comorbidity, the presence of an adverse event adds dollar 6826 to the cost of each admitted episode. The total cost of adverse events in this dataset in 2003-04 was dollar 460.311 million, representing 15.7% of the total expenditure on direct hospital costs, or an additional 18.6% of the total inpatient hospital budget. CONCLUSION: Adverse events are associated with significant costs. Administrative datasets are a cost-effective source of information that can be used for a range of clinical governance activities to prevent adverse events.     

Treatment and outcomes of community-acquired pneumonia at Canadian hospitals

BACKGROUND: Community-acquired pneumonia is a common disease with a large economic burden. We assessed clinical practices and outcomes among patients with community-acquired pneumonia admitted to Canadian hospitals. METHODS: A total of 20 hospitals (11 teaching and 9 community) participated. Data from the charts of adults admitted during November 1996, January 1997 and March 1997 were reviewed to determine length of stay (LOS), admission to an intensive care unit and 30-day in-hospital mortality. Multivariate analyses examined sources of variability in LOS. The type and duration of antibiotic therapy and the proportion of patients who were treated according to clinical practice guidelines were determined. RESULTS: A total of 858 eligible patients were identified; their mean age was 69.4 (standard deviation 17.7) years. The overall median LOS was 7.0 days (interquartile range [IQR] 4.0-11.0 days); the median LOS ranged from 5.0 to 9.0 days across hospitals (IQR 6.0-7.8 days). Only 22% of the variability in LOS could be explained by known factors (disease severity 12%; presence of chronic obstructive lung disease or bacterial cause for the pneumonia 2%; hospital site 7%). The overall 30-day mortality was 14.1% (95% confidence interval [CI] 11.8%-16.6%); 13.6% of the patients were admitted to an intensive care unit (95% CI 11.4%-16.1%). The median duration of intravenous antibiotic therapy was 5 days (range 3.0-6.5 days across hospitals). Although 79.8% of patients received treatment according to clinical practice guidelines, the rate of compliance with the guidelines ranged from 47.9% to 100% across hospitals. INTERPRETATION: Considerable heterogeneity exists in the management of community-acquired pneumonia at Canadian hospitals, the causes of which are poorly understood.     

Maternal mortality in women aged 35 years or older: United States

To examine maternal mortality among women aged 35 years or older, we used death certificates from the United States for 1974 through 1978. There were 425 maternal deaths, corresponding to a mortality rate of 58.3 deaths per 100,000 live births. This rate was higher than the rate for women 20 through 34 years of age (race-adjusted relative risk [RR] = 4.0; 95% confidence interval [CI], 3.6 to 4.4). The leading causes of death were obstetric hemorrhage and embolism. Black women had higher mortality rates than white women for deaths without abortive outcomes (RR = 3.3; CI, 2.7 to 4.1) and with abortive outcomes (RR = 9.4; 95% CI, 5.8 to 15.3), and the latter difference was largely due to a higher rate of deaths associated with ectopic pregnancy among black women. From 1974 through 1978, compared with 1982, maternal mortality rates for women aged 35 years or older reported by the National Center for Health Statistics declined approximately 50%. Among white women, changes in age and parity accounted for less than half of this decrease, suggesting that improvements have occurred in age- and parity-specific mortality for women aged 35 years or older.     

Racial and ethnic differences in outcome in zidovudine-treated patients with advanced HIV disease. Zidovudine Epidemiology Study Group

OBJECTIVES--To determine if racial-ethnic differences exist in survival, disease progression, and development of myelosuppression in zidovudine-treated patients with advanced human immunodeficiency virus (HIV) disease. DESIGN--Prospective observational study. SETTING.-Hospital and private clinics in 12 metropolitan centers. PATIENTS.-The study included 754 non-Hispanic white, 165 black, and 106 Hispanic patients with the acquired immunodeficiency syndrome (AIDS) or advanced AIDS-related complex (ARC) who received up to 2 years of zidovudine therapy. OUTCOME MEASURES--Survival, development of Pneumocystis carinii pneumonia (PCP), other opportunistic infections, and myelosuppression. RESULTS--At initiation of zidovudine therapy, Hispanic and particularly black patients had more advanced HIV disease than white patients, as indicated by lower baseline CD4+ counts, hematocrits, and AIDS-defining diagnoses. Black patients with AIDS also had a worse prognosis compared with white and Hispanic patients with AIDS. The product-limit survival rates at 2 years for white, black, and Hispanic patients with AIDS were 40%, 27%, and 39%, respectively (black vs white, P = .01; Hispanic vs white, P = .32, by the log-rank test). The respective proportions of patients who developed PCP at 2 years were 46%, 66%, and 44% (black vs white, P = .0001; Hispanic vs white, P = .86) and for other opportunistic infections the proportions were 56%, 63%, and 63%, respectively (black vs white, P = .03; Hispanic vs white, P = .09). There were no significant racial-ethnic differences in survival or in the development of opportunistic infections for patients with ARC, and there were no differences in the incidence of myelosuppression or dose reduction or suspension for patients with either ARC or AIDS. After adjusting for more advanced HIV disease (mainly low CD4+ counts and hematocrits), black race was no longer a significant independent predictor of survival. Adjustment for racial differences in the use of PCP prophylaxis accounted for most of the excess risk for the development of PCP in black patients compared with white patients with AIDS. CONCLUSIONS--Racial differences in survival and the development of opportunistic infections are mainly due to the more advanced HIV disease in black patients when zidovudine therapy is started and to their less frequent use of PCP prophylaxis. Innovative approaches are needed to ensure more widespread use of and earlier access to zidovudine therapy and PCP prophylaxis.     

Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery

CONTEXT: Morbidity and mortality rates in intensive care units (ICUs) vary widely among institutions, but whether ICU structure and care processes affect these outcomes is unknown. OBJECTIVE: To determine whether organizational characteristics of ICUs are related to clinical and economic outcomes for abdominal aortic surgery patients who typically receive care in an ICU. DESIGN: Observational study, with patient data collected retrospectively and ICU data collected prospectively. SETTING: All Maryland hospitals that performed abdominal aortic surgery from 1994 to 1996. PATIENTS AND PARTICIPANTS: We analyzed hospital discharge data for patients in non-federal acute care hospitals in Maryland who had a principal procedure code for abdominal aortic surgery from January 1994 through December 1996 (n = 2987). We obtained information about ICU organizational characteristics by surveying ICU medical directors at the 46 Maryland hospitals that performed abdominal aortic surgery. Thirty-nine (85%) of the ICU directors completed this survey. MAIN OUTCOME MEASURES: In-hospital mortality and hospital and ICU length of stay. RESULTS: For patients undergoing abdominal aortic surgery, in-hospital mortality varied among hospitals from 0% to 66%. In multivariate analysis adjusted for patient demographics, comorbid disease, severity of illness, hospital and surgeon volume, and hospital characteristics, not having daily rounds by an ICU physician was associated with a 3-fold increase in in-hospital mortality (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.9-4.9). Furthermore, not having daily rounds by an ICU physician was associated with an increased risk of cardiac arrest (OR, 2.9; 95% CI, 1.2-7.0), acute renal failure (OR, 2.2; 95% CI, 1.3-3.9), septicemia (OR, 1.8; 95% CI, 1.2-2.6), platelet transfusion (OR, 6.4; 95% CI, 3.2-12.4), and reintubation (OR, 2.0; 95% CI, 1.0-4.1). Not having daily rounds by an ICU physician, having an ICU nurse-patient ratio of less than 1:2, not having monthly review of morbidity and mortality, and extubating patients in the operating room were associated with increased resource use. CONCLUSIONS: Organizational characteristics of ICUs are related to differences among hospitals in outcomes of abdominal aortic surgery. Clinicians and hospital leaders should consider the potential impact of ICU organizational characteristics on outcomes of patients having high-risk operations.     

Racial inequalities in the use of procedures for patients with ischemic heart disease in Massachusetts

To examine interracial differences in the utilization of coronary angiography, coronary artery bypass grafting, and coronary angioplasty for white and black patients, we examined all admissions for circulatory diseases or chest pain to Massachusetts hospitals in 1985. After controlling for age, sex, payer, income, primary diagnoses, and the number of secondary diagnoses, whites underwent significantly more angiography and coronary artery bypass grafting procedures. Whites also underwent more angioplasty procedures, but the difference was not statistically significant. Although utilization differences may reflect patient preference or different levels of disease severity and socioeconomic status not adequately accounted for, this study suggests that substantial racial inequalities exist in the use of procedures for patients hospitalized with coronary heart disease.