Information superhighway or billboards by the roadside? An analysis of hospital web sites.

OBJECTIVES: To determine the prevalence of hospital web sites, the types of information provided within these sites, and the relationship of information to institutional characteristics. DESIGN: Online search of hospital web sites over a 6-week period in late 1999. Web sites were abstracted for content. Bivariate comparisons were made of hospital profit status and ownership or operation by a multihospital network. PARTICIPANTS: California acute care hospitals and their web sites. MAIN OUTCOME MEASURES: Operation of web sites and web site content. RESULTS: Among 390 California hospitals, 242 (62%) had easily identifiable web sites, 59 (15%) had no web sites, and 89 (23%) had sites identified only after telephone follow-up. Hospitals without sites were more likely not-for-profit, small, rural, or unaffiliated. The presentation of information was inconsistent, although most (93%) provided basic contact information. Many hospitals provided health content information (70%) or mentioned health classes (65%), but few guaranteed the quality of this information. Patient care features (online health profiles, risk identification, e-mail) were infrequent (13%) and rudimentary. Product advertising was frequent (54%) but was often nonhealth-related and unobtrusive. Of the 36% of hospitals that reported information on quality, few of the designated measures were valid and reliable measures of quality. Overall, 21% of hospitals reported accreditation (Joint Commission on Accreditation of Healthcare Organizations) status, and for-profit hospital web sites were more likely to report this accreditation. CONCLUSION: [corrected] Consumers should be aware of current limitations in using information on hospital web sites. In the future, hospitals may better realize the potential of web sites for the delivery of health care information and patient care.

The effect of hospital experience on mortality among patients hospitalized with acquired immunodeficiency syndrome in California.

BACKGROUND: Several studies in the 1980s suggested that mortality rates for patients hospitalized with the acquired immunodeficiency syndrome (AIDS) were lower in hospitals that cared for greater numbers of AIDS patients. We sought to determine whether this observation persisted in the mid-1990s in California. SUBJECTS AND METHODS: We performed an analysis of hospital discharge data for 7,901 adults discharged with human immunodeficiency virus (HIV) or AIDS-related diagnoses from all acute care hospitals (n = 333) in California during 1994. The main outcome measure was in-hospital mortality, adjusted for severity of illness, comorbidity, prior hospitalizations, and other patient and hospital characteristics. RESULTS: Among 7,901 persons hospitalized with AIDS, the unadjusted inpatient mortality was 9.0%. The adjusted mortality rate varied significantly (P <0.0001) from 12.4% among institutions with the lowest quartile of AIDS experience to 10.3%, 6.3%, and 7.6% by quartile of greater AIDS experience. Increasing severity of illness, comorbidity, and previous hospitalizations were also significant predictors of increased mortality. Sex, race, and insurance status were not associated with hospital mortality. CONCLUSIONS: Hospital mortality for AIDS patients was greater among less experienced hospitals. The difference in mortality rate was equivalent to more than four additional deaths per 100 patients with AIDS admitted to the least experienced hospitals. This finding was not explained by severity of illness, comorbidity, or other case-mix variables.

Underuse and overuse of diagnostic testing for coronary artery disease in patients presenting with new-onset chest pain.

PURPOSE: To determine the extent of overuse and underuse of diagnostic testing for coronary artery disease and whether the socioeconomic status, health insurance, gender, and race/ethnicity of a patient influences the use of diagnostic tests. SUBJECTS AND METHODS: We identified patients who presented with new-onset chest pain not due to myocardial infarction at one of five Los Angeles-area hospital emergency departments between October 1994 and April 1996. Explicit criteria for diagnostic testing were developed using the RAND/University of California, Los Angeles, expert panel method. They were applied to data collected by medical record review and patient questionnaire. RESULTS: Of the 356 patients, 181 met necessity criteria for diagnostic cardiac testing. Of these, 40 (22%) failed to receive necessary tests. Only 7 (3%) of the 215 patients who received some form of cardiac testing had tests that were judged to be inappropriate. Underuse was significantly more common in patients with only a high school education (30% vs 15% for those with some college, P = 0.02) and those without health insurance (34% vs 15% of insured patients, P = 0.01). In a multivariate logistic regression model, only the lack of a post-high school education was a significant predictor of underuse (odds ratio 2.2, 95% confidence interval 1.0 to 4.4). CONCLUSION: Among patients with new-onset chest pain, underuse of diagnostic testing for coronary artery disease was much more common than overuse. Underuse was primarily associated with lower levels of patient education.

The entry of African-American students into US medical schools: an evaluation of recent trends.

A need to reassess US medical schools' admission of African-American students exists based on recent challenges to affirmative action. The Association of American Medical Colleges (AMMC) provided US medical school enrollment data and characteristics. Measures of enrollment were constructed for each medical school and aggregated by ownership type and state. After peaking at 1311 students in 1994, African-American medical school matriculation decreased by 8.7% by 1996. This decline was disproportionately generated by public medical schools. However, it was not limited to institutions that are located in states where anti-affirmative action policies have been implemented. Several schools were consistently successful (e.g., UCLA, Case Western, and Robert Wood Johnson) or unsuccessful (e.g., Texas Tech and Texas A&M) in enrolling African-American students. Recent gains in the enrollment of African-American students are being reversed, particularly at public institutions. Implications exist, particularly for the health of poor and underserved communities that are more likely to be cared for by such students during their careers as physicians.

The entry of underrepresented minority students into US medical schools: an evaluation of recent trends.

OBJECTIVES: Recent challenges to affirmative action suggest the need to reassess the status of the admission of underrepresented minority students to US medical schools. METHODS: The Association of American medical colleges provided US medical school enrollment data and characteristics. Five measures of underrepresented minority enrolled and an overall performance scale were constructed for each school. Multivariate regression identified significant overall performance predictors. Predicted and observed values were compared. RESULTS: Underrepresented minority enrollment increased by 43% after 1986, peaked at 2014 in 1994, did not increase in 1995, and decreased by 5% in 1996. Enrollment was associated with increasing federal research funding and with percentage of underrepresented minorities in the sources population P < .001). The 1996 decline was almost entirely limited to public medical schools. Those in California, Texas, Mississippi, and Louisiana accounted for 18% of 1995 enrollment but 44% of the 1996 decline. CONCLUSIONS: Recent gains in medical school enrollment of underrepresented minorities are being reversed, particularly at public institutions. Implications exist for the health of poor, minority, and underserved communities, which are most likely to be cared for by underrepresented minority physicians.

Differences in the effect of patients' socioeconomic status on the use of invasive cardiovascular procedures across health insurance categories.

OBJECTIVES: This study evaluated the effect of patients' socioeconomic status on use of coronary angiography, bypass grafting, and angioplasty across health insurance categories. METHODS: Multiple logistic regression was used to compute the odds of receiving each procedure among 206 233 ischemic heart disease patients residing in urban California zip codes from 1991 through 1993. RESULTS: Residents of high socioeconomic status areas were more likely (odds ratios [ORs] = 1.20-1.41) and residents of low socioeconomic status areas were less likely (ORs = 0.79-0.84) than residents of middle socioeconomic status areas to undergo each procedure. These effects were common among Medicare and health maintenance organization patients and uncommon for privately insured and uninsured patients. CONCLUSIONS: The effect of socioeconomic status varies across health insurance categories.

Influence of payor on use of invasive cardiac procedures and patient outcome after myocardial infarction in the United States. Participants in the National Registry of Myocardial Infarction.

OBJECTIVES: We sought to determine the influence of payor status on the use and appropriateness of cardiac procedures. BACKGROUND: The use of invasive procedures affects the cost of cardiovascular care and may be influenced by payor status. METHODS: We compared treatment and outcomes of myocardial infarction among four payor groups: fee for service (FFS), health maintenance organization (HMO), Medicaid and uninsured. Multivariate comparison was performed on the use of invasive cardiac procedures, length of hospital stay and in-hospital mortality in 17,600 patients <65 years old enrolled in the National Registry of Myocardial Infarction from June 1994 to October 1995. To determine the appropriateness of coronary angiography, we compared its use in patients at low and high risk for cardiac events. RESULTS: Angiography was performed in 86% of FFS, 80% of HMO, 61% of Medicaid and 75% of uninsured patients. FFS patients were more likely to undergo angiography than HMO (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.13 to 1.42), Medicaid (OR 2.43, 95% CI 2.11 to 2.81) and uninsured patients (OR 1.99, 95% CI 1.76 to 2.25). Similar patterns for the use of coronary revascularization were found. Among those at low risk, FFS patients were as likely to undergo angiography as HMO patients but more likely than Medicaid and uninsured patients. For those at high risk, FFS patients were more likely to undergo angiography than patients in other payor groups. Adjusted mean length of stay (7.3 days) was similar among all payor groups, but adjusted mortality was higher in the Medicaid group (Medicaid vs. FFS: OR 1.55, 95% CI 1.19 to 2.01). CONCLUSIONS: Payor status is associated with the use and appropriateness of invasive cardiac procedures but not length of hospital stay after myocardial infarction. The higher in-hospital mortality in the Medicaid cohort merits further study.

Adverse asthma outcomes among children hospitalized with asthma in California.

OBJECTIVE: To use administrative data to determine whether adverse asthma outcomes for pediatric asthma hospitalizations are related to specific clinical and nonclinical patient characteristics. DESIGN: Cross-sectional study. SETTING: All pediatric (0 to 17 years of age) asthma-related hospital discharges, 1986 to 1993, in California. PATIENTS: A total of 113 974 eligible patients with asthma-related discharges. MAIN OUTCOME MEASURE: Adverse asthma outcomes (intubation, cardiopulmonary arrest, and death). RESULTS: Adverse asthma outcomes occurred in 0.48% of subjects. The frequency of adverse asthma outcomes increased during the 1990s compared with 1986. After controlling for differences in gender, age, specific comorbid conditions, year, race, and insurance type, adverse asthma outcomes were more likely to occur in the 5- to 11-year-old group (odds ratio [OR]: 1.39; 95% confidence interval [CI]: 1.13-1.69) and in the 12- to 17-year-old group (OR: 4.48; CI: 3.20-6.21) compared with those children in the 0 to 4-year-old age group. Asian Pacific-American children were more likely (OR: 1.59; CI: 1.24-2.59) than were white children to experience an adverse asthma outcome. Children who had a secondary diagnoses of pneumonia (OR: 1.54; CI: 1. 19-2.00) also were more likely to experience an adverse asthma outcome. The odds of an adverse outcome increased progressively after 1986, becoming significant after 1989. Gender and insurance type were not associated with increased odds of experiencing an adverse asthma outcome. CONCLUSIONS: Adverse asthma outcomes among hospitalized children are increasing in the 1990s and are associated with specific clinical and nonclinical patient characteristics.

Racial and ethnic disparities in the use of cardiovascular procedures: associations with type of health insurance.

OBJECTIVES: This study examined whether disparities in the use of cardiovascular procedures exist among African Americans, Latinos, and Asians relative to White patients, within health insurance categories. METHODS: Hospital discharge records (n = 104,952) of Los Angeles Country, California, residents with possible coronary artery disease were analyzed. RESULTS: After adjustment for confounders, lower odds of procedure use were found for African American and Latino patients for most types of insurance. Asians and Pacific Islanders had odds of procedure use similar to those of White patients. Disparities were absent among the privately insured. CONCLUSIONS: Racial and ethnic disparities in procedure rates were evident in all types of insurance except private insurance.

The effect of race and ethnicity on the use of selected health care procedures: a comparison of south central Los Angeles and the remainder of Los Angeles county.

The purpose of this study was to compare the use of eight hospital-based procedures (appendectomy, cesarean section, coronary artery angioplasty (PTCA), coronary artery bypass grafting (CABG), carotid endarterectomy, hysterectomy, mastectomy, and transurethral prostate resection) in South Central Los Angeles (SCLA) to the remainder of Los Angeles County. The authors used age- and gender-adjusted procedure rates and population-weighted multivariate regression techniques, adjusting for illness proxies, physician distribution, hospital distance, income, and ethnicity variation to quantitate the effect of SCLA residence. Four procedures were performed at significantly lower rates among residents of SCLA: PTCA, CABG, carotid endarterectomy, and cesarean section. In multivariate regression models, SCLA was also a significant predictor for appendectomy, mastectomy, and transurethral prostatectomy (TURP). The SCLA effect was diminished but not eliminated when ethnicity variables were incorporated into regression models. The use of selected procedures by residents of SCLA frequently differs from that of residents of the remainder of Los Angeles Country. Some differences are not attributable to level of health, income, ethnicity, or the availability of medical resources.

Geographic variation in rates of selected surgical procedures within Los Angeles County.

OBJECTIVE: We explore the contribution of income and ethnicity to geographic variation in utilization of surgical procedures. DATA SOURCES/STUDY SETTING: We assessed the use of eight procedures from 1986 through 1988 among residents of Los Angeles County using data from the California Discharge Dataset, the 1980 census, and other secondary sources. Procedures chosen for evaluation were coronary artery bypass grafting (CABG), coronary artery angioplasty, permanent pacemaker insertion, mastectomy, simple hysterectomy, transurethral prostate resection (TURP), carotid endarterectomy, and appendectomy. STUDY DESIGN: The amount of inter-zip code variation for each procedure was first measured using various estimates including the analysis of variance coefficient of variation (CVA). Population-weighted multivariate regression analysis was used to model variation in age- and gender-adjusted rates of procedure use among 236 residential zip codes. PRINCIPAL FINDINGS: Highest-variation procedures were coronary artery angioplasty (CVA = .392) and carotid endarterectomy (CVA = .374). The procedures with the lowest degree of variation were cardiac pacemaker implantation (CVA = .194) and hysterectomy (CVA = .195). Variation was significantly related to income (carotid endarterectomy) and either African American or Latino zip code ethnicity for all procedures except pacemaker implantation. For all procedures except appendectomy, the direction of the effect was toward fewer procedures with lower income. However, the effect of African American or Latino population ethnicity varied. CONCLUSIONS: In this large urban area both population ethnicity and socioeconomic status are significantly associated with the geographic utilization of selected surgical procedures.

Racial and ethnic differences in the use of invasive cardiac procedures among cardiac patients in Los Angeles County, 1986 through 1988.

OBJECTIVES: The purpose of the study was to compare use of invasive cardiovascular procedures among Latino, Asian, African-American, and White patients. METHODS: In a cross-sectional study of hospital discharge data, multiple logistic regression was used to model use of coronary artery angiography, bypass graft surgery, and angioplasty among adult Los Angeles County residents discharged from California hospitals between 1986 and 1988 with primary diagnoses consistent with possible ischemic heart disease. RESULTS: After potential demographic, socioeconomic, and clinical confounders, including hospital procedure volume, were controlled, Latinos were less likely than Whites to undergo angiography (odds ratio [OR] = 0.90) and bypass graft surgery (OR = 0.87). African Americans were less likely to receive bypass graft surgery (OR = 0.62) and angioplasty (OR = 0.80). Asians were as likely as Whites to receive each procedure. The impact of adjustment for hospital procedure volume was greater for Latinos and Asians than for African Americans. CONCLUSIONS: Administrative data suggest that disparities in use of invasive cardiovascular procedures are not limited to African Americans. Hospital procedure volume appears to be an important factor related to such disparities. The causes of racial/ethnic differences in reported procedure rates remain unclear.

Choosing quality of care measures based on the expected impact of improved care on health.

Consumers, payers, and policymakers are demanding to know more about the quality of the services they are purchasing or might purchase. The information provided, however, is often driven by data availability rather than by epidemiologic and clinical considerations. In this article, we present an approach for selecting topics for measuring technical quality of care, based on the expected impact on health of improved quality. This approach employs data or estimates on disease burden, efficacy of available treatments, and the current quality of care being provided. We use this model to select measures that could be used to measure the quality of care in health plans, but the proposed framework could also be used to select quality of care measures for other purposes or in other contexts (for example, to select measures for hospitals). Given the limited resources available for quality assessment and the policy consequences of better information on provider quality, priorities for assessment efforts should focus on those areas where better quality translates into improved health.

HMO vs fee-for-service care of older persons with acute myocardial infarction.

OBJECTIVES: Health maintenance organizations (HMOs) continue to grow in number and in their enrollment of Medicare recipients. They are also increasingly viewed as organizational structures that might contribute to control of health care costs. Yet little is known about the quality of care that elderly HMO enrollees receive. METHODS: We compared patients from three HMOs to a fee-for-service (FFS) sample that was national in scope. Sickness at admission, the quality of process of care, and mortality were assessed for patients aged 65 years and older who had been hospitalized with a diagnosis of acute myocardial infarction. RESULTS: After adjustment for sickness at admission, there were no significant mortality differences between the HMO and FFS groups at either 30 (23.2% vs 23.5%) or 180 days (34.4% vs 34.5%) after admission. Compliance with process criteria was higher for the HMO group as a whole (P < .05). The HMOs had greater compliance with three of five scales measuring different aspects of care for patients with acute myocardial infarction. CONCLUSIONS: We conclude that older patients from our participating HMOs who were hospitalized for acute myocardial infarction received hospital care that was generally better in terms of process than that received by patients in a national FFS sample.