July 26, 2021 – Black patients have a higher rate of adverse safety events than white patients when admitted to the same hospital, regardless of the type of insurance or the percentage of patients treated in the hospital who are black, according to a new study by the Urban Institute.
The study, funded by the Robert Wood Johnson Foundation, is one of several analyzes that have shown that there are racial differences in patient safety in hospitals. However, according to study author Anuj Gangopadhyaya, a senior research fellow at the Urban Institute, it is the first paper to show that this finding is true within the same hospital.
Gangopadhyaya looked at 2017 hospital discharge data from 26 states. The database included 2,347 hospitals, but facilities with too few black or white patient discharges at risk for patient safety indicators were excluded. Eighty percent of black admissions and 44 percent of white admissions were in just 348 hospitals.
For the study, the author used software developed by the US Agency for Research and Quality in Health Care (AHRQ) to identify avoidable adverse safety events in patients, with a focus on 11 patient safety indicators. Four of these were general safety measures, such as pressure ulcer rates and central venous catheter-related bloodstream infection rates. The other seven measures related to surgical interventions such as: B. the infection rates of sepsis after surgery.
For six of the eleven safety indicators, including four of the seven surgical interventions, black adults had a significantly higher rate of patient safety adverse events than white adults in the same age group, sex, and hospital treatment. White patients received worse care for two indicators. For the other three measures, the quality of care for black and white patients was similar.
The differences in patient safety events between white and black patients within the same hospital were particularly large for surgical indicators. The race difference was 20% for the perioperative bleeding or hematoma rate, 18% for the postoperative respiratory failure rate, 30% for the perioperative pulmonary embolism or deep vein thrombosis rate, and 27% for the postoperative sepsis rate.
In the same hospital, black patients also had higher rates of adverse safety events than white patients suffering from pressure ulcers and central line infections.
Insurance effect
Non-elderly black patients may be more likely to have Medicaid insurance or not and are less likely than white patients to have private insurance, according to the study. Previous research has shown that differences in types of insurance may be related to racial differences in financial incentives for hospital care services and that these may cause differences in the quality of care within the hospital.
The Urban Institute study found that adjustments to patient care types in hospitals “diluted” or weakened results, but did not change the overall trend. For example, it has been estimated that black patients have a 27% higher risk of postoperative respiratory failure than white patients treated in the same hospital. Adjusting by type of insurance reduced this difference to 14%, which is still a significant gap.
The study also looked at the intra-hospital differences in safety indicators among Medicare patients, who were the largest type of insurance among hospitalized patients. The differences in patient safety between black and white patients were slightly greater for Medicare participants than for anyone in the same hospital.
“Differences in insurance coverage between black and white patients are not a major factor that causes the differences in patient safety adverse events between black and white patients within the same hospital,” the study concluded.
Finally, the study looked at racial differences in patient safety in hospitals that cared for a larger proportion of black patients and in hospitals that had greater financial resources.
Hospitals in which more than 25% of the hospitalized patients were black were compared with the other hospitals in the sample. Despite some differences in the individual safety indicators, “the proportion of black patients who are cared for by a hospital is largely independent of the differences in quality that black and white patients are cared for within a hospital,” says the study.
Similarly, the amount of resources a hospital has – as measured by the percentage of privately insured patients – did not seem to affect the differences between patient safety indicators for black and white patients, the study found.
Reasons for security differences
Systemic racism plays a role in the differences between black and white patients on safety indicators, Shannon Welch, senior director of the Institute for Healthcare Improvement (IHI), told WebMD. But when people of different races are treated unequally by the same team of doctors and nurses in the same hospital, hospitals need to dig deeper into their data to find out how to provide the same quality of care to all.
One healthcare system found that black patients took longer to receive tPA treatment for suspected stroke than white patients. This was a very important finding as tPA can protect stroke patients from further brain damage. The system analyzed its process data and improved the process for everyone so that the difference between treating patients of different races disappeared.
The question that remains, however, is why there are these differences. One possible reason is that most doctors are white, so often black patients are not treated by a doctor of their own race.
“We know that the doctor-patient relationship is very important,” says Welch. “It has to be based on trust and understanding and there has to be clear communication. And what happens when a patient comes to a doctor who looks like them, who has the same cultural experience and background, is something to say. It helps to create a safe space. “
Some doctors might also be biased towards people of other races, whether they know it or not, she says.
“The reality is that we are all prejudiced because we are swimming in the water of our environment. The things we’ve been taught, the things we’ve heard, the things we’ve learned through observing others, shape the lens through which we see the world. And we know that there were false narratives in medical education: For example, that the nerve endings in blacks are different so that blacks have a greater pain tolerance. “
These false narratives, stemming from an earlier era, assume that there are biological differences between races – a theory that even persists in some clinical guidelines to this day.
“The false assumption that there are biological differences between the races has been baked into the practice of doctors,” says Welch.
Unequal maternal outcomes
Welch conducted extensive research on inequality in maternal outcomes for IHI.
“For example, if you look at maternal mortality rates, black women are more likely to die of pregnancy complications than white women, even if we control educational status, income levels and type of insurance – all of the things we expect would be protective factors. In this case, they are not.
“What I have learned from my work in improving maternal health is the need for respectful care. Even when black patients come to us, doctors should listen to their questions and concerns, and black patients should believe when they tell you they are Are in pain or have a specific problem. “
Since 2017, the IHI has been running an initiative to treat patient safety equally, which now includes 22 health systems, she says, and is pleased that the Urban Institute study has focused on these issues.
“This study shows that without equity we cannot achieve quality and safety in patient care,” says Welch.
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Urban Institute: “Do black and white patients experience similar rates of adverse safety events in the same hospital?”
Shannon Welch, Senior Director, Institute for Healthcare Improvement.
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