Abstract
OBJECTIVE: To understand the role of race, ethnicity, and affluence in elderly patients’ use of teaching hospitals when they have that option.
METHODS: Using a novel data set of 787,587 Medicare patients newly diagnosed with serious illness in 1993, we look at how sociodemographic factors influence whether patients use a teaching hospital for their initial hospitalization for their disease. We use hierarchical linear models to take into account differences in the availability of teaching hospitals to different groups. These models look within groups of people who live in the same county and ask what demographic factors make an individual within that county more or less likely to use a teaching hospital.
RESULTS: We find that blacks are much more likely than whites to use teaching hospitals (odds ratio [OR], 1.75; 95% confidence interval [95% CI], 1.73 to 1.77). However, Hispanics and Asian-Americans are less likely to use teaching hospitals than are whites (Hispanic OR, 0.92; 95% CI, 0.88 to 0.97; Asian-American OR, 0.89; 95% CI, 0.82 to 0.97). Medicaid patients are less likely to use teaching hospitals (given their opportunities) than are non-Medicaid recipients (OR, 0.91; 95% CI, 0.90 to 0.92). And we find a curvilinear relationship with affluence, with those in the poorest and those in the wealthiest neighborhoods most likely to use a teaching hospital.
CONCLUSION: The use of teaching hospitals is more complex that heretofore appreciated. Understanding why some groups do not go to teaching hospitals could be important for the health of those groups and of teaching hospitals.
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References
Association of American Medical Colleges. Meeting the Needs of Communities: How Medical Schools and Teaching Hospitals Ensure Access to Clinical Services. Washington, DC: AAMC; 1998.
Ludmerer KM. Time to Heal: American Medical Education from the Turn of Century to the Era of Managed Care. New York: Oxford University Press; 1999.
Kilpatrick AO, Beasley LW. Urban public hospitals: evolution, challenges, and opportunities in an era of health reform. J Health Hum Serv Adm. 1995;18:143–62.
Retchin SM. Adverse selection at academic health centers. Clin Perform Qual Health Care. 1998;6:38–43.
Wyatt SM, Moy E, Levin RJ, et al. Patients transferred to academic medical centers and other hospitals. Acad Med. 1997;72:921–30.
Danko WD, Janakiramanan B, Stanley TJ. Characterizing hospital inpatients: the importance f demographics and attitudes. Hosp Health Serv Adm. 1988;33:361–70.
Wolinsky FD, Kurz RS. How the public chooses and views hospitals. Hosp Health Serv Adm. 1984;29:58–67.
Heischmidt KA, Heischmidt CE. Hospital choice criteria: an empirical evaluation of active hospital clients. J Hosp Mark. 1991;5:5–16.
Heischmidt KA, Hekmat F, Gordon P. A multivariate analysis of choice criteria for hospitals. J Hosp Mark. 1993;8:41–54.
Smith DB, Gooding SS, Hebb JH. The uninsured consumer and hospital choice: an assessment of emergency department utilization. J Ambul Care Mark. 1996;6:87–98.
Bryk AS, Raudenbush SW. Hierarchical Linear Models. Newbury Park, Calif: Sage; 1992.
Hatten J. Medicare’s common denominator: the covered population. Health Care Financ Rev. 1980;Fall:53–64.
Christakis NA, Iwashyna TJ, Zhang JX. Care after the onset of serious illness (COSI): a novel claims-based data set exploiting substantial cross-set linkages to study end-of-life care. J Palliat Med. 2002. In press.
McBean AM, Babish JD, Warren JL. Determination of lung cancer incidence in the elderly using Medicare claims data. Am J Epidemiol. 1993;137:226–34.
McBean AM, Warren JL, Babish JD. Measuring the incidence of cancer in elderly Americans using Medicare claims data. Cancer. 1994;73:2417–25.
Benesch C, Witter DM Jr., Wilder AL, Duncan PW, Samsa GP, Matchar DB. Inaccuracy of the International Classification of Disease (ICD-9-CM) in identifying the diagnosis of ischemic cerebrovascular disease. Neurology. 1997;49:660–4.
Krumholz HM, Radford MJ, Wang Y, Chen J, Heiat A, Marciniak TA. National use and effectiveness of the beta-blockers for treatment of elderly patients after acute myocardial infarction. JAMA. 1998;280:623–9.
Lauderdale DS, Furner SE, Miles TP, Golderberg J. Epidemiologic uses of Medicare data. Epidemiol Rev. 1993;15:319–27.
Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83.
Deyo RA, Cherkin DC, Diol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45:613–9.
Zhang JX, Iwashyna TJ, Christakis NA. The impact of alternative lookback periods and sources of information on Charlson comorbidity adjustment in Medicare clims. Med Care. 1999;37: 1128–39.
American Hospital Association. The Annual Survey of Hospitals Database Documentation for 1993 Data. Chicago: American Hospital Association; 1994.
Lauderdale DS, Goldberg J. The expanded racial and ethnic codes in the Medicare data files: their completeness of coverage and accuracy. Am J Public Health. 1996;86:712–6.
Arday SL, Arday DR, Monroe S, Zhang J. HCFA’s racial and ethnic data: current accuracy and recent improvements. Health Care Financ Rev. 2000;21:107–16.
Word DL, Perkins RC Jr, Building a Spanish Surname List for the 1990s—A New Approach to An Old Problem. Washington, DC: Population Division, U.S. Bureau of the Census; 1996.
Lauderdale DS, Kestenbaum B. Asian American ethnic identification by surname. Popul Res Policy Rev. 2000;19:283–300.
Escarce J, Epstein K, Colby D, Schwartz J. Racial differences in the elderly’s use of medical procedures and diagnostic tests. Am J Public Health. 1993;83:948–54.
Carpenter L. Evolution of Medicaid coverage of Medicare cost sharing. Health Care Financ Rev. 1998;20:11–8.
Liu K, Long SK, Aragon C. Does health status explain higher Medicare costs of Medicaid enrollees. Health Care Financ Rev. 1998;20:39–54.
Ettner SL. Inpatient psychiatric care of Medicare beneficiaries with state buy-in coverage. Health Care Financ Rev. 1998;20:55–69.
Parente ST, Evans WN. Effect of low-income elderly insurance copayment subsidies. Health Care Financ Rev. 1998;20:19–38.
Pope GC, Adamache KW, Walsh EG, Khandker RK. Evaluating alternative risk adjusters for Medicare. Health Care Finance Rev. 1998;20:109–29.
Khandker RK, McCormack LA. Medicare spending by beneficiaries with various type of supplemental insurance. Med Care Res Rev. 1999;56:137–55.
Clark WD, Hulbert MM. Research issues: dually eligible Medicare and Medicaid beneficiaries, challenges and opportunities. Health Care Financ Rev. 1998;20:1–10.
Hofer TP, Wolfe RA, Tedeschi PJ, MacMahon LF, Griffith JR. Use of community versus individual socioeconomic data in predicting variation in hospital use. Health Serv Res. 1998;33:243–59.
Krieger N. Overcoming the absence of socioeconomic data in medical records: validation and application of a census-based methodology. Am J Public Health. 1992;82:703–10.
Geronimus AT, Bound J, Neidert LJ. On the validity of using census geocode characteristics to proxy individual socioeconomic characteristics. JASA. 1996;91:529–37.
Geronimus AT, Bound J. Use of census-based aggregate variables to proxy for socioeconomic group: evidence from national samples. Am J Epidemiol. 1998;148:475–86.
Robinson WS. Ecological correlations and the behavior of individuals. Am Sociol Rev. 1950;15:351–7.
Wennberg JE, Cooper MM. The Dartmouth Atlas of Health Care. Chicago, Ill: American Hospital Publishing; 1998.
Phibbs CS, Robinson JC. A variable-radius measure of local hospital market structure. Health Serv Res. 1993;28:313–24.
Sohn M-W. From regional to local markets: network study of competition in California hospital markets. PhD Dissertation. Chicago, Ill: University of Chicago; 1996.
Succi MJ, Lee SY, Alexander JA. Effects of market position and competition on rural hospital closures. Health Serv Res. 1997;31:679–99.
Kerstein J, Pauly MV, Hillman A. Primary care physician turnover in HMOs. Health Serv Res. 1994;29:17–37.
Banaszak-Holl J, Zinn JS, Mor V. The impact of market and organizational characteristics on nursing care facility service innovation: a resource dependency perspective. Health Serv Res. 1996;31:97–117.
Halfon N, Newacheck PW, Wood DL, St Peter RF. Routine emergency department use for sick care by children in the United States. Pediatrics. 1996;98:28–34.
Hartley D, Moscovice I, Christianson J. Mobile technology in rural hospitals: the case of the CT scanner. Health Serv Res. 1996;31:213–34.
Lafata JE, Koch GG, Weissert WG. Estimating activity limitation in the noninstitutionalized population: a method for small areas. Am J Public Health. 1994;84:1813–7.
Lambrew JM, Ricketts TC. Patterns of obstetrical care in single-hospital, rural counties. Med Care. 1993;31:822–33.
Mullan F, Politzer RM, Davis CH. Medical migration and the physician workforce. International medical graduates and American medicine. JAMA. 1995;273:1521–7.
Murtaugh CM. Discharge planning in nursing homes. Health Serv Res. 1994;28:751–69.
Padgett DK, Patrick C, Burns BJ, Schlesinger HJ. Ethnic differences in use of inpatient mental health services by blacks, whites, and Hispanics in a national insured population. Health Serv Res. 1994;29:135–53.
Wholey DR, Christianson JB, Engberg J, Bryce C. HMO market structure and performance: 1985–1995. Health Aff. 1997;16:75–84.
Roetzheim RG, Pal N, Gonzalez EC, et al. The effects of physician supply on the early detection of colorectal cancer. J Fam Pract. 1999;48:850–8.
McLaughlin CG, Normolle DP, Wolfe RA, McMahon LF Jr, Griffith JR. Small-area variation in hospital discharge rates: do socioeconomic variables matter. Med Care. 1989;27:507–21.
Sandefur GD, Martin M, Eggerling-Boeck J, Mannon SE, Meier AM. An overview of racial and ethnic demographic trends. In: Smessler NJ, Wilson WJ, Mitchell F, eds. America Becoming: Racial Trends and Their Consequences. Washington, DC: National Academy Press; 2001:40–102.
Yaun Z, Cooper GS, Einstadter D, Cebul RD, Rimm AA. The association between hospital type and mortality and length of stay: a study of 16.9 million hospitalized Medicare beneficiaries. Med Care. 2000;38:231–45.
Taylor DH Jr., Whellan DJ, Sloan FA. Effects of admission to a teaching hospital on the cost and quality of care for Medicare beneficiaries. N Engl J Med. 1999;340:293–9.
Mayberry RM, Mili F, Ofili E. Racial and ethnic differences in access to medical care. Med Care Res Rev. 2000;57:108–45.
Kahn KL, Pearson ML, Harrison ER, et al. Health care for black and poor hospitalized Medicare patients. JAMA. 1994;271:1169–74.
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This work was supported by a grant from the National Institute on Aging (R-01 AG 15326-01) (NAC), and in part by a National Research Service Award from the NIH/National Institute on Aging (T32-AG00243) (TJI).
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Iwashyna, T.J., Curlin, F.A. & Christakis, N.A. Racial, ethnic, and affluence differences in elderly patients’ use of teaching hospitals. J GEN INTERN MED 17, 696–703 (2002). https://doi.org/10.1046/j.1525-1497.2002.01155.x
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DOI: https://doi.org/10.1046/j.1525-1497.2002.01155.x