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Katherine L. Kahn, MD; Marjorie L. Pearson, PhD, MSHS; Ellen R. Harrison, MS; Katherine A. Desmond, MS; William H. Rogers, PhD; Lisa V. Rubenstein, MD, MSPH; Robert H. Brook, MD, ScD; Emmett B. Keeler, PhD

JAMA. 1994;271(15):1169-1174.

Abstract
Objective.
—To analyze whether elderly patients who are black or from poor neighborhoods receive worse hospital care than other patients, taking account of hospital effects and using validated measures of quality of care.

Design.
—We compare quality of care provided to insured, hospitalized Medicare patients who are black or live in poor neighborhoods as compared with others, using simple and multivariable comparisons of clinically detailed measures of sickness at admission, quality, and outcomes.

Setting.
—Two hundred ninety-seven acute care hospitals in 30 areas within five states.

Patients or Other Participants.
—The sample includes a nationally representative sample of 9932 patients 65 years of age or older who lived at home prior to hospitalization for congestive heart failure, acute myocardial infarction, pneumonia, or stroke.

Interventions.
—This was an observational study.

Main Outcome Measures.
—Processes of care, length of stay, instability at discharge, discharge destination, and mortality.

Results.
—Within rural, urban nonteaching, and urban teaching hospitals, patients who are black or from poor neighborhoods have worse processes of care and greater instability at discharge than other patients (P<.05). However, this worse quality is offset by patients who are black or from poor neighborhoods being 1.8 times more likely to receive care in urban teaching hospitals that have been shown to provide better quality of care (P<.001). Because these patients receive more of their care in better-quality hospitals, there are no overall differences in quality by race and poverty status. Death rates did not vary by race or poverty status.

Conclusions.
—Quality of hospital care for insured Medicare patients is influenced both by the patient's race and financial characteristics and by the hospital type in which the patient receives care.

(JAMA. 1994;271:1169-1174)

Author Affiliations
From the Health Program of RAND, Santa Monica, Calif (Drs Kahn, Pearson, Rogers, Rubenstein, Brook, Keeler, and Mss Harrison and Desmond); Department of Medicine, University of California—Los Angeles School of Medicine (Drs Kahn, Rubenstein, and Brook); Veterans Health Administration Medical Center, Sepulveda, Calif (Dr Rubenstein); and Department of Health Services, University of California—Los Angeles School of Medicine (Dr Brook).

Footnotes
The opinions, conclusions, and proposals in this article are those of the authors alone and do not necessarily represent the views of any of these organizations, RAND, University of California—Los Angeles School of Medicine, Veterans Affairs, the Health Care Financing Administration, and the Agency for Health Care Policy and Research.

Reprint requests to RAND, 1700 Main St, PO Box 2138, Santa Monica, CA 90407-2138 (Dr Kahn).

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