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BackgroundIn the US, disparities in surgical care impede the delivery of uniformly high-quality care to all patients. There is a lack of disparity-sensitive measures related to surgical care. The American College of Surgeons Metrics for Equitable Access and Care in Surgery group, through research and expert consensus, aimed to identify disparity-sensitive measures in surgical care.Study designAn environmental scan, systematic literature review, and subspecialty society surveys were conducted to identify potential disparity-sensitive surgical measures. A modified Delphi process was conducted where panelists rated measures on both importance and validity. In addition, a novel literature-based disparity-sensitive scoring process was used.ResultsWe identified 841 potential disparity-sensitive surgical measures. From these, our Delphi and literature-based approaches yielded a consensus list of 125 candidate disparity-sensitive measures. These measures were rated as both valid and important and were supported by the existing literature.ConclusionThere are profound disparities in surgical care within the US healthcare system. A multidisciplinary Delphi panel identified 125 potential disparity-sensitive surgical measures that could be used to track health disparities, evaluate the impact of focused interventions, and reduce healthcare inequity.

Medicare payments based on risk adjustment may be difficult to implement but should be more fair than the previous system. Risk adjustment means that the federal government will pay more money to a managed care plan to care for sicker patients than for healthy patients. The difficulty is how to measure risk. For hospital patients, the final diagnosis can be used to determine the payment. However, payments for outpatient care will require doctors to painstakingly record all aspects of the patient's condition. Nevertheless, risk adjustment is a laudable goal and should be implemented.

Changes in health insurance status of insurance policies were found to have a significant impact on health care access. Loss of health insurance coverage results in patients generally receiving poorer quality of health care. Patients who belong to this category delay seeking medical assistance, and post lower physician visits, and are less likely to purchase prescription drugs. Meanwhile, persons who change insurance plans tend to delay seeking medical help, even when they are ill.

Objectives. This study compared the relative effects on access to health care of relationship with a regular physician and insurance status. Methods. The subjects were 1952 nonretired, non-Medicare patients aged 18 to 64 years who presented with 1 of 6 chief complaints to 5academic hospital emergency departments in Boston and Cambridge, Mass, during a 1-month study period in 1995. Access to care was evaluated by 3 measures: delay in seeking care for the current complaint, no physician visit in the previous year, and no emergency department visit in the previous year. Results. After clinical and socioeconomic characteristics were controlled, lacking a regular physician was a stronger, more consistent predictor than insurance status of delay in seeking care (odds ratio [OR] = 1.6, 95% confidence interval [CI] = 1.2, 2.1), no physician visit (OR = 4.5, 9% CI = 3.3, 6.1), and no emergency department visit (OR = 1.8, 95% CI = 1.4, 2.4). For patients with a regular physician, access was no different between the uninsured and the privately insured. For privately insured patients, those with no regular physician had worse access than those with a regular physician. Conclusions. Among patients presenting to emergency departments, relationship with a regular physician is a stronger predictor than insurance status of access to care. (Am J Public Health. 1998;88:364-370)

The severity of disability rather than proof of negligence appears to predict whether a plaintiff will be awarded damages in a medical malpractice suit. This was demonstrated by researchers who followed 51 malpractice cases for a 10-year period. Of 24 cases that involved no adverse events, 10 were decided in favor of the plaintiff. Thirteen cases involved an adverse event but no negligence and 6 were decided in favor of the plaintiff. Five of 9 cases involving an adverse event due to negligence were decided in favor of the plaintiff. However, 7 out of 8 cases involving disability were decided in favor of the plaintiff.

Poor or medically uninsured patients may be more reluctant to sue for malpractice regardless of the presence or severity of medical injury. Researchers examined malpractice claims among approximately 31,000 hospital patients from 51 hospitals in New York State in 1984. They compared 51 patients with and without medical injuries who sued for malpractice to 255 patients who did not sue (control group). Fewer poor or insured patients sued for malpractice regardless of medical injury. Among the patients with medical injuries, elderly individuals were less likely to sue for malpractice. Fears of being sued should not influence a physician's decision to treat poor or elderly patients.

Patients may be more likely to receive substandard care at hospitals with fewer financial resources. Researchers examined the incidence of negligent medical injuries among 30,195 patients treated at 51 acute care hospitals in New York State during 1984. The hospitals with the lowest inpatient operating costs per patient had the highest incidence of medical injuries caused by negligence. Negligent medical injuries were more likely to occur at hospitals with fewer health care personnel to care for each patient. The effect of low inpatient operating costs was more pronounced at hospitals in financial crisis. These hospitals were more likely to treat indigent patients., Objective.--To assess the relationship among hospital financial characteristics, patient payer mix, and the incidence of negligent medical injuries. Design.--Retrospective medical record review linked to hospital financial reports. Setting.--Acute care hospitals in New York State in 1984. Population.--Stratified, random sample of 30 195 medical records from 51 acute care hospitals. Main Outcome Measures.--Hospital rates of medical injury and substandard care were developed from reviews of 30 195 medical records at 51 acute care hospitals in New York in 1984. Hospital-level variables representing financial status, hospital staffing, and the proportion of self-pay and Medicaid hospital discharges were compiled from a variety of secondary sources. Results.--The likelihood of negligent medical injury was highest in those hospitals with the lowest inpatient operating costs per hospital discharge (odds ration, 2.8; 95% confidence interval, 1.5 to 5.5). The effect of low inpatient operating costs was marked among hospitals in financial distress, many of which served indigent populations. Conclusions.--Patients admitted to hospitals that are unable to expend sufficient resources on patient care may be at higher risk of substandard care. Further study of the effect of hospital financial status on quality of care appears to be warranted. (JAMA. 1993;270:845-849)

Patients without health insurance may be more likely to suffer medical injuries caused by substandard medical care than those who are insured. A survey examined the medical records of 30,195 patients treated in 51 hospitals in New York state in 1984. Among the 1,278 medical injuries that occurred among these patients, 306 were caused by substandard medical care. Patients who were uninsured had a significantly higher risk of receiving substandard medical care than those who were insured. More medical injuries caused by negligence occurred among black patients and poor patients than among other patients. The risk of receiving substandard medical care was still not significantly higher for black patients or poor patients than for other patients. The characteristics of the different hospitals at which the patients were treated did not determine the risk of receiving substandard medical care.

Policy makers and stakeholders have reached a consensus that both quality and spending or resource use indicators should be jointly measured and prioritized to meet the objectives of our health system. However, the relative merits of alternative approaches that combine quality and spending indicators are not well understood. We conducted a literature review to identify different approaches that combine indicators of quality and spending measures to profile provider efficiency in the context of specific applications in health care. Our investigation identified seven alternative models that are either in use or have been proposed to evaluate provider efficiency. We then used publicly available data to profile hospitals using these approaches. Profiles of hospital efficiency using alternative models yielded wide variation in performance, underscoring the importance of model selection. By identifying the current efficiency models and evaluating their trade-offs within specific programmatic contexts, our analysis informs stakeholder and policy maker decisions about how to link quality and spending indicators when measuring efficiency in health care. [ABSTRACT FROM AUTHOR]