Academic journal article Inquiry

Explaining Racial/ethnic Disparities in Use of High-Volume Hospitals: Decision-Making Complexity and Local Hospital Environments

Academic journal article Inquiry

Explaining Racial/ethnic Disparities in Use of High-Volume Hospitals: Decision-Making Complexity and Local Hospital Environments

Article excerpt


Racial/ethnic minorities are less likely to use higher-quality hospitals than whites. We propose that a higher level of information-related complexity in their local hospital environments compounds the effects of discrimination and more limited access to services, contributing to racial/ethnic disparities in hospital use. While minorities live closer than whites to high-volume hospitals, minorities also face greater choice complexity and live in neighborhoods with lower levels of medical experience. Our empirical results reveal that it is generally the overall context associated with proximity, choice complexity, and local experience, rather than differential sensitivity to these factors, that provides a partial explanation of the disparity gap in high-volume hospital use.


disparities, hospital choice, hospital volume and outcomes, behavioral economics


Racial/ethnic disparities in health status and medical utilization have become a focus of research (Institute of Medicine [IOM], 2003) and a concern for policy makers (Ladenheim and Groman 2006). While a portion of these disparities can be attributed to insurance coverage and broader socio-economic differences, even after accounting for these factors, there remain health care disparities (IOM 2003; Medical Care Research and Review [MCRR], 2000). Only about 20 to 25 percent of the nation's physicians and hospitals provide most medical care for minority patients (Bach et al. 2004; Jha et al. 2007; Jha et al. 2008), and a range of quality disparities are associated with these providers and facilities: broad quality measures are lower for the hospitals and nursing homes used by minorities (Gaskin et al. 2008; Hasnain-Wynia et al. 2007; Hasnam-Wyma et al. 2010; Jha et al. 2007; Jha et al. 2008; Smith et al. 2007); process measures for specific conditions indicate lower quality (Barnato et al. 2005; Bradley et al. 2004); and minority patients are less likely to receive new treatment technologies (Groeneveld, Laufer, and Garber 2005). Blacks receive care from hospitals and surgeons with higher mortality rates (Clarke, Davis, and Nailon 2007; Konety, Vaughan Sarrazin, and Rosenthal 2005; Lucas et al. 2006; Mukamel et al. 2007; Mukamel, Weimer, and Mushlin 2006; Rothenberg et al. 2004; Skinner et al. 2005), and minorities are less likely to use higher-volume hospitals and surgeons (Bach et al. 2001; Birkmeyer et al. 2002; Birkmeyer et al. 2003; Dardik et al. 2000; Epstein et al. 2010; Harmon et al. 1999; Scarborough et al. 2010). These differences persist even after controlling for a variety of other factors (Epstein et al. 2010; Gray et al. 2009; Liu et al. 2006; Losima et al. 2007; Neighbors et al. 2007; Trivedi, Sequist, and Ayanian 2006). Moreover, research results have revealed that a large portion of the disparities in quality of care for minorities appear to be associated with between-hospital differences rather than within-hospital differences, that is, racial/ethnic disparities in quality and outcomes are associated with the fact that minorities and whites are obtaining care at different hospitals rather than because they receive different levels of care within the same hospital (Barnato et al. 2005; Bradley et al. 2004; Breslin et al. 2009; Gaskin et al. 2008; Goldstein et al. 2009; Groeneveld et al. 2005; Hausmann et al. 2009; Joynt, Orav, and Jha 2011).

These findings highlight the need to better understand the factors that influence where patients receive care, but there has been relatively little study of the particular pathways that lead to these disparities. In this article, we examine several potentially influential factors, which shed new light on how patients use their local medical delivery systems. Our starting point is the decision-making complexity associated with hospital use and how patient and physician decisions are affected by several features of the local hospital environment, including what we will term proximity choice complexity and local medical experience. …

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