Hospitals to ask more than usual patient data

Hospitals would have to document in detail the race, ethnicity, and education of all patients under proposed state and Boston regulations, supplying information that has been surprisingly hard to collect but could be crucial to reducing inequalities in care and implementing portions of the state's groundbreaking insurance law.

A growing body of national research shows dramatic inequalities in the health status of broadly defined racial groups and in the medical care they receive. But regulators say the data gloss over the mixed ethnicity of many people and often are inconsistently gathered by hospital staffs. This makes it difficult to accurately analyze health disparities and target solutions to the right populations.

''The biggest issue for hospitals is the fear of asking someone," said Judy Parlato, clinical adviser at the Massachusetts Division of Health Care Finance and Policy, one of the agencies pushing for hospitals to collect more detailed data. ''They feel it's very personal to ask someone for this information."

Currently, most hospitals ask patients to classify themselves as white, black, Hispanic, Asian, American Indian, or other. This bare-bones information can mask important differences between ethnic groups.

For example, 72 percent of Asian women in Massachusetts have adequate prenatal care, according to a 2003 report from the Massachusetts Department of Public Health. But when researchers collected data by ethnic group -- which is not usually done -- they found that 80 percent of pregnant Japanese women got adequate care, compared with just 45 percent of Cambodian women. The race categories are particularly challenging for Hispanics, some of whom consider themselves black and others who consider themselves white, depending on where they were born.

A number of Boston and state agencies and hospitals have been working to reduce disparities in healthcare, including improving data collection. Mayor Thomas M. Menino, calling health disparities one of Boston's most serious medical problems, has pressed hospitals to help improve the health of minorities.

The Boston Public Health Commission began working on the issue with hospitals in 2003 as part of a mayor's task force on health disparities. The commission expects to approve regulations next month that would require the city's 10 acute care hospitals -- and eventually all Boston hospitals and community health centers -- to ask patients their race; whether they belong to one of 24 different ethnic groups such as Haitian, Korean, and Mexican; in what language they prefer to discuss medical issues; and the highest grade they completed in school. Answering the questions would be voluntary.

The regulations would require hospitals to report data quarterly, and to use it to identify and address inequalities in treatment. John Auerbach, the commission's executive director, said no other US city collects such detailed data on the ethnicity of patients.

The state Division of Health Care Finance and Policy has proposed similar rules for all Massachusetts hospitals to collect ethnicity data beginning Oct. 1 and will hold a public hearing on the issue on June 13.

These various efforts dovetail with the new insurance law, which will require all Massachusetts residents to have medical insurance by July 1, 2007. The law allows hospitals to earn millions of dollars in new Medicaid payments -- the exact amount to be determined later -- if they prove they are reducing disparities in the delivery of care for minorities. To measure the hospitals' progress, Medicaid and several advisory groups will have to develop specific measures, such as satisfaction rates among different ethnic groups or the availability of interpreters.

''There are things that, based on their country of origin or the color of their skin, that people are just not getting," said Representative Peter Koutoujian, a Newton Democrat and cochairman of the Legislature's commission on health disparities, which pressed for the disparities language in the new law. ''If we put good standards in place, and providers adhere to them, I think we'll see an immediate reduction in disparities."

Even before the city public health commission adopts its new rules, Boston Medical Center will begin asking all patients for their race and ethnicity today. The hospital redesigned its computer patient registration system, trained staff, and printed posters that explain to patients why the hospital is collecting the information. Lisa O'Connor, vice president for operational improvement, said the hospital provided its staff with written scripts to make them more comfortable asking the questions.

Still, there is reluctance to push patients too hard. For now, the hospital will not focus on collecting patients' education level, which the health commission has included in its regulations as a proxy for income.

Meanwhile, a number of hospitals have started comparing their treatment of patients of different races, based on the more general data that do exist. Nationally, researchers have documented dozens of inequalities. Blacks, for example, are less likely to be prescribed beta blockers, drugs to treat heart attacks, than are whites, and black and Hispanic patients are less likely to receive pain medication for broken bones in the emergency room.

Dr. JudyAnn Bigby, an internist at Brigham and Women's Hospital and medical director of community health programs, said that when she investigated using race data collected by the hospital for research five years ago, she found that the hospital had not documented the race of many patients. She also looked up herself, and found she was listed as black, although no one had ever asked her the question.

Brigham, along with other hospitals owned by Partners HealthCare System, decided to collect more detailed data and helped test the public health commission's new questionnaire on 8,000 patients at Brigham, Massachusetts General Hospital, and Brookside Community Health Center.

Brigham earlier this year asked Press Ganey Associates, which conducts patient satisfaction surveys for hospitals, to break down that information by race. While white patients gave the hospital a score of about 85 on a scale of 1 to 100 for all satisfaction measures combined, blacks rated the hospital at 81, and Asians at 77. Hispanics were slightly more satisfied than whites.

In one of its initial studies, Mass. General found that 65 percent of white patients at its health center in Chelsea got colonoscopies at the appropriate age, compared with 47 percent of Hispanic patients. Dr. Joseph Betancourt, director of Mass. General's Disparities Solutions Center, said the hospital wants to understand the underlying reasons, which will be far more complicated. Did doctors fail to recommend the cancer screening test for Hispanic patients? Or did Hispanic patients neglect to schedule and come for the test? Do they have a cultural bias against the test?

Hospitals are hopeful that when the state adopts requirements for doling out new Medicaid money, officials consider factors hospitals can control that contribute to disparities -- and those they cannot. Poverty and crowded housing contribute to health problems experienced by minorities, and even if doctors offer equal treatment, it may not be enough to overcome these other factors and improve overall health.

''We want to make sure we're not holding people accountable for things they can't address. We're not going to say we want you to eliminate poverty in Roxbury," said Senator Richard T. Moore, Democrat of Uxbridge and cochairman of the Joint Committee on Health Care Financing. ''But some things they do have control over. They have control over whether they have interpreters, and what treatment regimens they provide."