risk adjustment


In-hospital mortality is very high among patients hospitalized for aspiration pneumonia, especially among the elderly. Baine et al., using a 5% sample of Medicare claims, demonstrate that admissions caused by aspiration pneumonia have a case-fatality rate of 23.1%. They also demonstrate that in this population of patients over age 65 the rate of hospitalization for aspiration pneumonia is significantly higher for African Americans. While this evidence for racial disparities in hospitalization rates included adjustments for differences in age characteristics, no adjustments were made for differences in comorbid disease.

Racial and ethnic disparities in hospitalization and case-fatality rates have been reported in many disease groups. The evidence for these disparities comes primarily from studies using Medicare and other administrative data. According to a recent report by the Institute of Medicine, most of the evidence for racial and ethnic disparities lacks adequate statistical adjustments for the effects of comorbid disease and other baseline characteristics on the risk of hospital death. Comorbid diseases, because they can influence the risk of hospital death, are likely to confound the observed effects of race and ethnicity. To the extent that different racial and ethnic groups are unequally affected by comorbid disease, inadequate adjustment for the effects of comorbid disease undermines the validity of evidence for racial and ethnic disparities drawn from studies using administrative data. Moreover, adjustments for comorbid disease usually assume that those effects are the same for individuals of different race and ethnicity. This investigation was motivated by the possibility that both the frequency and effects of comorbid disease on mortality risk from aspiration pneumonia may vary in important ways by race and ethnicity.
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In this study, we examine the evidence for racial and ethnic disparities in hospital mortality among aspiration pneumonia discharges, using California hospital discharge data from 1996 through 1999.

The study was approved by the institutional review board at the University of Virginia Health System. California hospital discharge data identifies patient diagnoses that are present on admission, and we use these diagnoses to measure and control for differences in patient baseline health status. We divide these diagnoses into categories of comorbid disease and of conditions closely related to aspiration pneumonia, using a formal physician panel review process. California hospital discharge data classifies patient race using these six categories: white, African-American, Native American/Eskimo/Aleut, Asian/Pacific Islander, other, and unknown. Patient ethnicity is classified separately as either Hispanic, non-Hispanic, or unknown.
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