BRIEF REPORT Is There an Association Between Quality of In-Hospital Cardiac Care and Proportion of Low-Income Patients? Steven D. Culler, PhD,* Linda Schieb, MSPH,† Michele Casper, PhD,† Isaac Nwaise, MA,† and Paula W. Yoon, ScD, MPH† Background: Process measures have been developed and imple- mented to evaluate the quality of care patients receive in the hospital. This study examines whether there is an association be- tween the quality of in-hospital cardiac care and a hospital’s pro- portion of low-income patients. Methods and Results: A retrospective analysis of 1979 hospitals submitting information on 12 quality of care (QoC) process mea- sures for acute myocardial infarction (AMI) and congestive heart failure (CHF) patients to the Hospital Quality Alliance during 2005 and 2006 and meeting all study inclusion criteria. Mean hospital performance ranged from 84.2% (ACE inhibitor for left ventricular systolic dysfunction) to 95.9% (aspirin on arrival) for AMI QoC process measures and from 64.4% (discharge instructions) to 92.4% (left ventricular function assessment) for CHF QoC process mea- sures. Regression analyses indicated a statistically significant nega- tive association between the proportion of low-income patients and hospital performance for 10 of the 12 cardiac QoC process mea- sures, after controlling for selected hospital characteristics. Conclusions: Hospital adherence to QoC process measures for AMI and CHF patients declined as the proportion of low-income patients increased. Future research is needed to examine the role of commu- nity characteristics and market forces on the ability of hospitals with a disproportionate share of low-income patients to maintain the staffing, equipment, and policies necessary to provide the recom- mended standards of care for AMI and CHF patients. Key Words: heart failure, myocardial infarction, quality indicators, hospitals (Med Care 2010;48: 273–278) T he 1999 Institute of Medicine report “To Err Is Human: Building a Safer Health System” asserted that medical errors in hospitals resulted in up to 98,000 deaths annually. 1 This report has led to a number of responses to improve health care safety. One effort, led by the Hospital Quality Alliance (HQA), in partnership with the Centers for Medicare and Medicaid Services (CMS), reports on compliance with quality of care (QoC) process measures for acute myocardial infarction (AMI) and congestive heart failure (CHF) patients, among others, treated at community hospitals. 2 In fact, CMS has implemented a pay-for-performance (P4P) incentive in the Medicare program based on adherence to selected HQA QoC process measures because these processes have the potential to improve the quality of care provided in US hospitals. 3,4 However, it is concerning that even with addi- tional disproportionate share payments, hospitals providing care to predominantly poor patients have had poorer (often negative) operating margins than hospitals with fewer low income patients. 5–8 In fact, several studies have found that hospitals treating larger proportions of poor patients and hospitals in rural areas have lower adherence to QoC process measures. 9 –14 This raises the question of whether a P4P approach would have the unintended impact of increasing health care disparities between hospitals because these hos- pitals may lack the financial ability to improve adherence to QoC process measures. The purpose of this study is to examine the relationship between a hospital’s proportion of low-income patients and the quality of in-hospital cardiac care, as measured by adher- ence to the 12 QoC measures for AMI and CHF collected by the HQA. METHODS We conducted a retrospective hospital-level study of the quality of care provided to AMI and CHF patients treated in US hospitals by pooling quality of care data for 2005 and 2006. The data analyzed in this study were obtained from several data sources and merged using the hospital’s unique Medicare provider number. First, we obtained information on the quality of care provided to AMI and CHF patients for the calendar years 2005 and 2006 from HQA. Second, we used information from the CMS Prospective Payment System Payment Impact File concerning the hospital’s disproportion- ate patient percentage and the hospital’s patient case-mix during fiscal years 2005 and 2006. Third, we used informa- From the *Department of Health Policy and Management Rollins School of Public Health, Emory University, Atlanta, GA; and †Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA. The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Reprints: Steven D. Culler, PhD, Department of Health Policy and Manage- ment, Rollins School of Public Health, Emory University, 1518 Clifton Road, NE, Atlanta, GA 30322. E-mail: sculler@sph.emory.edu. Copyright © 2010 by Lippincott Williams & Wilkins ISSN: 0025-7079/10/4803-0273 Medical Care • Volume 48, Number 3, March 2010 www.lww-medicalcare.com | 273