Luis R. Castellanos, MD, MPH

Luis R. Castellanos, MD, MPH

2006-2007

Director, Diversity in Medicine and Faculty Outreach, Cardiovascular Medicine Attending, Associate Clinical Professor of Medicine, UCSD School of Medicine - Division of Cardiology, San Diego, CA

Dr. Luis R. Castellanos graduated from Harvard School of Public Health with an M.P.H. in 2007 as a CFHU Fellow. During his fellowship year, he studied how to effectively utilize existing data collection instruments and datasets in order to identify, monitor, and develop strategies to eliminate racial and ethnic disparities in cardiovascular care, using the Massachusetts Cardiac Care Quality Reporting System in order to identify and monitor racial and ethnic disparities in cardiac bypass surgery. He has been involved in several independent research projects in Cardiovascular Medicine and has co-authored articles for the “Journal of Cardiac Failure” and the “American Journal of Cardiology.” His community service efforts include previous volunteer work with Doctors of the World, former Chair of MeSLA (Medical Students of Las Americas), and teacher/mentor at the Timilty Middle School, Roxbury, MA.

Dr. Castellanos received his medical degree from Harvard Medical School in 2003 and completed an Internal Medicine residency from the University of California, San Diego Medical Center in June 2006.

2011

2010

2009

2008

Monitoring Racial and Ethnic Disparities in Cardiovascular Procedures Using the Massachusetts Cardiac Care Quality Reporting System

Objectives:

The purpose of this study is to analyze the Massachusetts Cardiac Care Quality Reporting System on racial and ethnic disparities in cardiac care with respect to health care quality and access to care. This analysis will assess the feasibility and impact of implementing a statewide quality performance reporting system that documents and reports racial and ethnic quality outcomes for health systems and cardiac surgeons.

Background:

In order for state policy makers, agencies, and health providers to formulate interventions that improve quality of care and eliminate health disparities, there must be adequate data collection systems that include race and ethnicity as part of the measurement instrument.  In 2000, the Massachusetts State Legislature mandated the Massachusetts Department of Public Health to collect patient specific outcome data and evaluate hospital programs and cardiac surgeons for assurance of high health care quality standards. Although reported unadjusted 30-day mortality rates and Standardized 30-day Mortality Incidence Rates (SMIR) for isolated cardiac bypass surgeries for Massachusetts hospitals are similar to neighboring states, little is known on how the implementation of the Massachusetts Cardiac Care Quality Reporting System has affected racial and ethnic groups in need of cardiac care.

Methods:

Clinical data of patients who underwent isolated cardiac bypass surgery in Massachusetts between January 1, 2002 and December 31, 2004 were collected, verified, and adjudicated by the Massachusetts Data Analysis Center (Mass-DAC). Cardiac surgeons were identified and those with fewer than 10 isolated CABG surgeries across the three year period were excluded from all analysis and reporting. A total of 56 surgeons performed 12,973 CABG surgeries during the specified time period. A surgeon’s SMIR was used to define quality performance.  High quality performing surgeons were those with the lowest SMIR, while low quality surgeons had the highest SMIR.  Four provider performance groups were created: top decile, top quartile, bottom quartile and bottom decile. Each quality performance group was stratified by race and ethnicity and proportions were calculated to determine if minority patients were disproportionately treated by surgeons in the top or bottom deciles or quartiles of quality performance. Odds ratios (OR) were calculated and statistical significance was determined by constructing the respective 95 percent confidence interval.

Results:

White patients comprised the majority CABG surgeries with 11,800 (91%), Hispanics had 413 (3.18%) and African Americans experienced 251 (1.93%). Surgeons’ mean SMIR for subgroups were very close to the state average 2.23%.

Compared with Whites, Hispanic patients were 49% less likely to be treated by surgeons in the highest quality performance group, OR 0.51, 95% CI (0.35-0.75). In addition, Hispanics were the only subgroup that was more likely to be operated by surgeons in the lowest quality performance group, OR 1.65, 95% CI (1.24-2.19).

Compared with Whites, there was no statistical difference in the proportion of African American patients that were treated by surgeons in high or low quality performance groups.

Hispanics were almost three times more likely to be treated by surgeons in the bottom decile when compared to the top decile group, OR 2.85, 95% CI (1.82-4.47), p-value <0.0001. There were a higher proportion of African American patients in the top decile group when compared to the bottom decile, but this difference was not statistically significant.

Conclusions:

Hispanic patients may be less likely to be treated by high quality surgeons and more likely to be operated by surgeons with lower quality performance rates.

Similar to White patients, African Americans were fairly equally treated by surgeons in high and low quality groups.

Further adjustment using variables such as socioeconomic status, insurance coverage, and level of English proficiency, may help elucidate the underlying etiology for the observed differences in access to high quality cardiac surgeons between Whites, African Americans and Hispanic patients.

On an annual basis, without publication bias or concern for non-standardized methodologies, clinical data provided by Massachusetts hospitals and processed by Mass-DAC may be used by advocacy groups to inform policy makers, health agencies, and consumers about the quality of cardiac surgery that is provided to racial and ethnic groups.

Faculty Preceptors:

John Z. Ayanian MD, MPP
Harvard Medical School, Department of Health Care Policy