Health Equity

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New Index Reveals Unequal Access to 40 Common Hospital Procedures

From Skin Grafts to Cesareans, a New Tool Measures Regional Availability of Surgeries to Help Decision Makers Track the Impact of Policies to Increase Equitable Access

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Living in a rural or urban area, high-income or low-income neighborhood, or politically red or blue state can affect health and access to care. Previously, LDI Senior Fellows Alon Bergman and Guy David demonstrated that people in areas with greater socioeconomic disadvantages have less access to newer, minimally invasive surgical procedures. 

Their new research supports this finding. It also presents a metric for health system leaders who determine procedures that hospitals offer, and agencies that regulate the procedures, to quantify and track how their decisions affect accessibility. “To address disparities in care,” Bergman said, “you have to be able to measure them.” 

To measure access inequalities, Bergman, David, LDI Senior Fellows Ashwin Nathan, Jay Giri, and colleagues created the Procedure Access Inequality (PAI) index. In its first-ever use, the researchers found wide variation in access for 40 common hospital procedures. “PAI is another index that should be on the dashboard of decision-makers, alongside metrics for financial, quality, and safety factors,” David said. “It’s a concrete way to measure equity, across procedures and over time.” 

Creating an Accessibility Index

Regional variations in disease occurrence can complicate access measurements. Medical procedures may be more common in an area simply because more residents have the condition it treats.

To quantify overall geographic inequalities in hospital procedures while accounting for these regional differences, the researchers created the PAI index using 2016-2019 inpatient procedure volume data, from 18 states, for more than 80,000 procedures, grouped into 356 categories. Patient zip code and demographic information allowed them to examine potential drivers of PAI differences. They also measured hospital market share to determine how the concentration of procedures among hospitals affected accessibility.

Scores Show Variable Access

Procedures with a high PAI score are not equally accessible across the United States. Applying the PAI index to the 40 inpatient procedures with the highest U.S. 2019 volume showed that about two-thirds of the procedures with higher PAI scores—indicating unequal access—were newer, minimally invasive methods. These included minimally invasive gastrectomy and pacemaker and defibrillator implants.

Generally, however, accessibility varied widely across treatment indication and specialty category, including plastic surgery, cardiology, and orthopedics. Inequitable access was strongly linked to procedures that were less common, offered in fewer hospitals, and performed in concentrated hospital markets. The results, David said, identify procedures that are most salient for policy actions to increase accessibility.

At the patient level, lower access was associated with younger age, fewer comorbidities, not having Medicare, and Hispanic ethnicity. Accessibility was also linked to travel distance to hospitals offering a procedure, a finding that supports interventions addressing transportation and other social barriers to health care.

The study, Measuring Hospital Inpatient Procedure Access Inequality in the United States, was published in Health Affairs Scholar on November 6, 2024. Authors include Alon Bergman, Guy David, Ashwin Nathan, Jay Giri, Michael Ryan, Soumya Chikermane, Christin Thompson, Seth Clancy, and Candace Gunnarsson.

Author

Chris Tachibana

Chris Tachibana, PhD, MS

Staff Writer

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