A study published in the Archives of Internal Medicine this week principally authored by St. Thomas native Dr. Marcella Nunez-Smith finds the mortality rate for pneumonia, heart attack and heart failure are all substantially higher in the U.S. territories than stateside.
"The study was not about blame or pointing fingers," Nunez-Smith said Thursday, reached at her desk at Yale School of Medicine, where she is an assistant professor of medicine. "We want the territories to join the national conversation about hospital quality of care and racial/ethnic health care disparities," she said.
They looked at heart attack, heart failure and pneumonia admissions and mortalities because these are very common causes of admission and death, she said.
"The stunning finding for us, is that your risk of dying of these conditions is drastically higher in the territories, including the U.S. Virgin Islands, than on the mainland," said Nunez-Smith. "For every 100 patients admitted for these problems in the territories and stateside, you will have two more people who die of heart attacks in the territories; three more die from pneumonia and one more of heart failure. Those are really high numbers."
Rather than sampling data, Nunez-Smith and colleagues used Medicare and Medicaid reimbursement records detailing covered treatments and outcomes in 57 territorial hospitals and 4,799 stateside institutions, among other sources of data. The study examines data from 2005 through 2008 rather than a single year in order to get enough cases in each territory so the results are statistically meaningful, she said.
Because Puerto Rico has 90 percent of the population of all the territories, the study also compares Puerto Rico with all the other territories: Guam, American Samoa, the Northern Marianas and the U.S. Virgin Islands, and found hospitals in the smaller territories performed similarly to Puerto Rico. While V.I. data is not examined separately, the population numbers and health care conditions are similar in the smaller territories and nothing in the data suggests that outcomes are different in the U.S. Virgin Islands compared with other territories.
Nunez-Smith and the research team determined hospitals in the territories are smaller and have fewer specialists, but found that did not explain the divergent outcomes. The lower rates of Medicare and Medicaid reimbursement in the territories versus the states is one likely candidate, but there may be many layers to the problem, said Nunez-Smith.
Delegate Donna Christensen issued a statement Wednesday suggesting conditions have improved since 2008, the last year of data in the study.
“We now have a full service Cardiac Center and Cancer Center,” she said. “The University of the Virgin Islands now has a Center for Health Disparities Research, and through the stimulus legislation and the health care reform which was passed over the last two years, the territories now have increased Medicaid and other hard fought for inclusion in most health care reform programs,” she said.
Asked about that assessment, Nunez-Smith said years of data on hospitals across the U.S. suggest that changes in mortality rates occur slowly, over years and are unlikely to have changed dramatically in the time since the study period. At the same time, she strongly endorsed Christensen’s work to increase Medicare and other federal health care funding for the territory, and her work to publicize health disparities among minority populations.
Christensen praised aspects of the report, saying it clearly demonstrates the inequities in federal funding and how that has impacted poorer health and increased mortality in the territories. “It is strong justification that I can utilize for more funding in Washington,” Christensen said in her statement.
