Inform Health Soc Care, 41:128–142, 2016

Copyright ©
© Taylor &
& Francis Group, LLC
ISSN: 1753-8157 print / 1753-8165 online
DOI: 10.3109/17538157.2014.965304

Differences in pneumonia treatment

between high-minority and low-minority
neighborhoods with clinical decision
support system implementation
Jordan Mitchell,1 Janice C. Probst,2 Kevin J. Bennett,3
Saundra Glover,4 Amy Brock Martin,5 and James W. Hardin6
1
Department of Healthcare Administration, University of Houston Clear Lake,
Houston, TX, USA,
2
Department of Health Services Policy and Management, University of South
Carolina, Columbia, SC, USA,
3
Department of Family and Preventive Medicine,
4
Institute for Partnerships to Eliminate Health Disparities,
5
Department of Stomatology, University of South Carolina, Columbia, SC, USA, and
6
Edwards College of Medicine, Medical University of South Carolina, Charleston,
SC, USA

Background: The relationship between clinical decision support systems (CDSS) and
quality is a relatively new, and in light of the new health information technology (HIT)
legislation, policy-relevant area. Moreover, very few studies exist examining the link
between HIT and healthcare disparities. The purpose of this article is to examine the
association between CDSS and the treatment of pneumonia care within high-minority
(29.1% non-White, non-Hispanic) and low-minority (529.1%) Zip Code Tabulation
Areas (ZCTAs). Research design: This study employed a cross-sectional design and used
2009 data from the American Hospital Association, the Centers for Medicare and
Medicaid Services and the Research Triangle Institute. Adjusted analysis controlled for
a hospital’s propensity to use CDSS. Results: In the unadjusted analysis, hospitals in
high-minority ZCTAs had lower pneumonia quality composite scores than their low-
minority counterparts. When adjusting for other hospital and ZCTA-level variables, we
found that CDSS use had stronger positive associations with quality in high-minority
hospitals. Conclusions: Results support policy directives may support higher quality
improvements by focusing CDSS adoption in high-minority hospitals.

Keywords Clinical decision support systems, disparities, quality, pneumonia

INTRODUCTION
In 2008, pneumonia, together with influenza, were the eighth leading causes of
death in the United States (1,2). Pneumonia is also the number one infectious
disease killer in the United States, with approximately 52 000 deaths or 2.2%
of total deaths (1,3). Associated clinical symptoms typically include fever,
cough, sputum production, pleurisy and dyspnea— caused by fluid in the lungs

Correspondence: Dr. Jordan Mitchell, PhD, Department of Healthcare Administration,

University of Houston Clear Lake, 2151 W. Holcombe Blvd., Houston 77204, SC, USA.
E-mail: mitchellj@uhcl.edu
 CDSS and minority neighborhood disparities 129

(3). The majority of patients with community-associated pneumonia (CAP) do

not require hospitalization and are treated as outpatients. The hospitalization
rate due to CAP is approximately 258 per 100 000 people and 962 per 100 000
people aged 65 years and older; mortality rates among persons hospitalized for
CAP range from 5 to 15% (4,5). In an effort to better quality for their inpatient
pneumonia patients, hospitals started using evidence-based medicine clinical
guidelines.
Guidelines for the inpatient treatment of pneumonia were developed by the
American Thoracic Society in 1993 (6). These guidelines include administration
of the influenza and pneumococcal vaccinations, an initial antibiotic within six
hours after arrival, smoking cessation counseling, an initial blood culture
performed before the first hospital dose of antibiotics and a pathogen-specific
initial antibiotic. Capelastegui et al. (7), using a pre and post intervention study
design, found that pneumonia guideline implementation resulted in shorter
durations of antibiotic treatment, better coverage of atypical pathogens and
improved appropriate antibiotic treatment. Furthermore, both 30-d mortality
and in-hospital mortality decreased. In 2009, six inpatient pneumonia guide-
lines were incorporated by the Centers for Medicare and Medicaid Services
(CMS) and the Hospital Quality Alliance into the Hospital Compare dataset (8).
With the advancement of these pneumonia clinical guidelines, racial healthcare
quality disparities persist in the United States.

RACIAL DISPARITIES IN PNEUMONIA INCIDENCE AND TREATMENT

Black adults are more likely contract pneumonia and less likely to receive
appropriate inpatient care when hospitalized than White adults. In 2003–2004,
the pneumonia incidence rate among Black adults in nine states with active
pneumonia surveillance was 24.2 per 100 000 versus 10.1 per 100 000 among
White adults; the incidence rate was positively associated with poverty (9).
Controlling for metropolitan area, young Black adults had higher incidence
rates of pneumococcal infection, as compared to their White counterparts (10).
Black and Hispanic patients are less likely to receive evidence-based
inpatient care for pneumonia (11–13). Disparities in quality experienced by
minority patients may stem from the hospitals where they receive care (14).
Hospitals that serve a high volume of Black patients had significantly lower
quality performance scores for pneumonia (15). In addition, hospitals that
predominantly serve Black patients had higher rates of potential safety
events among both Black and White patients than other hospitals (16).
Within Veterans Administration hospitals, there is a high concentration of
Black patients at a limited subset of hospitals (17). Within this centralized
system of care, Black patients at minority-serving institutions received lower
quality pneumonia care than their white peers (17). Finally, pneumonia
mortality for patients within hospitals that treated predominately Black or
Hispanic patients was significantly higher than predominately White hos-
pitals (11).
Disparities in process quality translate into health outcomes. Black patients
have higher readmission rates than White patients, and minority-serving
hospitals have higher readmission rates than non-minority serving hospitals
for acute myocardial infarction, pneumonia and congestive heart failure (18).
130 J. Mitchell et al.

CONTEXTUAL FACTORS FOR PNEUMONIA QUALITY OF CARE

Area-level factors also influence quality of care. Jencks et al. (19) reported that
states in the southeast and more populous states consistently ranked low in
Medicare process quality measures. This study is complemented by the work of
Jha et al. (20) by showing Northeastern and Midwestern hospitals generally
perform better than hospitals in the South and West. These regional process
variations have manifested into regional variations in health outcomes (21). At
the small area level, neighborhood socio-economic status (employment,
household income and education) have been shown to positively affect physical
health (22,23). Neighborhood racial segregation influences increased admis-
sion of minorities into high-mortality hospitals, even after controlling for
closer-proximity low-mortality hospitals (24). In an effort to better implement
evidence-based guidelines into pneumonia care, clinical decision support
systems (CDSS) have been implemented into hospital’s electronic medical
records.

CDSS AND QUALITY OF CARE

CDSS deliver tools to the physician that increase quality via evidence-based
guidelines and reminders, which have been shown to decrease medical errors
and increase adherence to recommended guidelines (25,26).
Related to quality of care, CDSS use can improve adherence to recom-
mended medical tests, provide warning signs due to blood test results, and
apply patient preferences into provided care (27–29). Applied to pneumonia
care, CDSS can improve treatment, including appropriate antibiotic prescrib-
ing practices (30).
Pneumonia is a key diagnosis for studying the effectiveness of electronic
systems at reducing health disparities for two reasons. First, the mortality
associated with the disease is substantial, giving public health emphasis to the
need for better care. Second, the presence of relatively long-standing guide-
lines for treatment provides a measure against which the performance of
practitioners can be measured, and factors associated with that performance
can be examined.
Prior research, as outlined above, has shown disparities not only between
Black and Hispanic patients and White patients but also disparities between
hospitals located in the neighborhoods of Black and Hispanic patients and
White patients. The research presented in this study attempts to study
whether a tool, CDSS, is associated with higher process quality measures,
while adjusting for the hospital’s location in either a High or Low Minority Zip
Code Tabulation Area (ZCTA).
We used Medicare Compare data to examine whether there is an association
between Clinical Decision Support System (CDSS) use and quality disparities,
measured at the hospital level. We believed that the use of CDSS would act as
a structural intervention against disparities in pneumonia care. In particular,
we focused on hospitals classified as high minority serving (located in a high-
minority ZCTA), based on research showing that members of racial/ethnic
minority groups are less likely to travel to distant hospitals as compared to
Whites, even when controlling for severe illnesses (31). Consequently, we
 CDSS and minority neighborhood disparities 131

hypothesize that hospitals in high-minority ZCTAs that use CDSSs will not
significantly differ in pneumonia process quality from those in low-minority
ZCTAs.

METHODS
Conceptual framework
Two theoretical frameworks guide this study: Andersen’s Behavioral Health
Model and Donabedian’s Quality Model. Andersen’s Behavioral Health Model
(15) suggests that characteristics within the external environment affect care
processes and outcomes. Andersen’s model, first developed in the 1960s, was
designed to help understand why families use health services and to promote
equitable access to those services. This model suggests that families use health
services as a function of their predisposition to use services: either enabling or
impeding. Over the years, this model has been updated to include factors
within one’s environment. Within Anderson’s Model, the principal independent
variable is hospital location within a high-minority ZCTA. Additional proxies
for the hospital’s external environment include urban/rural location, percent
65+ populations living in poverty, percent 65+ populations and percent without
a high school diploma within the ZCTA. Due to data limitations, we could
not control for patient-level characteristics and behaviors. Donabedian’s
quality model (Structure – Process – Outcome) (32) was used as a framework
to examine the association between a hospital structural element, CDSS
implementation and process quality indicators. Donabedian’s model posits that
there are three classifications, which inferences can be drawn for quality
assessment: structure, process and outcome. Structure refers to the attributes
of a healthcare setting—facilities , human resources and financial elements.
Process refers to the actions of what is actually happening—did the physician
render evidence-based medicine? Finally, outcome refers to the effects of care—
did the patient’s health status improve? The parts of this model that are
important are the relationships between structure – process – and outcome. In
other words, certain structural elements increase the likelihood of processes
being carried out, which then influence health outcomes. In this study, other
hospital-level variables within the Donabedian Model include size, ownership,
JCAHO accreditation, teaching hospital status and system membership/
management structure. It is necessary to use both the Donabedian and
Andersen models in this study to control for not only hospital-level structure
and process variables (Donabedian), but also the environment in which the
hospital operates (Andersen). Specifically, using these two models in conjunc-
tion, we can determine associations between the hospital structural element of
CDSS and processes (Donabedian), within the context of the ZCTA environ-
ment (Anderson).

Data sources and population studied

We conducted a cross-sectional analysis of hospital performance, drawing data
from two sources, the FY2009 Hospital Compare dataset from the CMS (4681
hospitals) and the FY2009 American Hospital Association (AHA) EHR
Adoption survey (3616 hospitals), a supplement to the annual hospital
survey, within which 2336 responded to the CDSS questions. Finally, the
132 J. Mitchell et al.

Research Triangle Institute’s (RTI) Spatial Impact database provided the

independent variable of percent minority within the ZCTA (as calculated by
the inverse of percent Non-Hispanic White). All data sources are publicly
available, with the exception of the AHA EHR Adoption Survey, which was
purchased through our AHRQ support. The RTI Spatial Impact database,
developed from a National Institutes of Health grant, provides ecological and
environmental variables that describe the contextual environment where
people live; separated by census tract, ZCTA, county, Primary Care Service
Area, and Medical Service Study Area.
The Hospital Compare dataset was created for health consumers to access
quality ratings of hospitals online, based on guideline adherence and health
outcomes. Acute care hospitals, governmental hospitals, and Critical Access
Hospitals (CAHs) all report to this dataset. CAHs are rural, safety net
hospitals with 25 or fewer beds that are under a cost-based reimbursement
system from Medicare (33). While CAHs are not required to report pneumonia
process indicators to CMS Hospital Compare, approximately 71% report at
least one inpatient or outpatient indicator (34).
After merging the three datasets as described above, our study population
included 2315 hospitals, 837 of which operated in high-minority ZCTAs. A total
of 383 CAHs were included in the analysis, 43 of which were located in high-
minority ZCTAs.

Variables
Dependent variable
The pneumonia quality measure used was a calculated composite score, based
on six pneumonia process indicators from the Hospital Compare dataset for
FY2009. Landrum et al. (35) assert that within cross-sectional studies,
composite scoring of process measures better summarize quality at a provider
level. These scores were calculated using the opportunity method developed by
the Hospital Core Performance Measurement Project for the Rhode Island
Public Reporting Program for Health Care Services in 1998 (36). This method
controls for individual weighting, missing data and differences in case
volumes. It is calculated by dividing the total number of instances of rendered
evidence-based care by the total number of opportunities for those treatments.
Values for the composite measure ranged from 4.00% to 100.00% (mean
92.50%, SD ¼ 6.60%). Individual quality indicators used to create the compos-
ite score included: pneumococcal vaccination, having an ER blood culture
before antibiotic administration, smoking cessation counseling, having initial
antibiotics within six hours of arrival, receiving the most appropriate
antibiotic, and receiving the influenza vaccination.

Independent variables
Independent variables were location (high-minority ZCTA versus other) and
CDSS (use versus not). Shorter travel patterns found among minority
populations suggest that hospitals in high-minority ZCTAs will disproportion-
ately serve these populations (31). Therefore, this analysis used comparisons of
process quality indicators for pneumonia between hospitals within high-
minority ZCTAs and hospitals in low-minority ZCTAs.
 CDSS and minority neighborhood disparities 133

High-minority ZCTA status was calculated by using the inverse of the

percent Non-Hispanic White variable (range ¼ 0%–97.9%, SD ¼ 22.5, mean
¼ 19.7%) from the Research Triangle Park’s (RTI) Spatial Impact Factor
Database (2011). This variable was divided into quartiles and the top quartile
(429.1% minority) was designated ‘‘High-Minority.’’ All other ZCTAs were
classified as ‘‘Low-Minority.’’ The bottom three quartiles – ‘‘Low-Minority’’
have upper limits of 3.35%, 10.28% and 29.1%, respectively.
The second independent variable, CDSS use came from responses to two
questions within the AHA EHR Adoption Survey: ‘‘Does your hospital have a
computerized system which allows for: decision support for clinical guide-
lines?’’ and ‘‘Does your hospital have a computerized system which allows for:
decision support for clinical reminders?’’ Responses to these CDSS questions
were characterized as ‘‘Fully implemented across all units’’ versus all other
conditions (‘‘fully implemented in at least one unit,’’ ‘‘beginning to implement
in at least one unit,’’ ‘‘have resources to implement in the next year,’’ ‘‘do not
have resources but considering implementing,’’ and ‘‘not in place and not
considering implementing’’). Because of significant overlap between hospitals
that use CDSS for guidelines and those that use CDSS for reminders, the
researchers dichotomized these responses as either (guidelines or reminders)
or neither.

Control variables
Control variables were used to hold community and hospital characteristics
that might be anticipated to be related to pneumonia quality measures but are
not of interest for this work. Control variables used in this analysis came from
the 2011 RTI Spatial Impact Factor Database, the 2010 AHA EHR Adoption
Survey, the 2010 AHA Annual Hospital Survey, CMS Hospital Compare
Database and the Department of Agriculture’s Rural-Urban Commuting Area
Codes (RUCA).
Community variables used, which reflect the external environment portion
of Anderson’s Model, came from the RTI Database and consisted of percent 65+
population in poverty, percent 65+ population and percent without a high
school diploma, all at the ZCTA level. Rural–Urban Commuting Area Codes
(RUCAs) from the Department of Agriculture were used to control for level of
rurality; hospitals located in a metropolitan ZCTAs were defined as urban
(RUCA ¼ 1–3); others as rural (RUCA ¼ 4–10). Within rural hospitals, CAHs
were assigned as a separate designation.
Hospital-level characteristics affect pneumonia quality processes. The
researchers therefore controlled for hospital characteristics, other than
CDSS, reflecting the structural component of Donabedian’s Model. These
variables consisted of ownership (for-profit, not-for-profit and Non-Federal
Governmental), total number of beds (565, 65–149, and 150+), JC accredit-
ation, teaching status and being a system member/management style.
Characteristics that positively affect quality include being part of a hospital
system and having a centralized management structure (37). Other charac-
teristics associated with increased quality include being not-for-profit, not
being part of the Council of Teaching hospitals, being in a non-West region and
having fewer than 100 beds (20). Finally, accreditation by JCAHO positively
affects pneumonia quality (38).
134 J. Mitchell et al.

Propensity scores
Both quality of care and use of CDSS may be endogenous, in that hospitals
interested in improving quality of care may choose to invest in CDSS.
Therefore, in an effort to control for this endogeneity, we employed propensity
scores. Because of the nature of observational studies, the ‘‘treatment’’ subjects
are not randomized. Therefore, the CDSS-treated hospitals may have other
non-observed characteristics that improve quality, creating a selection bias
toward higher process measures. The propensity score technique controls for
this bias by balancing treatment and control groups on a set of factors
described below.
Rosenbaum and Rubin (39) highlight three propensity score techniques for
constructing a matched sample: pair matching on balancing scores, sub-
classification on balancing scores and covariance adjustment on balancing
scores. This study used the regression covariance adjustment propensity score
technique. This method reduces bias by adjusting for the pattern of observed
confounders (40,41). This will allow researchers to determine a more precise
(less biased) estimate of CDSS specifically on the association of disparities in
pneumonia processes. Propensity scores were calculated using a multivariable
logit model to predict use of CDSS based on ownership, bed size and urban/
rural location.

Statistical analysis
Preliminary and unadjusted analyses were performed using SAS (SAS
Institute, Cary, NC). The adjusted analysis using propensity scores was
conducted using Stata (Stata Corporation, College Station, TX) (42).
Preliminary analysis described the study population across high and low
minority ZCTAs. Unadjusted analysis estimated pneumonia composite scores
by high and low minority ZCTAs and other hospital and community charac-
teristics; significant differences were identified using Wald chi square tests.
Finally, a multivariable ordinary least squares regression analysis was
performed to determine hospital and ZCTA-level characteristics significantly
associated with pneumonia process quality.

RESULTS
Several differences exist between the 2315 hospitals that both responded to the
CDSS question in the EHR Adoption Survey and reported quality measures to
the Hospital Compared and non-responding hospitals. Those hospitals that
both responded to the CDSS question and reported quality indicators are more
likely to be accredited by JCAHO and either be an independent hospital or
have a centralized management structure. Conversely, non-respondents are
more likely to be a teaching hospital and have a decentralized management
structure.
Study hospitals are listed in Table 1. Hospitals in high-minority ZCTAs were
no different in their use of CDSS as compared to low-minority ZCTAs (33.1%
and 31.1%, respectively). Significantly more high-minority ZCTAs were located
in urban areas, as compared to rural areas. The majority of high-minority
hospitals had 150+ beds. The majority of both high-minority and low-minority
hospitals used in the analysis were not-for-profit. High-minority hospitals used
 CDSS and minority neighborhood disparities 135

Table 1. Hospital characteristics of the study sample, by high-minority and low-minority

hospital ZCTAs.

Significance
High Lower 3 across minority
minority quartiles status

Number of hospitals 837 1478

CDSS
Yes 33.09% 31.12% 0.3280
Rurality
Urban 71.09% 44.38% 50.0001
Rural 23.78% 32.61%
CAH 5.14% 23.00%
Size
565 15.77% 30.92% 50.0001
65–149 18.88% 29.16%
150+ 65.35% 39.92%
Ownership
Government 26.35% 17.39% 50.0001
Not for Profit 57.96% 73.27%
For Profit 15.69% 9.34%
Region
Northeast 13.38% 18.74% 50.0001
Midwest 12.07% 43.44%
South 52.33% 27.06%
West 22.22% 10.76%
JCAHO accredited
Yes 89.01% 76.73% 50.0001
Teaching hospital
Yes 35.13% 14.68% 50.0001
Management style
Not a system member 42.17% 48.44% 0.0115
Decentralized system member 28.08% 26.05%
Centralized/mod-centralized system member 29.75% 25.51%
Education
Less than high school diploma 7.65% 4.60% 50.0001
Population
At or above 65 11.99% 16.66% 50.0001
65+ poverty
Below FPL 15.71% 8.65% 50.0001

in the analysis were mainly located in the South, while the majority low-
minority hospitals were located in the Midwest. High-minority hospitals have
a lower percentage of CAHs than low-minority ZCTAs. Finally, high-minority
ZCTAs had higher amounts of JCAHO accredited hospitals as well as teaching
hospitals, as compared to low-minority ZCTAs.
Unadjusted estimates for the pneumonia process composite scores are listed
in Table 2. Hospitals located within high-minority ZCTAs had significantly
lower composite scores as compared to those hospitals within non-
high-minority ZCTAs (91.6% versus 93.1%, respectively). Hospitals that use
CDSS had higher pneumonia process composite scores than their non-CDSS
using counterparts (93.5% and 92.0%, respectively). Other factors associated
with higher pneumonia process scores included: being in an urban ZCTA,
136 J. Mitchell et al.

Table 2. Unadjusted estimates for pneumonia process composite scores.

Significantly
different at
Composite p50.05

Minority status
High minority 91.62% *
Low minority 93.14%
CDSS
Yes 93.52% *
No 92.01%
ZCTA
Urban 93.38% a: b, c
Rural 92.54% b: a, c
CAH 90.08% c: a, b
Size
565 (a) 91.09% a: b, c
65–149 (b) 92.71% b: a
150+ (c) 93.07% c: a
Ownership
Government (a) 89.62% a: b, c
Not for profit (b) 93.08% b: a, c
For profit (c) 94.39% c: a, b
Region
Northeast (a) 92.95% a: b, c, d
Midwest (b) 90.08% b: a
South (c) 93.57% c: a
West (d) 92.48% d: a
JCAHO accredited
Yes 93.20% *
No 89.39%
System member
Yes 93.66% *
No 91.08%
Teaching
Yes 92.52%
No 92.49%
Management style
Not a system member (a) 91.08% a: b, c
Decentralized system member (b) 93.23% b: a, c
Centralized/mod-centralized system member (c) 94.14% c: a, b

*Significant at p50.05.

both mid-size (65–149 beds) and large (150+ beds) hospitals, for profit
hospitals, hospitals in the South, JCAHO accredited hospitals, not being a
CAH, and hospitals that were part of a system and had a centralized
management style. CAHs have significantly lower composite measures than
both urban and other rural hospitals. No significant differences between
teaching and non-teaching hospitals were detected.
Table 3 represents the adjusted least squares logistic regression analysis for
the pneumonia process composite scores. Five models are offered, predicting
the pneumonia composite score based on the following: (1) high-minority
ZCTAs versus low-minority, (2) high-minority ZCTAs and other control
 CDSS and minority neighborhood disparities 137

Table 3. Adjusted least squares regression analysis for pneumonia process composite
scores for hospitals with propensity to use CDSS for guidelines.

Model 1 Model 2 Model 4

(high-minority (N0 CDSS or Model 3 interaction
only) propensity) (all variables) model

Intercept 93.139 99.719 92.964 92.873

High-minority ZCTA
Yes 1.516a 1.255a 1.834b
CDSS
Fully implemented 0.924b
CDSS/minority interaction
(Ref: no CDSS and high minority)
Reserved for interaction modelb
No CDSS and low minority 2.085b
CDSS and low minority 2.388b
CDSS and high minority 1.406b
Rurality (Ref: urban)
Rural 1.724b PS PS
CAH 0.029 PS PS
Percent 65+ poverty Population 0.103a 0.135b 0.138b
Percent 65+ in ZCTA 0.024 0.049b 0.098b
Percent without high 0.069 0.048 0.045
school diploma
Bed size (Ref: 150+)
565 0.055 PS PS
65–149 0.131 PS PS
Ownership (Ref: for profit)
Non-federal government 3.480a PS PS
Not For Profit 1.530a PS PS
Region (Ref: West)
Northeast 1.635a 2.515b 2.470b
Midwest 0.718 0.610 0.578
South 1.083b 1.407b 1.362b
Teaching status
Teaching 0.522 0.352b 0.345
JCAHO
Accredited 2.126a 3.055b 3.093a
System/management style
(centralized system)
Not part of a system 1.807a 3.486a 3.526a
Part of system, decentralized 0.827b 1.510b 1.559b
Propensity adjustment 6.888 7.009
R-square 0.0132 0.1542 0.1353 0.1364
a
Significant at p50.0001.
b
Significant at p50.05.
PS ¼ used in calculating the propensity score.

variables, (3) high-minority ZCTAs, control variables, the hospital’s propensity

to use CDSS for guidelines and if the hospital uses CDSS for guidelines, and (4)
an interaction model using minority-status and CDSS use with control
variables of the previous models. Controlling for no other factors, hospitals
located in a high-minority ZCTAs have significantly lower pneumonia process
composite scores than do other hospitals. In model 2, while controlling for
138 J. Mitchell et al.

Table 4. Adjusted estimates for Pneumonia Process Composite Scores, by hospital

location and CDSS use.

Correlation matrix
Adjusted
Score CDSS, low CDSS, high None, low None, high

CDSS present:
Low-minority location 91.87 * * * *
High-minority location 90.89 0.3039 * * *
No CDSS:
Low-minority location 91.56 0.6687 0.4068 * *
High-minority location 89.48 0.0047 0.0250 0.0017 *

Estimates adjusted for: rurality, percent 65+ poverty population, percent 65+, percent less
than high school education, region, teaching status, JCAHO accreditation, central-
izatio'n, and propensity for CDSS implementation.

several hospital-level and other ZCTA-level variables, high-minority ZCTA

hospitals retain their negative association with the pneumonia process
composite score. Model 3 added CDSS use to model 2. In this model, both
CDSS use and high-minority status were significant. In model 4, we interacted
ZCTA minority status and CDSS use to ascertain whether CDSS use had
consistent effects across settings. We found that CDSS use was associated with
improved process measures within high minority ZCTAs, but not within
hospitals located in low minority areas. Both models 3 and 4 used the
propensity covariate adjustment; neither model saw significance with this
variable in predicting pneumonia process quality composite scores.
To illustrate the associations of CDSS across hospital locations, we
calculated adjusted mean pneumonia quality score for each treatment
(Table 4). While controlling for the aforementioned hospital and contextual
variables, high-minority hospitals without CDSS have lower measures as
compared to their low-minority counterparts and hospitals that use CDSS. No
significant differences were calculated between hospitals with CDSS in low-
minority and high-minority ZCTAs, as well with hospitals in low-minority
ZCTAs that do not use CDSS.
In sum, unadjusted analysis showed hospitals located in high-minority
ZCTAs had significantly lower composite scores as their non-high-minority
ZCTA counterparts and hospitals that use CDSS had higher pneumonia
process composite scores than their non-CDSS using counterparts. In the
adjusted analysis, using the CDSS/minority status interaction term, we found
that CDSS use was associated with improved process measures in hospitals in
high minority ZCTAs but not in hospitals in low-minority ZCTAs.

DISCUSSION
The work presented in this study affirms and builds upon previous research
(27–30) by means of CDSS being associated with higher quality measures and
maintaining that relationship in high-minority hospitals. Specifically, we
found positive associations between hospital CDSS use and pneumonia process
indicator composite scores. This association was not uniform. In adjusted
 CDSS and minority neighborhood disparities 139

analysis, the implementation of CDSS did not significantly improve adjusted

quality for hospitals located in low minority ZCTAs. However, for hospitals
located in high minority ZCTAs, the addition of CDSS brought quality levels
up to equality with hospitals in low minority areas. Therefore, hospitals that
serve a high-minority ZCTA have better process measures associated with
pneumonia when they use CDSS, as compared to their non-CDSS counter-
parts. Our findings strengthen the current racial health disparity research by
identifying a structural hospital characteristic, CDSS, which may reduce
disparities in quality of care.
Reflecting Donabedian’s model, CDSS use was positively associated with the
pneumonia process quality indicators. However, reflecting Anderson’s model, it
is important to examine the structure –process relationship theory within the
context in which it operates, in this case, the hospital’s ZCTA. As shown by the
interaction model, the size of the quality association with CDSS use depends
on the external environment within which it is deployed. The absence of a
CDSS association in low-minority hospitals may stem from the limited range of
improvement possibility, as those institutions were already achieving high
pneumonia process scores.
Other variables in the analysis that were positively associated with
pneumonia process composite scores in adjusted analysis included for-profit
hospital status, location outside the West region, having 150+ beds and being
accredited by JCAHO. The positive association of for-profit status and
pneumonia process quality contradicts a study by Jha et al. (20). Differences
may stem from differing respondent groups. The previous study linked quality
measures to the complete AHA Annual Survey, while this study was limited to
respondents to the AHA EHR Adoption survey. It is possible that only higher-
quality for-profit hospitals responded to the EHR survey. The proportion of for-
profit hospitals in our dataset, 11.5%, is less than the representation of for-
profit’s among all community hospitals, 20.3% (43).
Factors that had a significant negative relationship on the pneumonia
process composite scores were as follows: percent poverty among those age 65
years and older in the ZCTA, percent without a high-school diploma, being a
teaching hospital, being either a Non-Federal Government or Not-For-Profit
hospital and not being in a hospital system, and having a decentralized
management structure. The negative associations between area-level indica-
tors suggestive of social and economic disadvantage and hospital process
quality may exacerbate the already poor health outcomes, as seen in our
calculations of 65+ population in poverty and low educational achievement in
high-minority ZCTAs (Table 1). Our research could not fully implement the
individual components of Andersen’s model (44); incorporating individual
health characteristics and behaviors within aggregate contextual health
factors may be an important research direction for future study.

STUDY LIMITATIONS
Our study did not have patient-level data and thus did not directly calculate
process-level quality indicators and composite scores; we relied on hospital
reported data. Furthermore, without patient data, the researchers must rely
on aggregate measures of ZCTA poverty, education and 65+ population.
140 J. Mitchell et al.

Therefore, this study may be limited by ecological fallacy (45); hospitals located
in high-minority neighborhoods may not have a higher concentration of
minority patients. Given the goals of this study, the contextual variables that
reflect local built environment may be appropriate when examining external
health risk.
Second, the data source did not document the extent that the physicians
actually use CDSS, but was limited to whether CDSS had been implemented in
all units. We make the assumption that CDSS implementation corresponds
with actual physician CDSS use, although the degree of that correspondence is
not known. Furthermore, the CDSS used in this study within support clinical
guideline reminders and alerts, we cannot confirm whether or not pneumonia
care is included. Currently, there is no public-use dataset that documents
actual physician/nurse use of CDSS. Future researchers should focus within
individual hospitals or health systems, where it may be possible to identify
physician-usage of CDSS and other health information technologies.
Finally, we had to address missing data. Specifically, some hospitals
reported on fewer than the complete six process indicators. Hospitals may
have elected to report only for those guideline elements on which their
performance ranked high.

CONCLUSION
In the research reported in this study, the implementation of CDSS was
associated with reduced quality disparities between hospitals located in high-
minority ZCTAs and those in low-minority areas. If replicated by future
research, the link suggests a strategy that hospitals may pursue to ensure that
quality goals are met even among otherwise high-risk patient populations.
From a policy perspective, results support efforts to direct policy toward
broader adoption of CDSS.

DECLARATION OF INTEREST
The authors report no conflicts of interest. The authors alone are responsible
for the content and writing of this article.

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