This week’s contributor is Shooshan Danagoulian, an assistant professor of economics at Wayne State University. As a health economist, Shooshan’s research focuses on health insurance utilization, health care delivery, emergency department care and environmental health outcomes.

Common wisdom advises us to avoid hospitals on busy days, as we might not get as much attention or care. A recent NBER working paper tests this wisdom, but with a twist: Does quality of care change more for Black than white patients when a hospital is busy? 

The finding: Racial bias may be magnified when a hospital is at capacity. 

Prior studies have shown that medical provider and health care system bias often contributes to lesser care for Black patients: longer wait times, reduced access to technology, reduced use of appropriate pain control. While hospitals generally like to keep busy, the strain on hospital capacity has increased with COVID-19, as more patients seek care. 

Using thousands of admissions to two large hospitals over a period of 15 months – a time frame that included COVID – researchers Manasvini Singh and Atheendar Venkataramani examined changes in in-hospital mortality for Black and white patients when a hospital experienced varying levels of capacity strains, measured by proportion of occupied beds. 

They found that if a Black patient arrived at the hospital at a time of high capacity strain (91-93% of beds filled on average), rather than at a less busy time, they faced a 20% greater likelihood of death compared to white patients. Interestingly, however, the researchers found this widening disparity was not created by an increase in likelihood of Black patient death, but by a decreasing likelihood of white patient death as the strain on capacity increases. This counterintuitive result implies that while Black patients receive the same level of care regardless of capacity strain, white patients receive something additional as capacity strain rises — perhaps more resources or attention.

The researchers found this mortality disparity was greatest for Black women and Black uninsured people, two of the most marginalized patient groups, which the authors suggest is evidence of implicit and explicit biases at play. For example, in busier times, health systems may overly rely on biased algorithms to allocate resources or providers may be more susceptible to pressure from patients with the tools to advocate more aggressively for scarce resources.   

The data used in the study limits the generalizability of its findings. The study’s short time-period and its focus on just two hospitals does not allow for wider understanding of care delivered in other settings, nor variability across states and years. 

Still, the researchers concluded that 8.5% of Black deaths in the time period they studied were driven by strains on hospital capacity, and therefore avoidable. Black patients are more likely to access care at under-resourced hospitals, and this study’s results suggest that such chronic capacity strains may be driving the disparity in quality of care provided to these communities.