Impact of race and ethnicity on length of stay, discharge location, and total charges for inpatients with skin ulcers in New York

Black patients receiving outpatient care for skin ulcers are less likely to see a physician and are at risk for higher stage pressure injuries. While racial/ethnic differences in outpatient treatment of skin ulcers have been described, this study aims to elucidate potential differences in the inpatient setting using publicly available data. We conducted a retrospective cohort study of the Statewide Planning and Research Cooperative System database, a de-identified, patient-level dataset for inpatient visits in New York between 2009 and 2021. Admissions were filtered by diagnosis-related group (APR-DRG) code 380 (skin ulcers). Compared to non-Hispanic white patients, non-Hispanic black patients demonstrated longer mean LOS (8.15 vs. 7.48 days, p = 0.009), higher mean charges ($44,400 vs. $37,600, p < 0.001), and were more frequently discharged home without services (38.1% vs. 32.4%, p < 0.001). Black Hispanic patients had similar mean LOS (7.22 vs. 6.36 days, p = 0.133), similarly discharged home without services, and had higher mean charges ($45,800 vs. $36,700, p = 0.031). After adjusting for patient factors, non-Hispanic black patients had a longer LOS by 0.26 days (p = 0.028) with $2331 higher inpatient charges (p = 0.001) compared to non-Hispanic white patients. The findings suggest racial and ethnic differences in hospitalizations for skin ulcers, with black patients experiencing greater LOS and charges. The reasons for these differences merit investigation, yet could be related to delays in outpatient care, more severe disease, presence of comorbid conditions, or complications requiring intensive inpatient services.

Racial/ethnic disparities in dermatologic care are well documented, with black patients having lower survival rates for Merkel cell carcinoma and melanoma [1]. Additionally, black patients receiving outpatient care for skin ulcers are less likely to see a physician and are at risk for higher stage pressure injuries [2][3][4]. While racial/ethnic differences in outpatient treatment of skin ulcers have been described [2], this study aims to elucidate potential differences in the inpatient setting using publicly available data.
We conducted a retrospective cohort study of the Statewide Planning and Research Cooperative System database, a de-identified, patient-level dataset for inpatient visits in New York between 2009 and 2021 [5]. Admissions were filtered by diagnosis-related group (APR-DRG) code 380 (skin ulcers). Baseline patient characteristics and outcomes (length of stay [LOS], total charges, and discharge location) were evaluated for white, black, and Hispanic patients through unadjusted and mixed effects modeling. Unadjusted effects were examined using independent t-tests for continuous outcome variables and chi-squared tests for categorical variables. Adjusted models included age, sex, race, ethnicity, insurance type, facility, and risk of mortality as potential confounders. An alpha level of 0.05 was chosen.
Among The findings suggest racial and ethnic differences in hospitalizations for skin ulcers, with non-Hispanic black patients experiencing greater LOS and charges. The reasons for these differences merit investigation, yet could be related to outpatient care delays [2], more severe disease [3], comorbid conditions, or complications. These differences align with an earlier study suggesting delays in pressure ulcer healing among black nursing home patients [4]. The table displays the baseline characteristics and unadjusted outcome data for all patients in the sample by race and ethnicity. Unadjusted effects were examined using the independent t-test for continuous outcome variables and chi-squared test for categorical variables. An alpha level of 0.05 was chosen to determine significance. There were 259 multi-racial patients, 10,256 patients of other races, and 107 patients of unknown race, but patients of unknown or ambiguous races were not included The associated higher charges for black patients may pose financial challenges given they more frequently had Medicaid or were self-pay. It is unclear why LOS among Hispanic patients was shorter, yet these patients were more frequently discharged home without health services, which could have expedited discharges for logistical reasons. This warrants further comparison of long-term skin ulcer outcomes across races/ethnicities. There are several limitations to this study. The intersection between race and ethnicity is nuanced. Also, a minority of included hospitals have hospice services; this risk of bias on LOS was mitigated by adding the facility as the intercept term in the modeling. Furthermore, there are no data on ulcer severity or type to include as potential confounders. Still, the analysis provides greater insight regarding racial/ethnic differences for inpatient dermatologic care and encourages further research at the national level.
Author contributions HF designed and conceived of the project. NH acquired the data, performed the data analysis, and prepared the tables. NH and CD wrote the main manuscript text. All authors reviewed the manuscript.
Funding None.

Data availability
The data that support the findings of this study are openly available through the Statewide Planning and Research Cooperative System Database by the New York State Department of Health at https:// health. data. ny. gov/. The dataset used here is also available in the supplementary files. IRB approval status This study utilized publicly available online datasets and did not qualify as human subject research; therefore, institutional review board approval was not required at the University of Connecticut Health Center.

Conflict of interest
Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Table 2 Mixed effects modeling for length of stay and total charges with facility as the intercept and non-Hispanic white as the reference category, adjusting for ethnicity, race, age, sex, risk of mortality, and insurance type, [2009][2010][2011][2012][2013][2014][2015][2016][2017][2018][2019][2020][2021] Bold means that the p value was less than 0.05 The table displays the adjusted outcome data for all patients in our sample by their race and ethnicity. All outcomes were adjusted for age, sex, race, ethnicity, insurance type, facility, and risk of mortality. An alpha level of 0.05 was chosen to determine significance