Public Release: 

Quality of hospital care in US territories appears lower than in US states

The JAMA Network Journals

Hospitals in U.S. territories appear to have poorer outcomes and higher mortality rates for patients with acute myocardial infarction (heart attack), heart failure or pneumonia, compared to hospitals in U.S. states, according to a report published Online First today in the Archives of Internal Medicine, one of the JAMA/Archives journals.

U.S. territories, including the Commonwealth of Puerto Rico, Guam, American Samoa, the Commonwealth of the Northern Mariana Islands and the U.S. Virgin Islands are home to almost five million residents, according to background information in the article. "Studies about hospital quality of care in the U.S. typically exclude hospitals in the U.S. territories or combine them with other U.S. regional areas, masking potential differences between quality of care between the territories and states," writes Marcella Nunez-Smith, M.D., M.H.S., of Yale University School of Medicine, and colleagues.

Using process measures (publicly reported, evidence-based standards of care specific to patient conditions), Nunez-Smith and colleagues sought to compare performance of hospitals in the U.S. territories and U.S. states. The authors examined data on 57 territorial hospitals and 4,799 stateside hospitals that discharged at least one Medicare fee-for-service adult patient with a primary diagnosis of acute myocardial infarction (AMI), heart failure (HF) or pneumonia (PNE) between July 2005 and June 2008.

Compared with hospitals in the states, hospitals in the territories demonstrated worse performance on all core processes measured for AMI, HF and PNE. Hospitals in Puerto Rico performed similarly to other territories on most core processes measured. The hospital mean (average) 30-day risk standardized rate for all-cause mortality (death) was significantly higher in the territories compared with the states for AMI, HF and PNE. After adjusting for condition-specific core process measures and hospital characteristics, mortality rates in the territories compared with states remained high for all three conditions. Additionally, the unadjusted mean 30-day risk-standardized readmission rates also were significantly higher in U.S. territories for AMI and PNE, but not for HF.

Based on their findings, the authors note that "in comparison with the states, for every 100 AMI admissions in the U.S. territories there are approximately two additional deaths, for every 100 HF admissions there is one additional death, and for every 100 pneumonia admissions there are three additional deaths."

"Compared with hospitals in the U.S. states, hospitals in the U.S. territories have significantly higher 30-day mortality rates and lower performance on every core process measure for patients discharged after AMI, HF and PNE," the authors conclude. "Despite the national effort to address health care disparities through increased public reporting and standardizing hospital performance, hospitals in the U.S. territories have been largely neglected."

(Arch Intern Med. Published online June 27, 2011. doi:10.1001/archinternmed.2011.284. Available pre-embargo to the media at

Editor's Note: The analyses on which this publication is based were supported by the Agency for Healthcare Quality and Research, the United Health Fund and the Commonwealth Fund. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Commentary: Understanding Health Care Disparities in the U.S. Territories

"I applaud Nunez-Smith and colleagues for embarking on an effort to assess the quality of care in the U.S. territories despite the limited data available in national health care and disparity reports and heath care policy data warehouses," writes Nilsa Gutierrez, M.D., M.P.H., of the Department of Health & Human Services, Centers for Medicare & Medicaid Services, New York, in an accompanying commentary.

"To understand the complexity of factors contributing to health care disparities in the U.S. territories, it is necessary to appreciate key federal funding policy differences between U.S. states and territories, given that Medicare and Medicaid are the two principal sources of federal health care funding. The unintended negative effects of these policy differences are evident, and their impact on access to care and treatment, services and delivery system infrastructure are measurable."

"Lack of publicly available data are the single most important factor in limiting our knowledge base on the quality of care and services in the U.S. territories," Dr. Gutierrez concludes. "Beyond the imperative for the establishment of publicly available databases that feature 'territory-only' public health data, territorial public health leaders may consider it necessary to monitor additional socioeconomic and geopolitical factors that influence the availability and quality of health care, treatment and services. This will go a long way in demonstrating the extent of unintended effects on the U.S. citizens and nationals residing in the territories, their role in widening the quality gap, and the interventions necessary to fully develop territorial health care delivery systems."


(Arch Intern Med. Published online June 27, 2011. doi:10.1001/archinternmed.2011.305. Available pre-embargo to the media at

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

To contact Marcella Nunez-Smith, M.D., M.H.S., call Karen Peart at 203-432-1326 or e-mail

To contact commentary author Nilsa Gutierrez, M.D., M.P.H., call Brian Cook at 202-690-6145 or e-mail

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