Date of Award


Document Type

Campus Access Dissertation


Health Services and Policy Management

First Advisor

Janice Probst


Purpose: To determine associations between Clinical Decision Support use and Community-Acquired Pneumonia (CAP) process and outcome quality disparities between hospitals in rural/urban ZCTAs and racial/ethnic groups, controlling for other hospital and spatial characteristics. This analysis has presently yielded three manuscripts, and will yield seven additional manuscripts. Methods: We used secondary data from the American Hospital Association (AHA), Agency for Healthcare Quality and Research (AHRQ), and the Centers for Medicare and Medicaid Services to identify differences between hospitals that use CDSS and those that do not and their respective CAP mortality rates and quality process indicators. Findings: Paper 1. Hospitals in metropolitan ZCTAs had significantly higher unadjusted process composite scores as compared to micropolitan and small rural hospitals. Hospitals that use CDSS for clinical guidelines and those that use CDSS for clinical reminders had significantly higher unadjusted pneumonia process composite scores than each of their non-CDSS implemented counterparts.
When controlling for CDSS use and other variables, hospitals in micropolitan and small rural ZCTAs did not have significantly different process composite scores as compared to the metropolitan counterparts. Paper 2. Unadjusted analysis showed hospitals in high-minority ZCTAs had significantly lower composite scores as compared to hospitals in lower-minority ZCTAs. Hospitals that use CDSS had higher pneumonia process composite scores than their non-CDSS implemented counterparts. In the adjusted analysis, high- minority hospitals retained their significant lower pneumonia composite score after controlling for a host of community and hospital characteristics. Moreover, CDSS use retains its significant positive relationship with the pneumonia composite scores after controlling for hospital and community factors. Paper 3. CDSS use was not associated with CAP mortality. Adjusting for patient characteristics, age, being male, increase in number of chronic conditions, and length of stay all contribute to inpatient mortality. In multi-level analysis, patient-level variables remain significant, and HPSA status becomes significantly associated with increased inpatient mortality. Conclusions. While disparities between high-minority and low-minority hospitals persist, after controlling for CDSS, it is notable that CDSS has positive associations to quality, after controlling for high-minority hospitals. Further analysis suggests, racial disparities in inpatient mortality is explained by County-level contextual factors, outside of hospital control.