Minorities more likely to be Readmitted

Prevention of hospital readmissions serves as one of the primary metrics for quality improvement under the Affordable Care Act. In 2012, the Centers for Medicare and Medicaid Services (CMS) began levying penalties for hospitals that had 30-day readmissions for acute myocardial infarction, heart failure, and pneumonia. In 2015, CMS expanded this metric to include total hip arthroplasties (replacements) or THAs.

Source: Joaquim Alves Gaspar (CC)

Source: Joaquim Alves Gaspar (CC)

Elective THA is the sixth most common procedure and has an 8.1% readmission rate, costing nearly $17 billion per year. With the expansion of the THA readmission penalty, growing research seeks to understand .

Researchers reviewed the California State Inpatient Database to answer two questions: first, is there a difference in 30-day readmission rates for those patients with THA based upon race, SES, and insurance; and second, to what extent does each of these three variables explain a difference in readmission.

They found that . Black patients had a substantially higher prevalence of hypertension compared to Whites, Hispanics, and Asians. Similarly, Black and Hispanic patients had a higher prevalence of obesity and diabetes. Economically, these groups account for the greatest proportion in the lowest quartile for SES: 41% for Blacks and 26% for Hispanics vs. 14% for Whites. They also had a higher percentage enrolled either in Medicaid or uninsured (10% and 5%, respectively) compared to Asians or Whites.

When controlling for comorbidities, Blacks and Hispanics tended to have higher readmission rates compared to their Asian and White counterparts – 6.1% and 5.2%, respectively, versus 4.3% and 4.4%, respectively – a statistically significant difference. When adjusted for comorbidities, Blacks were 38% more likely to be readmitted, and Hispanics 16%, compared to Whites.

This racial disparity in readmission may hurt hospitals in underserved communities. The study noted significant increases in 30-day readmission rate for Black patients in poor communities on either Medicaid or uninsured. It notes that hospitals in underserved areas tend to have lower surgical quality and post-operative care. As CMS leverages penalties against safety net hospitals, the disparity in care for these communities will worsen.

commentary by Neil Wingkun

Abstract

BACKGROUND: Policymakers have expanded readmissions penalties to include elective total hip arthroplasties (THA), but little is known whether disparities exist on the basis of race, socioeconomic status, or payer.

OBJECTIVE: To identify disparities in elective primary THA readmissions based on race, socioeconomic status, and type of insurance.

RESEARCH DESIGN: This analysis is a retrospective cohort study of patients discharged for an elective THA. The Healthcare Cost & Utilization Project’s State Inpatient Database from California was used to identify index hospitalizations for elective primary THA and rehospitalizations within 30 days of discharge. We used multivariate logistic regression to examine differences in readmissions by race, socioeconomic status, and insurance.

SUBJECTS: Subjects included patients discharged from California hospitals from 2009 through 2011 after THA. MEASURES: Risk-adjusted odds of all-cause 30-day readmission.

RESULTS: The overall rate of unplanned 30-day all-cause readmissions was 4.6%. African American [odds ratio (OR)=1.38; 95% confidence interval (CI), 1.16-1.64] and Hispanic (OR=1.16; 95% CI, 1.00-1.34) patients had a higher risk of readmission than white patients after THA, when accounting for comorbidities and hospital factors. The observed difference for Hispanic patients, however, was null after adjusting for socioeconomic status and payer. Lower socioeconomic status was associated with higher odds of readmission (OR=1.24; 95% CI, 1.10-1.39). Compared with private insurance, Medicare (OR=1.26; 95% CI, 1.13-1.43), Medicaid (OR=1.86; 95% CI, 1.49-2.32), and uninsured status (OR=1.31; 95% CI, 1.01-1.69) were also associated with increased readmission risk.

CONCLUSIONS: We found significant differences in the odds of 30-day readmissions on the basis of race, socioeconomic status, and payer. As readmissions penalties become widely adopted, payers need to be mindful of their effects on vulnerable populations. PMID: 26390068

Oronce, CI, et al. Med Care. 2015; 53 (11): 924-30.