Hospitals serving disadvantaged patients need special consideration for readmission penalties, study says

A new probe into why colorectal surgery patients end up back in the hospital after their procedures suggests it has more to do with patient factors than hospital error, and calls for special consideration for hospitals who treat large numbers of socially disadvantaged patients when penalties loom.

Lead study author Waddah B. Al-Refaie, MD, surgeon-in-chief at Georgetown Lombardi Comprehensive Cancer Center and chief of surgical oncology at MedStar Georgetown University Hospital, along with a team of researchers at MedStar GUH and MedStar Health Research Institute, examined outcomes in colorectal surgery, a common procedure in the U.S. each year as a treatment for colorectal cancer, inflammatory bowel disease and diverticulitis. This procedure has a high risk for postoperative complications and hospital readmissions within 30 days of discharge.

The researchers examined outcomes and patient factors in more than 168,000 colorectal surgery patients treated in 374 California hospitals from 2004-2011. Forty-seven of these hospitals were considered minority-serving hospitals for having a high percentage of minority patients. Hispanic and black patients comprise about 63 percent of the patient population in minority-serving hospitals, compared with 17 percent in other hospitals, the study said.

[Also: Safety-net hospitals slash readmissions, but changes to penalty formula needed, study says]

After discounting a patient's age, sex, comorbidities and the year and type of procedure, the researchers found that, overall, 30-day, 90-day, and repeated remission rates were 11.6 percent, 17.4 percent, and 3.0 percent, respectively. However, the rates in minority-serving hospitals was 13.6 percent, 20.1 percent, and 4.0 percent, respectively. At 4.9 percent, inpatient mortality was also significantly higher at minority-serving hospitals compared to non-minority-serving hospitals, which had an inpatient mortality rate of 3.8 percent.

Mining the data further, the investigators found that patient factors  such as race, low income and insurance status accounted for up to 65 percent of the observed increase in odds for readmission at minority-serving hospitals, while hospital-level factors -- procedure volume and procedure type, etc. -- accounted for up to 40 percent.

Al-Refaie said CMS should consider patients' socioeconomic factors when it compares readmission rates.

"We know that safety-net hospitals -- those providing healthcare to a large proportion of uninsured and patients with Medicaid -- are more commonly penalized under the HRRP program, and we worry that imposing unfair fines for surgery readmission on hospitals that are already financially vulnerable will have unintended consequences on patients," he said. "These hospitals may become less inclined to take in sicker patients and reduce spending necessary for patient safety, and that puts more patients' health at risk."

[Also: Rural hospitals outperformed urban in value, readmissions, hospital acquired condition programs]

The Hospital Readmissions Reduction Program, put in place in 2012 by the Centers for Medicare and Medicaid Services, penalizes hospitals for higher-than-expected readmission rates for six conditions: heart attacks, heart failure, pneumonia, COPD and hip and knee replacement. To date, it has penalized more than half of the nation's hospitals for failing to meet those expectations, imposing more than $500 million in fines.

While the study contends hospitals treating a large number of socially disadvantaged patients, those who may not be able to afford their medications, or lack a supportive social environment, should receive extra consideration, CMS argues that all hospitals should be held to the same standard, Al-Refaie said.

He stressed that numerous studies have shown that patient factors do make a difference in the risk of readmission.

[Also: CMS awards $347 million to help reduce readmissions, hospital-acquired conditions]

"Minority-serving status of a hospital is important," he said in a statement. "These hospitals typically serve as a safety net in low-income communities; their patients tend to have more comorbidities and less resources to support their health."

Writing in the journal Surgery, the investigators say the federal government should take these patient factors into account in their push to reduce hospital readmission rates.

"If these factors are not balanced out, we fear minority-serving hospitals will face substantial, crippling financial penalties, and may end up being selective about the patients they admit," said Al-Refaie.

Twitter: @JELagasse