Effect of Hospital Safety-Net Burden on Cost and Outcomes After Surgery

Hoehn, Richard S.; Wima, Koffi; Vestal, Matthew A.; Weilage, Drew J.; Hanseman, Dennis J.; Abbott, Daniel E.; Shah, Shimul A.

doi:10.1001/jamasurg.2015.3209

Cited by 157 publications

(130 citation statements)

References 42 publications

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“…There is a growing body of evidence demonstrating that readmission rates at safety-net hospitals, a subset of MSH, among surgical patients may be largely driven by hospital-level factors. 20,21 For example, Tsai et al 15 demonstrated that greatest case volume was associated with significantly lower 30-day readmission rates among Medicare patients undergoing colectomy and that lower hospital mortality rates were significantly associated with decreased readmissions. We also found that low procedure volume was associated with significantly increased odds for readmission among colorectal patients, regardless of MSH status; however, this was only demonstrated for the 90-day time frame.…”

Section: Discussionmentioning

confidence: 99%

Do hospital factors impact readmissions and mortality after colorectal resections at minority-serving hospitals?

Hechenbleikner

Zheng

Lawrence

et al. 2017

Surgery

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Background Minority-serving hospitals have greater readmission rates after operative procedures including colectomy; however, little is known about the contribution of hospital factors to readmission risk and mortality in this setting. This study evaluated the impact of hospital factors on readmissions and inpatient mortality after colorectal resections at minority-serving hospitals in the context of patient and procedure-related factors. Methods More than 168,000 patients who underwent colorectal resections in 374 California hospitals (2004–2011) were analyzed using the State Inpatient Database and American Hospital Association Hospital Survey data. Sequential logistic regression analyses were performed to determine the associations between minority-serving hospital status and 30-day, 90-day, and repeated readmissions. Results Thirty-day, 90-day, and repeated readmission rates were 11.2%, 16.9%, and 2.9%, respectively. Odds for 30-day, 90-day, and repeated readmissions after colorectal resections were 19%, 20%, and 38% more likely at minority-serving hospitals versus non-minority-serving hospitals, respectively (P < .01), after controlling for age, sex, comorbidities, year, and procedure type. Patient factors accounted for up to 65% of the observed increase in odds for readmission at minority-serving hospitals while hospital-level factors contributed roughly 40%. Inpatient mortality was significantly greater at minority-serving hospitals versus non-minority-serving hospitals (4.9% vs 3.8%; P <.001). Risk factors significantly associated with readmissions and inpatient mortality included Medicaid/Medicare primary insurance, emergent operation, and ostomy creation. Low procedure volume was significantly associated with increased odds for inpatient mortality. Conclusion Patient-level factors seemed to dominate the increased readmission risk after colorectal resections at minority-serving hospitals while hospital factors were less contributory. These findings need to be further validated to shape quality improvement interventions to decrease readmissions.

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Section: Discussionmentioning

confidence: 99%

Do hospital factors impact readmissions and mortality after colorectal resections at minority-serving hospitals?

Hechenbleikner

Zheng

Lawrence

et al. 2017

Surgery

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“…15–17 In a similar analysis by Hoehn and colleagues, 18 worse surgical outcomes and increased readmissions were found at SNHs when compared with non-SNHs. The observed higher mortality, readmission rates, and cost of care were largely attributed to hospital-related factors rather than patient-related factors.…”

Section: Discussionmentioning

confidence: 67%

“…The observed higher mortality, readmission rates, and cost of care were largely attributed to hospital-related factors rather than patient-related factors. 18 These findings were reinforced by a recent systematic review that found that SNHs had worse performance than non-SNHs in measures of timeliness and patient-centeredness, with less equitable surgical care. 19 These investigations, together with ours, suggest that increased SNH readmission rates might be driven predominantly by hospitals rather than patient factors.…”

Section: Discussionmentioning

confidence: 96%

“…18,19 Similar to a systematic review by Mouch and colleagues, 19 which evaluated the quality of SNHs based on hospital factors of safety, effectiveness, efficiency, timeliness, patient-centeredness, and equity, our study focused on hospital factors, such as number of beds, ownership status, teaching status, and having a Commission on Cancer-designated cancer program within the American Hospital Association database. Although different variables were analyzed for patient care outcomes at SNH, both studies revealed hospital-based infrastructures that were inferior to those of non-SNHs.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Vulnerable Hospitals and Cancer Surgery Readmissions: Insights into the Unintended Consequences of the Patient Protection and Affordable Care Act

Hong

Zheng

Hechenbleikner

et al. 2016

Journal of the American College of Surgeons

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BACKGROUND Penalties from the Hospital Readmission Reduction Program can push financially strained, vulnerable patient-serving hospitals into additional hardship. In this study, we quantified the association between vulnerable hospitals and readmissions and examined the respective contributions of patient- and hospital-related factors. METHODS A total of 110,857 patients who underwent major cancer operations were identified from the 2004–2011 State Inpatient Database of California. Vulnerable hospitals were defined as either self-identified safety net hospitals (SNHs) or hospitals with a high percentage of Medicaid patients (high Medicaid hospitals [HMHs]). We used multivariable logistic regression to determine the association between vulnerable hospitals and readmission. Patient and hospital contributions to the elevation in odds of readmission were assessed by comparing estimates from models with different subsets of predictors. RESULTS Of the 355 hospitals, 13 were SNHs and 31 were HMHs. After adjusting for Hospital Readmission Reduction Program variables, SNHs had higher 30-day (odds ratio [OR] = 1.32; 95% CI, 1.18–1.47), 90-day (OR = 1.28; 95% CI, 1.18–1.38), and repeated readmissions (OR = 1.33; 95% CI, 1.18–1.49); HMHs also had higher 30-day (OR = 1.18; 95% CI, 1.05–1.32), 90-day (OR = 1.28; 95% CI, 1.16–1.42), and repeated readmissions (OR = 1.24; 95% CI, 1.01–1.54). Compared with patient characteristics, hospital factors accounted for a larger proportion of the increase in odds of readmission among SNHs (60% to 93% vs 24% to 39%), but a smaller proportion among HMHs (9% to 15% vs 60% to 115%). CONCLUSIONS Vulnerable status of hospitals is associated with higher readmission rates after major cancer surgery. These findings reinforce the call to account for socioeconomic variables in risk adjustments for hospitals who serve a disproportionate share of disadvantaged patients.

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“…Based on outpatient days, only 1% of the population has commercial insurance, 10% uninsured, 57% Medi-Cal, 21% Medicare, and the remaining 11% covered by other mostly public sources [51]. Others have categorized hospitals according to safety-net burden, with high-burden ranging from 33 or 36% to 100% of patients as those with Medicaid or no coverage [52, 53]. …”

Section: Methodsmentioning

confidence: 99%

Implementation science for ambulatory care safety: a novel method to develop context-sensitive interventions to reduce quality gaps in monitoring high-risk patients

McDonald

Lisker

et al. 2017

Implementation Sci

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Background: Missed evidence-based monitoring in high-risk conditions (e.g., cancer) leads to delayed diagnosis. Current technological solutions fail to close this safety gap. In response, we aim to demonstrate a novel method to identify common vulnerabilities across clinics and generate attributes for context-flexible population-level monitoring solutions for widespread implementation to improve quality.

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Effect of Hospital Safety-Net Burden on Cost and Outcomes After Surgery

Cited by 157 publications

References 42 publications

Do hospital factors impact readmissions and mortality after colorectal resections at minority-serving hospitals?

Do hospital factors impact readmissions and mortality after colorectal resections at minority-serving hospitals?

Vulnerable Hospitals and Cancer Surgery Readmissions: Insights into the Unintended Consequences of the Patient Protection and Affordable Care Act

Implementation science for ambulatory care safety: a novel method to develop context-sensitive interventions to reduce quality gaps in monitoring high-risk patients

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