WASHINGTON — A new probe into why colorectal surgery patients end up back in the hospital after surgery suggests that it has less to do with the hospital or treatment received but rather more determined by patient factors such as race, income, and insurance status.
The study underscores the vast challenge in leveling health disparities especially as some hospitals that serve these populations face disproportionately harsh penalties for outcomes directly impacted by such factors.
The Hospital Readmission Reduction Program (HRRP), put in place in 2012 by the U.S. Centers for Medicare & Medicaid Services (CMS), 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 expectations, imposing more than $500 million in fines.
Under debate is whether hospitals treating a large number of socially disadvantaged patients — individuals who may not be able to afford their medications or lack a supportive social environment — should receive extra consideration. CMS posits that all hospitals should be held to the same standard, says the study's senior investigator, Waddah B. Al-Refaie, MD, FACS, surgeon-in-chief at Georgetown Lombardi Comprehensive Cancer Center and chief of surgical oncology at MedStar Georgetown University Hospital (GUH).
According to Al-Refaie, numerous studies, however, have shown that patient factors do make a difference in the risk of readmission.
"Minority-serving status of a hospital is important," he says. "These hospitals typically serve as a safety net in low-income communities; their patients tend to have more co-morbidities and less resources to support their health."
Writing in the journal Surgery published online Oct. 28, 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," says Al-Refaie.
Al-Refaie, along with a team of researchers at MedStar GUH and MedStar Health Research Institute, set out to look at outcomes in colorectal surgery, a common procedure in the U.S. each year as 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 (47) of these hospitals were considered minority-serving hospitals for having a high percentage of minority patients. Hispanic and black patients comprise 63 percent of the patient population in minority-serving hospitals, compared with 17 percent in other hospitals.
After discounting patient's age, sex, comorbidities, and 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. The rate in minority-serving hospitals, in comparison, was 13.6 percent, 20.1 percent, and 4.0 percent, respectively. Inpatient mortality was also significantly higher at minority-serving hospitals (4.9 percent) compared to non-minority-serving hospitals (3.8 percent).
Mining the data further, the investigators found that patient factors (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 (such as procedure volume and procedure type) accounted for up to 40 percent.
"These findings suggest that CMS should account for patient socio-economic factors when they compare readmission rates," says Al-Refaie.
"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 says. "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."
Study co-authors include Elizabeth M. Hechenbleikner, MD, Chaoyi Zheng, MS, Samuel Lawrence, Young Hong, MD, and Lynt B. Johnson, MD, from MedStar Georgetown University Hospital, and Nawar Shara, PhD, of the MedStar Health Research Institute.
The research was supported by a National Cancer Institute Cancer Center Support Grant (#P30 CA051008) to Georgetown Lombardi. The authors report having no personal financial interests related to the study.
About Georgetown Lombardi Comprehensive Cancer Center
Georgetown Lombardi Comprehensive Cancer Center is designated by the National Cancer Institute as a comprehensive cancer center — the only cancer center of its kind in the Washington, DC area. A part of Georgetown University Medical Center and MedStar Georgetown University Hospital, Georgetown Lombardi seeks to improve the diagnosis, treatment, and prevention of cancer through innovative basic and clinical research, patient care, community education and outreach, and the training of cancer specialists of the future. Connect with Georgetown Lombardi on Facebook (Facebook.com/GeorgetownLombardi) and Twitter (@LombardiCancer).
About Georgetown University Medical Center
Georgetown University Medical Center (GUMC) is an internationally recognized academic medical center with a three-part mission of research, teaching and patient care (through MedStar Health). GUMC's mission is carried out with a strong emphasis on public service and a dedication to the Catholic, Jesuit principle of cura personalis — or "care of the whole person." The Medical Center includes the School of Medicine and the School of Nursing & Health Studies, both nationally ranked; Georgetown Lombardi Comprehensive Cancer Center, designated as a comprehensive cancer center by the National Cancer Institute; and the Biomedical Graduate Research Organization, which accounts for the majority of externally funded research at GUMC including a Clinical and Translational Science Award from the National Institutes of Health. Connect with GUMC on Facebook (Facebook.com/GUMCUpdate), Twitter (@gumedcenter) and Instagram (@gumedcenter).