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Study finds social, community factors affect readmissions

476243761Aside from quality of care, there are other factors — out of providers’ control — that affect whether a patient is readmitted to the hospital. 

These factors include poverty level, living alone, and age. All of these affect a person’s chances of being readmitted to a hospital after discharge, despite the quality of care provided the hospital.

At least that’s what a new study by Henry Ford Health System researchers found. The links between readmission rates and social factors suggest readmission isn’t  just an issue of quality care patients receive at the hospital.

“The use of readmission rate as a basis for financial penalties to hospitals assumes that readmissions are a result of poor-quality care,” Jianhui Hu, a research associate at the Henry Ford’s Center for Health Policy and Health Services Research, said in a press release. “Our team found that there is much more to it than that.”

Active debate

The Affordable Care Act (ACA) established the Hospital Readmissions Reduction Program, which reduces payments to hospitals with “excess” 30-day readmissions. However, the study noted that the proper role of readmission data as a measure of hospital quality is under active debate in the healthcare policy arena.

Reason: Earlier studies suggested that readmissions are a product of a complex set of factors — one of which is quality of care. Many of those studies used data collected from hundreds of hospitals nationwide, where it’s often hard to separate effects of variables like poverty from effects of variations in the quality of care provided by hospitals serving low-income patients.

“Few of them identified and controlled for various hospital-specific factors that might be related to readmission, such as staffing, organizational structure, discharge-planning protocols and the hospital’s role in an integrated system of care,” Hu explains.

Effects of socioeconomic status

To account for all of that, the researchers studied data from one urban hospital – Henry Ford Hospital in Detroit. By doing this they could determine the effects of patients’ socioeconomic status under a single, fixed organizational and staffing structure, and standard protocols of care for all patients.

The researchers identified Medicare fee-for-service patients age 65 and older who were discharged in 2010 from Henry Ford Hospital. They also excluded all patients who died in the hospital, were discharged against medical advice or were hospitalized for certain special treatments. The final study group included 4,646 patients.

Then the researchers mapped patients’ addresses to census data to determine neighborhood socioeconomic factors, including percentage of families with incomes below the federal poverty level, median household income and percentage of the population older than 25 without a high school diploma.

Study results

The study revealed: 80% of the 4,646 patients had no 30-day readmissions during the year, and 5% had multiple readmissions.

It also found:

  • married patients were less likely to be readmitted
  • older male patients were more likely to have at least one readmission compared to young and female patients, and
  • patients with congestive heart failure, acute myocardial infarction and certain types of diseases (end-stage liver disease, acute renal failure, diabetes and malnutrition) were at significantly higher risk of being readmitted.

These findings suggest that effects of social factors at the patient and community levels were not confounded with variations in hospital resources.

And according to Hu, it should add to the debate of refining the Centers for Medicare & Medicaid Services’ (CMS) readmissions measures for hospital reimbursement by raising the questions:

  • Are demographic and socioeconomic factors empirically associated with risk of readmission?
  • Do some hospitals treat a disproportionate share of patients who are at higher risk for readmission?
  • Should hospitals be responsible for taking actions to address socioeconomic disparities in risk of readmission and if so, is there a limit on what they should or can do?

“Whether hospitals should be held accountable for the effects of poverty, illiteracy, lack of proficiency in English or lack of social support in the patients and communities they serve has not yet been resolved,” Hu says. “Our findings underscore the importance of reaching consensus on this issue and, if appropriate, changing the risk-adjustment models, related penalties or both.”

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