Catherine Nash
Credit: Columbia University Department of Pediatrics
A new study found that only a small percentage of hospitals succeeded in ensuring readmissions fairly when broken down by race and insurance type.
“Equity weighting has been proposed as a potential way to address the shortcomings associated with simple stratification,” the researchers wrote. “Our study builds on this recent work and advances the field by interrogating hospital performance on a hospital-level readmission measure.”
Health care systems have strived to identify disparities in health care, such as mortality, life expectancy, burden of disease, mental health, uninsured or underinsured, and lack of access to care.2 Researchers in a new cross-sectional study, led by Katherine A. Nash, MD, MHS, of the Department of Pediatrics at Columbia University Vagelos College of Physicians and Surgeons, noted that there are insufficient designs for equity in hospitals.2
The current study sought to measure fair readmission rates, identify hospitals with fair readmission rates, and compare hospitals with fair readmission rates to hospitals without fair readmission rates.
Specifically for comparison, researchers looked for patient demographics, hospital characteristics, insurance type (dual-eligible vs. non-dual-eligible), and hospital performance on measures such as quality, cost and value. Hospital characteristics of interest included average disproportionate share of patients in the hospital, average percentage of Medicaid/dual Medicare eligible patients who were black, ownership status, teaching status, urbanicity, geographic location, number of staff beds, and percentage of nurses To the beds.
For the purpose of the analysis, high quality was defined as a score of 4 or 5 on the Hospital Care Compare, which evaluates readmissions, mortality, patient experience, and timely and effective care. In contrast, low quality was defined as CMS Medicare spending per beneficiary grade in the lowest quartile of all hospitals.
The team obtained Medicare data from July 2018 to June 2019 and examined 4,638 hospitals that qualified for the Hospital-Level Readmissions Measure from the Centers for Medicare and Medicaid Services. To determine what constitutes equitable readmission, researchers evaluated hospitals based on two criteria: outcomes for populations at risk for disparities and disparities in care within patient populations in hospitals.
“We found that among eligible hospitals, 17% provided equitable readmissions to dual eligible beneficiaries and 30% to black beneficiaries,” the investigators wrote. “These hospitals had readmission rates at or below the national average for at-risk groups, and they had narrow performance gaps between at-risk and non-at-risk groups within their patient population.”
In hospitals, 74% had dual eligible patients and 42% had black patients. Only 17% had fair readmission rates by insurance and 30% by race. However, hospitals with readmission equity by insurance or race had a lower proportion of black patients (insurance, 1.9%; 1.9% (interquartile range (IQR), 0.2%-8.8%)) versus 3.3% (IQR). , 0.7%-10.8%)., s <.01; Race, 7.6% (IQR, 3.2%-16.6%) versus 9.3% (IQR, 4.0%-19.0%); s = .01)
As for insurance, the researchers found that hospitals with lower costs were more likely to equitably readmissions to dually eligible beneficiaries (odds ratio (OR), 1.57; 95% CI, 1.38 – 1.77) and observed no relationship between quality, value, and cost. justice. Hospitals with higher overall quality were more likely to have equitable readmissions and more black beneficiaries (OR, 1.14; 95% CI, 1.03 – 1.26) with no relationship between cost, value, and equity.
The researchers noted that Medicare administrative data have relatively high validity for black race, which may influence the results. In addition, defining high quality, low cost, and high value can hide subtle relationships. Because hospitals with equitable readmissions had fewer Black patients, the findings revealed racial inequities, the team concluded, writing.
“These findings reinforce the structurally determined fact that hospitals serving higher proportions of black patients often provide lower quality care,” the team wrote. “This phenomenon reflects structural racism rooted in unequal reimbursement for Medicaid compared to other public and private payers, and systemic disinvestment in both hospitals and communities that serve predominantly Black individuals.”
References
- Nash KA, Weerahande H, Yu H, et al. Measuring readmission equity as a distinct assessment of hospital performance. Gamma. 2024;331(2):111-123. doi:10.1001/jama.2023.24874
- 6 examples of health disparities and potential solutions. University of Southern California. November 17, 2023. https://healthadministrationdegree.usc.edu/blog/examples-of-health-disparities. Accessed January 9, 2024.