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

Abstract

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.

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

“…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.…”

Hospital safety net burden is associated with increased inpatient mortality and postoperative morbidity after total hip arthroplasty: a retrospective multistate review, 2007–2014

“…10 Several studies have found that hospital factors such as safety net burden impact surgical outcomes. [31][32][33][34][35] Hoehn et al 21 reported that high safety net burden hospitals had higher postsurgical mortality and LOS; subgroup analysis of THA patients found increased costs with procedures performed at high burden hospitals but no mortality or readmissions difference. Jergesen and Yi 36 examined single surgeon lower extremity arthroplasties and found that early complications and reoperations were more common at a safety net hospital than a university medical center.…”

Is home parenteral nutrition safe for cancer patients? Positive effects and potential catheter‐related complications: A systematic review

“…In one study, it was found that the ratio of cancer patients who were admitted to the hospitals in the last 30 days of their lives due to a reason relating to cancer was 80% (Matter‐Walstra et al, ). In other studies, the ratio of cancer patients’ contacting emergency services and being admitted to the hospital again was 30% (Ang et al, ; Hong et al, ). The most important reason for these admissions was related to gastrointestinal problems such as nausea, vomiting and lack of oral intake within a range between 20% and 40% (Kunisawa et al, ; Merchant et al, ; Weaver et al, ).…”

“…In other studies, the ratio of cancer patients' contacting emergency services and being admitted to the hospital again was 30% (Ang et al, 2015;Hong et al, 2016). The most important reason for these admissions was related to gastrointestinal problems such as nausea, vomiting and lack of oral intake within a range between 20% and 40% (Kunisawa et al, 2016;Merchant et al, 2015;Weaver et al, 2006).…”

“…In cancer patients, depending on the type of primary tumour and degree of disease, weight loss and malnutrition in the range of 20% and 85% can develop (Aria Guerra et al, ; Bozzetti et al, ; Culine et al, ; Dreesen et al, ; Girke et al, ) and especially for patients with gastrointestinal system cancers or for cancer patients at the end of their lives, there is a requirement for Total Parenteral Nutrition (TPN) due to nausea vomiting and lack of oral intake (Bozzetti et al, ; Chermesh et al, ; Cotogni et al, ; Culine et al, ; Drissi et al, ; Higuera et al, ; Senesse et al, ). Patients having nausea and vomiting contact emergency services due to insufficient oral intake and thus are admitted to the hospital, or in countries such as Canada, Spain and USA Home Parenteral Nutrition (HPN) is offered (Ang et al, ; Gomez‐Candela et al, ; Higuera et al, ; Hong et al, ; Kunisawa, Fushimi, & Imanaka, ; Mackenzie & Gramlich, ; Merchant et al, ; Shatnawei et al, ; Weaver et al, ).…”