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



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.



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%).



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.
Department of Surgery, MedStar Georgetown University Hospital, Washington, DC.
Young
Y
Hong
Department of Surgery, MedStar Georgetown University Hospital, Washington, DC.
Chaoyi
C
Zheng
Department of Surgery, MedStar Georgetown University Hospital, Washington, DC.
Elizabeth
E
Hechenbleikner
Department of Surgery, MedStar Georgetown University Hospital, Washington, DC.
Lynt B
LB
Johnson
MedStar Health Research Institute, Washington, DC.
Nawar
N
Shara
Department of Surgery, MedStar Georgetown University Hospital, Washington, DC; MedStar Health Research Institute, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; Georgetown Lombardi Comprehensive Cancer Center, Washington, DC. Electronic address: wba6@georgetown.edu.
Waddah B
WB
Al-Refaie
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002140:California; D016208:Databases, Factual; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008484:Medicaid / Q000706:statistics & numerical data; D008875:Middle Aged; D009369:Neoplasms / Q000601:surgery*; D058991:Patient Protection and Affordable Care Act; D010359:Patient Readmission / Q000331:legislation & jurisprudence / Q000592:standards / Q000706:statistics & numerical data*; D019984:Quality Indicators, Health Care / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data*; D020379:Risk Adjustment; D064876:Safety-net Providers / Q000331:legislation & jurisprudence / Q000592:standards / Q000706:statistics & numerical data*; D014481:United States; D055815:Young Adult