JAMA: Black, elderly patients see higher readmissions, overhaul needed
African-American and elderly Medicare recipients are more likely to be readmitted to the hospital after cases of acute MI, congestive heart failure and pneumonia when compared with whites, according to a study published in the Feb. 16 issue of the Journal of the American Medical Association.

“Disparities in healthcare are well documented and remain present and understanding more about why they might exist is really important in figuring out how to address them,” lead author Karen E. Joynt, MD, MPH, of the Harvard School of Public Health and Brigham and Women’s Hospital in Boston, told Cardiovascular Business News.

Joynt and colleagues used national Medicare data to study 30-day readmission rates for acute MI, congestive heart failure (CHF) and pneumonia to assess whether or not black patients had higher odds of readmission than white patients and what the disparities were related to.

“Readmission rates are particularly important because it’s getting a lot of health policy play. It’s a situation where reducing readmissions could both reduce cost and improve quality at the same time and there aren’t a lot of places in healthcare where that’s the case,” Joynt offered.

Joynt and colleagues studied the files of more than 3.1 million Medicare fee-for-service recipients who were discharged from the hospital between 2006 and 2008. Of this sample, 8.7 percent were black and 91.3 percent were white.

For all three conditions, black patients were younger, more likely to be women and had higher rates of diabetes, hypertension, chronic kidney disease and obesity compared with whites.

Black patients had 13 percent higher odds of all-cause 30-day readmission when compared with white patients.

The researchers reported that black patients had higher rates of readmissions when compared with white patients, 24.8 percent versus 22.6 percent. Patients who were treated at minority-serving hospitals also had higher rates of readmission compared with those patients treated at non-minority serving hospitals, 25.5 percent versus 22 percent, respectively.

Seventy percent of the minority-serving hospitals were located in the South and also were more likely to be teaching hospitals, have fewer nurses per 1,000 patient-days and have lower performance on Hospital Quality Alliance measures.

Black patients treated at minority-serving hospitals had the highest rates of readmission, 26.4 percent, and white patients treated at minority-serving hospitals had lower readmission rates compared with blacks, 24.6 percent. Black patients treated at non-minority serving hospitals had a readmission rate that was equal to 23.3 percent.

“We weren’t able to determine why some of these groups were at a higher risk for readmission but we can theorize that it may be because they have less access to high quality outpatient, transitional care programs or disease management programs and perhaps less of a  social support system or difficulty obtaining medications and appointments,” says Joynt.

In an accompanying editorial, Adrian Hernandez, MD, and Lesley H. Curtis, PhD, both of the Duke University School of Medicine in Durham, N.C., outlined how 30-day readmission rates may not be the most reliable predictor of hospital quality.

Rather than a sole focus on 30-day outcomes, Hernandez told Cardiovascular Business News, there should be more emphasis placed on 30-day mortality rates in combination with 30-day readmission rates or analyzing how well hospitals are performing in terms of length of stay.

In addition, Hernandez offered that “there should be policies that help reward hospitals that improve over time as well as meet the challenges for vulnerable patient populations that may have differences in terms of support systems or access to care or other factors that contribute to readmission after they leave the hospital door.

“Right now, we have silos of care that are focused on the inpatient side and also silos of care that are focused on the outpatient side; we need incentives to encourage those two to come together,” he said.

Hernandez said there is limited evidence as to how hospitals can go about reducing readmission rates, so a better focus should be on finding the best delivery of care systems and new technologies or interventions that help manage patients 30 days after a hospital discharge.

Like Hernandez, Joynt said that readmission rates may not be the greatest marker of hospitals' quality and new and innovative ways to improve the transition of care are necessary.

“A hospital is certainly responsible for what happens within its walls, but once that patient leaves the hospital there is such a complex set of things that need to happen for that patient to be able to get the care, advice and support as well as the medicines and nutrition he or she needs,” said Joynt.

“It takes a village and holding the hospital responsible for things that happen after the patient has been discharged from the hospital after a full month has been particularly tricky when you are talking about a situation which the resources for certain patient populations may be pretty different,” she said

Joynt said future studies must focus not so much on specific patient populations but instead on what strategies can be put in place to make outcomes better.