Few Hospitals Achieve Equitable Readmissions by Race, Insurance

Katherine Nash

Credit: Columbia University Department of Pediatrics

Only a small percentage of hospitals were successful in ensuring equitable readmissions when stratified by race and insurance type, a new study found.1

“Equity weighting has been proposed as a potential method to address shortcomings associated with simple stratification,” wrote investigators. “Our study builds on this recent work and advances the field by interrogating hospital performance on the Hospital-Wide Readmission measure.”

Healthcare systems have strived to identify healthcare disparities, such as mortality, life expectancy, burden of disease, mental health, uninsured or underinsured, and lack of access to care.2 Investigators of a new cross-sectional study, led by Katherine A. Nash, MD, MHS, from the department of pediatrics at Columbia University Vagelos College of Physicians and Surgeons, pointed out there is a lack of sufficient designs to bring equity to hospitals.2

The current study sought to measure equitable readmission rates, identify hospitals with equitable readmission rates, and compare hospitals with equitable readmission rates to hospitals without equitable readmissions.

Specifically for the comparison, the investigators 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 mean Disproportionate Share Hospital Patient Percentage, mean percentage of patients Medicaid/Medicare dual-eligible and Black, ownership status, teaching status, urbanicity, geographic location, number of staffed beds, and nurse-to-bed ratio.

For the purpose of analysis, high quality was defined as a score of 4 or 5 rating on the Hospital Care Compare, which evaluates readmission, mortality, patient experience, timely, and effective care. In contrast, low quality was defined as CMS Medicare spending per beneficiary score in the lowest quintile of all hospitals.

The team obtained Medicare data from July 2018 – June 2019 and examined 4638 hospitals eligible for the Centers for Medicare and Medicare Services Hospital-wide Readmission measure. To determine what was equitable readmission, the investigators evaluated hospitals on 2 criteria: outcomes for populations at risk for disparities and disparities in care within hospitals’ patient populations.

“We found that among eligible hospitals, 17% provided equitable readmissions for dual eligible beneficiaries and 30% for Black beneficiaries,” investigators wrote. “Those hospitals had readmission rates at or below the national median for at-risk groups and had narrow gaps in performance between at-risk and not at-risk groups within their own patient population.”

In the hospitals, 74% had dual-eligible patients and 42% had Black patients. Only 17% had equitable readmission rates by insurance and 30% by race. Though, hospitals with equitable readmissions by insurance or race had a lower percentage of Black patients (insurance, 1.9%; 1.9% [interquartile range [IQR], 0.2% - 8.8%] vs 3.3% [IQR, 0.7%-10.8%], P < .01; race, 7.6% [IQR, 3.2% - 16.6%] vs 9.3% [IQR, 4.0% - 19.0%]; P = .01)

As for insurance, the investigators found hospitals with low costs were more likely to have equitable readmissions for dual-eligible beneficiaries (odds ratio [OR], 1.57; 95% CI, 1.38 – 1.77) and noted no relationship between quality, value, and equity. Hospitals with high overall quality were more likely to have fair readmissions and more Black beneficiaries (OR, 1.14; 95% CI, 1.03 – 1.26) with no relationship between cost, value, and equity.

The investigators noted Medicare administrative data has relatively high validity for Black race, which could have affected the results. Additionally, defining high quality, low cost, and high value could hide subtle relationships. The team concluded writing since hospitals with equitable readmissions had fewer Black patients, the findings reveal racial inequities.

“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 embedded in the unequal reimbursement of Medicaid compared to other public and private payors, and systemic disinvestment in both hospitals and communities that predominantly serve Black individuals.”

^References

1. ^{Nash KA, Weerahandi H, Yu H, et al. Measuring Equity in Readmission as a Distinct Assessment of Hospital Performance. JAMA. 2024;331(2):111-123. doi:10.1001/jama.2023.24874}
2. ^{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.}