Minding the Gap Between Efforts to Reduce Readmissions and Disparities

Abstract

HOSPITAL READMISSION IS COMMON AND EXPENsive, and longstanding variations in readmission rates nationwide suggest that the system of transitional care is flawed. The Centers for Medicare & Medicaid Services (CMS) began publicly reporting hospital readmission rates in 2009, leading hospitals and health care professionals to devote considerable attention and resources to reducing both readmission rates and disparities. The prospect of bundled payments for episodes of care, as described in the Patient Protection and Affordable Care Act of 2010, has further intensified this focus. Hospitals large and small have joined national initiatives, such as Hospital to Home, to exchange best practices, and they have been inundated with promising but largely unproven solutions for reducing readmission rates. In this issue of JAMA, Joynt and colleagues describe racial disparities in hospital readmission rates for 3 major clinical conditions and in so doing highlight a major challenge facing policies that reward and penalize hospitals on the basis of readmission rates. Using national Medicare data, the authors found that risk-adjusted 30-day readmission rates for heart failure, myocardial infarction, and pneumonia were higher for black patients than for white patients, even after adjustment for the proportion of patients at each site who were black, hospital teaching status, and other structural characteristics. The disparities also remained after adjustment for the proportion of patients covered by Medicaid at each site—a limited surrogate of socioeconomic status and financial stress. Moreover, readmission rates for heart failure and myocardial infarction were higher for white patients at minority-serving hospitals (ie, hospitals with relatively high proportions of black patients) than for black patients at non–minority-serving hospitals. Based on these findings, the authors conclude that financial incentives based on readmission rates may unfairly penalize minorityserving hospitals and thereby widen the gap in care for disadvantaged minorities. The study raises important questions about the unintended consequences of policies designed to improve the quality of health care. The Institute of Medicine’s landmark 2002 Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care report elevated the problem of racial and ethnic disparities to a national priority. Black patients are less likely to receive cardiovascular procedures, such as placement of implantable cardioverter-defibrillators, and are more likely to die of cardiovascular disease. Black patients are more likely to receive care at hospitals that provide lower quality of care, suggesting that hospitals have a large role in explaining disparities in care. There is some evidence that diseasebased quality-improvement programs reduce disparities, but a comprehensive approach to eliminating disparities has not been identified. Whether 30-day readmission rates are a good measure of hospital quality remains a subject of debate. According to one view, hospital readmission reflects a failure of the health care system. Patients are discharged without a complete understanding of their disease, including how to manage symptoms, when to take medications, and when and how to access follow-up care. Patients discharged to skilled nursing facilities are dependent on systems of care in place at those settings. According to another view, hospital readmission reflects factors that are intrinsic to a population of aging patients with complex disease processes, a high burden of comorbidity, impaired functional status, and limited social support. In this view, hospital readmission is not a failure, but is the right care at the right time. The risk models currently used by CMS to compare hospital outcomes do not incorporate race or socioeconomic status, even though prior studies have shown that both factors are associated with a higher risk of readmission. If quality of care differs by race, then excluding race from the risk models appropriately incentivizes hospitals and reinforces that disparate care is unacceptable. On the other hand, if race is a proxy for socioeconomic status and other factors unrelated to the system of care, exclusion of race from the risk models unfairly penalizes hospitals that care for vulnerable populations. The addition of financial penalties for hospitals treating vulnerable populations may paradoxically worsen care coordination and exacerbate health disparities. Because both sides are correct, a more progres-