Elderly Medicare black patients have a higher 30-day hospital readmission rate for several conditions including congestive heart failure and pneumonia compared to white patients, that is related in part to higher readmission rates among hospitals that disproportionately care for black patients, according to a study in the February 16 issue of JAMA.1
"Racial disparities in health care are well documented, and eliminating them remains a national priority. Reducing readmissions has become a policy focus because it represents an opportunity to simultaneously improve quality and reduce costs, yet little is known about racial disparities in this area," according to background information in the article. "Understanding whether and why there are racial disparities in readmissions has implications for efforts to reduce readmissions."
Karen E. Joynt, M.D., M.P.H., of the Harvard School of Public Health and Brigham and Women's Hospital, Boston, and colleagues conducted a study to determine whether black patients have higher odds of readmission than white patients and whether these disparities are related to where black patients receive care. They categorized hospitals as "minority-serving" (the 10 percent of hospitals serving the most black patients) vs. "non-minority serving" (the other 90 percent of hospitals). Using national Medicare data, the researchers examined 30-day readmissions after hospitalization for acute myocardial infarction (MI; heart attack), congestive heart failure (CHF), and pneumonia and determined the odds of readmission for black patients compared with white patients at minority-serving vs. non-minority-serving hospitals. Of the 3,163,011 discharges (from 2006-2008) in this data sample, 276,681 (8.7 percent) were for black patients and 2,886,330 (91.3 percent) were for white patients, and about 40 percent of black patients and 6 percent of white patients were cared for at hospitals designated as minority-serving.
The researchers found that overall, black patients had 13 percent higher odds of all-cause 30-day readmission than white patients (24.8 percent vs. 22.6 percent) and patients discharged from minority-serving hospitals had 23 percent higher odds of readmission than patients from non-minority-serving hospitals (25.5 percent vs. 22.0 percent). Among patients with acute MI, black patients had 13 percent higher odds of readmission, irrespective of the site of care, while patients from minority-serving hospitals had 22 percent higher odds of readmissions, even accounting for patient race.
The authors also found that white patients at non-minority-serving hospitals consistently had the lowest odds of readmission and that black patients at minority-serving hospitals had the highest odds. Among patients with heart attack, using white patients at non-minority-serving hospitals as the reference group, black patients at minority-serving hospitals (35 percent higher odds), white patients at minority-serving hospitals (23 percent higher odds), and black patients at non-minority-serving hospitals (20 percent higher odds) had progressively higher odds of readmission. The results were similar for CHF and pneumonia.
"We found that the association of readmission rates with the site of care was consistently greater than the association with race, suggesting that racial disparities in readmissions are, at least in part, a systems problem—the hospital at which a patient receives care appears to be at least as important as his/her race," the researchers write.
"Our findings that racial disparities in readmissions are related to both patient race and the site where care is provided should spur clinical leaders and policy makers to find new ways to reduce disparities in this important health outcome."
Effective approaches that address the health care system's shortcomings on disparities in readmission rates are needed, write Adrian F. Hernandez, M.D., M.H.S., and Lesley H. Curtis, Ph.D., of the Duke University School of Medicine, Durham, N.C., in an accompanying editorial.2
"Rather than a one-size-fits-all approach, programs should be developed that address the specific needs of vulnerable patients and the hospitals that care for them. Hospitals in one area of the country may have different needs than hospitals in other areas, because of local infrastructure, resources, access to care, and integration of outpatient practices. To varying degrees, hospitals face enduring extrinsic problems, such as patient populations with inadequate social support, less healthy lifestyles, and higher rates of mental illness, as well as factors directly related to heart failure, acute myocardial infarction, and pneumonia. Policies that promote care outside the hospital in areas with these challenges are needed to ensure that vulnerable patient populations do not continue to receive the majority of their health care in hospital settings."
1. JAMA 2011;305:675-681.
2. JAMA 2011;305:715-716.