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Challenges in Reducing Readmissions: Lessons from Leadership and Frontline Personnel at Eight Minority-Serving Hospitals.

ABSTRACT: BACKGROUND:Hospitals that serve minority patients have higher readmission rates than other hospitals and, as a result, receive higher penalties under the federal government's Hospital Readmissions Reduction Program. A study was conducted to determine how minority-serving hospitals are responding to federal readmissions policy and whether they face specific challenges as they work to reduce readmissions. METHODS:In-depth case studies were created for eight minority-serving hospitals, selected to reflect a range of geographies and sizes. Semistructured interviews with hospital leaders and frontline personnel focused on knowledge of readmission rates and prioritization of readmission reduction, strategies to reduce readmissions, barriers to reducing readmissions, and opinions about federal readmissions policy. RESULTS:Each hospital had only a general awareness of its performance on readmissions metrics but placed a high priority on reducing readmissions, largely spurred by federal readmissions policy. Respondents reported that socioeconomics, rather than race alone, was a key factor in readmissions reduction. The hospitals followed a similar progression in strategies to reduce readmissions-moving from working on the discharge process to creating customized approaches to transitional care to, finally, focusing more on building community supports and resources. Salient barriers to reducing readmission rates included scarce resources, the variety of patient needs, limited ability to influence care in the community, and a misalignment of financial incentives. CONCLUSIONS:Among eight hospitals serving a high proportion of minority patients, the findings uncovered the importance of addressing issues specific to the patient population and community and reaching outside the walls of the hospital to implement programs that improve outpatient access and management.

SUBMITTER: Joynt KE

PROVIDER: S-EPMC6948718 | biostudies-literature | 2014 Oct

REPOSITORIES: biostudies-literature

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Challenges in Reducing Readmissions: Lessons from Leadership and Frontline Personnel at Eight Minority-Serving Hospitals.

Joynt Karen E KE Sarma Nandini N Epstein Arnold M AM Jha Ashish K AK Weissman Joel S JS

Joint Commission journal on quality and patient safety 20141001 10

<h4>Background</h4>Hospitals that serve minority patients have higher readmission rates than other hospitals and, as a result, receive higher penalties under the federal government's Hospital Readmissions Reduction Program. A study was conducted to determine how minority-serving hospitals are responding to federal readmissions policy and whether they face specific challenges as they work to reduce readmissions.<h4>Methods</h4>In-depth case studies were created for eight minority-serving hospital ...[more]

PMID: 26111303

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Project description:Minority-serving hospitals have greater readmission rates after operative procedures including colectomy; however, little is known about the contribution of hospital factors to readmission risk and mortality in this setting. This study evaluated the impact of hospital factors on readmissions and inpatient mortality after colorectal resections at minority-serving hospitals in the context of patient- and procedure-related factors.More than 168,000 patients who underwent colorectal resections in 374 California hospitals (2004-2011) were analyzed using the State Inpatient Database and American Hospital Association Hospital Survey data. Sequential logistic regression analyses were performed to determine the associations between minority-serving hospital status and 30-day, 90-day, and repeated readmissions.Thirty-day, 90-day, and repeated readmission rates were 11.2%, 16.9%, and 2.9%, respectively. Odds for 30-day, 90-day, and repeated readmissions after colorectal resections were 19%, 20%, and 38% more likely at minority-serving hospitals versus non-minority-serving hospitals, respectively (P < .01), after controlling for age, sex, comorbidities, year, and procedure type. Patient factors accounted for up to 65% of the observed increase in odds for readmission at minority-serving hospitals while hospital-level factors contributed roughly 40%. Inpatient mortality was significantly greater at minority-serving hospitals versus non-minority-serving hospitals (4.9% vs 3.8%; P < .001). Risk factors significantly associated with readmissions and inpatient mortality included Medicaid/Medicare primary insurance, emergent operation, and ostomy creation. Low procedure volume was significantly associated with increased odds for inpatient mortality.Patient-level factors seemed to dominate the increased readmission risk after colorectal resections at minority-serving hospitals while hospital factors were less contributory. These findings need to be further validated to shape quality improvement interventions to decrease readmissions.

Project description:BackgroundRisk factors common to nursing home (NH) residents are potentially not fully captured by the Hospital Readmissions Reduction Program (HRRP). The unique challenges faced by hospitals that disproportionately serve NH residents who are at greater risk of readmissions have not been studied.MethodsUsing 100% Medicare Provider Analysis and Review File and the Minimum Data Set from 2010-2013, we constructed a measure of hospital share of NH-originating hospitalizations (NOHs). We defined hospital share of NOHs as the proportion of inpatient stays by patients aged 65 or older who were directly admitted from NHs. To evaluate the impact of the share of NOHs on readmission penalties, we categorized hospitals into quartiles according to their share of NOHs and estimated the differences in the adjusted penalties across hospital quartiles after accounting for hospital characteristics, market characteristics and state fixed effects. We repeated the analyses for the penalties incurred in each year between 2015 and 2019.ResultsHospitals varied substantially in the share of NOHs (median [interquartile range], 11.3% [8.2%-15.1%]), with limited variation over time. In 2015, hospitals in the highest quartile of NOH received on average 0.58% Medicare payment reduction compared to 0.44% reduction among those in the lowest quartile (32.9% higher penalties, p < 0.001). The increase in penalties continued to grow in 2017 and 2018 when the HRRP expanded to include additional target conditions (47.3% and 66.7%, respectively, p < 0.001 for both). Although the effect diminished in 2019 following the additional adjustment for hospital's dual-eligible share, hospitals in the highest quartile of NOH still incurred 43.0% (p < 0.001) higher penalties than those in the lowest quartile.ConclusionsHospitals varied considerably in their share of NOHs. Hospitals having a higher share of NOHs were disproportionately penalized for excess readmissions, even under the revised policy that adjusts for the share of dual-eligible admissions.

Project description:Rationale: Whether critical care improvements over the last 10 years extend to all hospitals has not been described.Objectives: To examine the temporal trends of critical care outcomes in minority and non-minority-serving hospitals using an inception cohort of critically ill patients.Measurements and Main Results: Using the Philips Health Care electronic ICU Research Institute Database, we identified minority-serving hospitals as those with an African American or Hispanic ICU census more than twice its regional mean. We examined almost 1.1 million critical illness admissions among 208 ICUs from across the United States admitted between 2006 and 2016. Adjusted hospital mortality (primary) and length of hospitalization (secondary) were the main outcomes. Large pluralities of African American (25%, n = 27,242) and Hispanic individuals (48%, n = 26,743) were cared for in minority-serving hospitals, compared with only 5.2% (n = 42,941) of white individuals. Over the last 10 years, although the risk of critical illness mortality steadily decreased by 2% per year (95% confidence interval [CI], 0.97-0.98) in non-minority-serving hospitals, outcomes within minority-serving hospitals did not improve comparably. This disparity in temporal trends was particularly noticeable among African American individuals, where each additional calendar year was associated with a 3% (95% CI, 0.96-0.97) lower adjusted critical illness mortality within a non-minority-serving hospital, but no change within minority-serving hospitals (hazard ratio, 0.99; 95% CI, 0.97-1.01). Similarly, although ICU and hospital lengths of stay decreased by 0.08 (95% CI, -0.08 to -0.07) and 0.16 (95% CI, -0.16 to -0.15) days per additional calendar year, respectively, in non-minority-serving hospitals, there was little temporal change for African American individuals in minority-serving hospitals.Conclusions: Critically ill African American individuals are disproportionately cared for in minority-serving hospitals, which have shown significantly less improvement than non-minority-serving hospitals over the last 10 years.

Project description:Racial/ethnic differences in palliative care resource use after stroke have been recognized, but it is unclear whether patient or hospital characteristics drive this disparity. We sought to determine whether palliative care use after intracerebral hemorrhage and ischemic stroke differs between hospitals serving varying proportions of minority patients.Population-based cross-sectional study.Inpatient hospital admissions from the Nationwide Inpatient Sample between 2007 and 2011.A total of 46,735 intracerebral hemorrhage and 331,521 ischemic stroke cases.Palliative care use.Intracerebral hemorrhage and ischemic stroke admissions were identified from the Nationwide Inpatient Sample between 2007 and 2011. Hospitals were categorized based on the percentage of ethnic minority stroke patients (< 25% minorities ["white hospitals"], 25-50% minorities ["mixed hospitals"], or > 50% minorities ["minority hospitals"]). Logistic regression was used to evaluate the association between race/ethnicity and palliative care use within and between the different hospital strata. Stroke patients receiving care in minority hospitals had lower odds of palliative care compared with those treated in white hospitals, regardless of individual patient race/ethnicity (adjusted odds ratio, 0.65; 95% CI, 0.50-0.84 for intracerebral hemorrhage and odds ratio, 0.62; 95% CI, 0.50-0.77 for ischemic stroke). Ethnic minorities had a lower likelihood of receiving palliative care compared with whites in any hospital stratum, but the odds of palliative care for both white and minority intracerebral hemorrhage patients was lower in minority compared with white hospitals (odds ratio, 0.66; 95% CI, 0.50-0.87 for white and odds ratio, 0.64; 95% CI, 0.46-0.88 for minority patients). Similar results were observed in ischemic stroke.The odds of receiving palliative care for both white and minority stroke patients is lower in minority compared with white hospitals, suggesting system-level factors as a major contributor to explain race disparities in palliative care use after stroke.

Dataset Information

Challenges in Reducing Readmissions: Lessons from Leadership and Frontline Personnel at Eight Minority-Serving Hospitals.

Publications

Challenges in Reducing Readmissions: Lessons from Leadership and Frontline Personnel at Eight Minority-Serving Hospitals.

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