Racial and Ethnic Disparities in 30-Day Readmissions An  Analysis  of  Connec.cut  Hospital  Discharge  Data  

Connec.cut  State  Medical  Society  and    Connec.cut  Health  Founda.on  Symposium  

 Tackling  Racial  and  Ethnic  Dispari3es  in  Connec3cut’s  Acute  

Care  Hospitals        

Robert  H.  Asel.ne,  Jr.,  PhD  February  4,  2015  

Collaborators and Contributors

•  MaG  Katz,  CSMS  

•  Catherine  Wagner,  CSMS  

•  Jun  Yan,  UCONN  

•  Greg  MaGhews,  Loyola  University  

•  Claudia  Gruss,  ProHealth    

•  Ross  Benthien,  HarTord  Hospital  

•  Courtland  Lewis,  HarTord  Hospital  

•  Steve  Fleischman,  Yale-­‐New  Haven  

•  Mark  DeFrancesco,  ACOG  •  Natalie  Achong,  Yale  

University  

Background •  Race  and  ethnic  dispari.es  in  hospital  readmissions  well  

documented:    –  Blacks  higher  than  Whites  for  diabetes,  AMI,  CHF,  pneumonia,  

cirrhosis,  TJA,  and  following  ambulatory  surgery  

–  Hispanics  higher  than  Whites  for  diabetes,  CHF,  AMI  

–  Rates  of  30  day  readmission  are  generally  10-­‐20%  higher  among  racial  and  ethnic  minori.es  

•  CT  appears  to  have  substan.al  dispari.es  in  health  outcomes  and  access  to  care  –  Connec.cut  Health  Founda.on  report  (2010)  –  10  year  analysis  –  Connec.cut  Health  Care  Survey  (2014)  

Overview  of  CSMS  Connec.cut  Hospital  Readmission  Ini.a.ve  

•  Calculate  30  day  readmission  rates  across  range  of  condi.ons/procedures  using  hospital  discharge  data  –  Expand  condi.ons  to  those  not  previously  studied  and  those  affec.ng  younger  pa.ents  

–  Control  for  pa.ent  characteris.cs  confounded  with  race  and  ethnicity:      

•  Pa.ent  sickness  and  comorbidi.es  

•  Pa.ent  SES  •  Insurance  coverage  (public  vs.  private)  

Overview  of  CSMS  Connec.cut  Hospital  Readmission  Ini.a.ve

•  Conducted  focus  groups  with  specialists  in  OB-­‐GYN,  orthopedic  surgery,  gastroenterology,  cardiology  – Discussed  role  of  pa.ent  sickness,  insurance  type  in  fostering  dispari.es  

– Discussed  unmeasured  factors  (e.g.,  pa.ent  engagement,  connec.on  to  primary  care,  pa.ent  –  provider  communica.on)  

– Discussed  poten.ally  strategies  to  address  dispari.es  

Overview  of  CSMS  Connec.cut  Hospital  Readmission  Ini.a.ve

•  Reported  hospital  specific  data  to  7  partner  ins.tu.ons  

–  Norwalk  Hospital,  Milford  Hospital,  Yale-­‐New  Haven  Hospital,  Bristol  Hospital,  St.  Mary’s  Hospital,  Rockville  General  Hospital,  Manchester  Memorial  Hospital  

–  Discussed  factors  that  might  account  for  beGer/worse  performance  than  State  

•  Disseminate  findings  in  peer-­‐reviewed  manuscripts  

Measures 30 Day Readmissions – Diagnosis-Related Groups (DRGs)

DRG   Condi*on   Number  of  Admissions  

%  30  Day  Readmissions  

775   Vaginal  Delivery   167,807   .8%  

766   Cesarean  Delivery   75,552   1.5%  

291,292   Heart  Failure   39,985   23.1%  

312,  313   Chest  Pain   23,450   9.8%  

332-­‐395   Esophagi.s,  Gastroenteri.s,  and  Misc  Diges.ve  Disorders   284,471   11.6%  

470   Total  Joint  Replacement  (ICD  9  CM  81.51,  81.52,  81.54,  81.56)   51,843     5.2%  

191-­‐193   Pneumonia   44,616   15.3%  

870-­‐872   Sep.cemia   40,306   18.0%  

602,  603   Celluli.s   27,943   11.9%  

689,690   Kidney  and  Urinary  Infec.ons   31,357   16.3%  

Measures •  Race/ethnicity:    pa.ent  or  facility  reported  •  Pa.ent  Sickness:  Elixhauser  AHRQ  comorbidity  index  

•  29  discrete  comorbid  and/or  complica.ng  medical  condi.ons    

• Up  to  10  primary  and  secondary  diagnoses  were  recorded  for  each  hospitaliza.on    

•  Pa.ent  age,  sex,  length  of  stay,  facility  volume,  payer  

Methods

•  Up  to  8  years  of  data  from  HIDD  (2005  -­‐  2012)  

•  Es.mated  logis.c  regression  models    – Used  generalized  es.ma.ng  equa.ons  to  account  for  clustering  of  observa.ons  within  person  (mul.ple  admissions)  

Results Race and Ethnic Differences in 30 Day Readmissions in

Connecticut Hospitals

2.05  

1.85  

1.62  

1.35  

1.27  

1.39  

1.12  

1.03  

1.19  

1.13  

1.09  

0.0   0.5   1.0   1.5   2.0   2.5  

Cesarean  Sec.on    

Vaginal  Delivery    

Total  Joint  Arthroplasty  

Sep.cemia  

Celluli.s  

Gastroenteri.s  -­‐  Surgical  

Gastroenteri.s  -­‐  Medical  

Heart  Failure  and  Shock  

Chest  Pain    

Kidney  Disease  

Pneumonia  

Black  vs.  White  –  Rela*ve  Risk    

*

**

**

**

*

*p  <  0.05  

30  Day  Readmissions  for  10  Common  Reasons  for  Hospitaliza.on  

30  Day  Readmissions  for  10  Common  Reasons  for  Hospitaliza.on  

1.56  

1.34  

1.52  

1.10  

0.86  

1.16  

1.00  

1.30  

1.07  

0.90  

1.04  

0.0   0.5   1.0   1.5   2.0   2.5  

Cesarean  Sec.on  

Vaginal  Delivery  

Total  Joint  Arthroplasty  

Sep.cemia  

Celluli.s  

Gastroenteri.s  -­‐  Surgical  

Gastroenteri.s  -­‐  Medical  

Heart  Failure  and  Shock  

Chest  Pain  

Kidney  Disease  

Pneumonia  

Hispanic  vs.  White  –  Rela*ve  Risk  

*  

*  

*  

*  

*p  <  0.05  

Facility  Level  Differences  Diseases  of  the  Circulatory  System  

0.5

0.7

0.9

1.1

1.3

1.5

1.7

1.9

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29

Black/White OR

13  

Race and Ethnic Differences in Insurance

Status and Patient Sickness

Race,  Ethnicity,  and  Payer  in  CT  Findings  from  the  CTHCS  (N  =  4,608)  

Race/Ethnicity    %  Covered  by  Medicaid  

Hispanic  or  La.no   28.2  

White,  Non-­‐Hispanic   9.4  

Black,  Non-­‐Hispanic   24.3  

Asian,  Non-­‐Hispanic   1.4  

Other  Race  or  Mul.-­‐Racial   28.9  

3x    

2.5x    

1.28  

1.30  

1.44  

1.51  

1.53  

1.48  

1.40  

1.45  

2.16  

1.17  

1.60  

0.0   0.5   1.0   1.5   2.0   2.5  

Cesarean  Sec.on    

Vaginal  Delivery    

Total  Joint  Arthroplasty  

Sep.cemia  

Celluli.s  

Gastroenteri.s  -­‐  Surgical  

Gastroenteri.s  -­‐  Medical  

Heart  Failure  and  Shock  

Chest  Pain    

Kidney  Disease  

Pneumonia  

Hispanic  vs.  White  

All  Stat  Sig  except    Kidney  Disease  

30  Day  Readmissions  –    Comparing  Medicaid  to  Private  Payers  

Race  and  Ethnic  Differences  in  Chronic  Disease  in  CT  Findings  from  the  CDC  

Race and Ethnic Disparities in 30 Day

Readmissions

The Role of Payer and Patient Sickness

30  Day  Readmissions    Comparing  Black  –  White  Differences    with  and  without  controls  for  payer  and  comorbidi.es    

0.0   0.5   1.0   1.5   2.0   2.5  

Cesarean  Sec.on    

Vaginal  Delivery    

Total  Joint  Arthroplasty  

Sep.cemia  

Celluli.s  

Gastroenteri.s  -­‐  Surgical  

Gastroenteri.s  -­‐  Medical  

Heart  Failure  and  Shock  

Chest  Pain    

Kidney  Disease  

Pneumonia  

Model  1   Model  2  

* ** *

* ***

**

*

*

*p  <  0.05  

30  Day  Readmissions    Comparing  Hispanic  –  White  Differences    with  and  without  controls  for  payer  and  comorbidi.es    

0.0   0.5   1.0   1.5   2.0   2.5  

Cesarean  Sec.on  

Vaginal  Delivery  

Total  Joint  Arthroplasty  

Sep.cemia  

Celluli.s  

Gastroenteri.s  -­‐  Surgical  

Gastroenteri.s  -­‐  Medical  

Heart  Failure  and  Shock  

Chest  Pain  

Kidney  Disease  

Pneumonia  

Model  1   Model  2  

* **

*

*

*

*

*

*

*p  <  0.05  

*  

If Not Payer or Patient Sickness, Then What?

Exploring the Connection to Outpatient Care

Methods •  Analyzed  Medicaid  hospitaliza.ons  for  PQI  01  &  PQI  03  (Short  and  Long  Term  Diabetes  Complica.ons)  

•  One  year  of  Medicaid  claims  data:    –  Iden.fied  hospitaliza.ons  between  9/1/2012  and  2/28/2013    

– Documented  office  visits  6  months  prior  to  admission  

2012  Hospitaliza.on  among  Medicaid  Pa.ents  PQI  01  &  PQI  03  Short  and  Long  Term  Diabetes  Complica.ons  

Office  Visit  #  of  

Admissions  %  of  

Admissions  

PCP  Only   198   31%  

Endocrinologist  Only   8   1%  

PCP  &  Endocrinologist   8   1%  

Neither   435   67%  

Totals   649   100%  

Conclusions •  Substan*al  race  and  ethnic  dispari*es  in  30  day  readmissions  across  range  of  condi*ons  –  Especially  for  TJA,  childbirth  

•  Substan*al  variability  in  readmissions  across  payers  –  Rates  much  higher  among  Medicaid  recipients  compared  to  privately  insured  

•  BUT  –  race  differences  not  totally  aYributable  to  payer  or  pa*ent  sickness  –  YES:    Chest  Pain,  GI,  Celluli.s  –  NO:      TJA,  Childbirth,  Sep.cemia,  Heart  Failure  

Discussion •  Explana*ons  for  dispari*es  in  readmission  typically  fall  into  3  interrelated  categories:  

-­‐  Hospital  performance  &  prac.ces  -­‐  Pa.ent  characteris.cs  and  behavior  (e.g.,  Tx  adherence)  -­‐  Community  resources  (e.g.,  access  to  outpa.ent  care)  

•  This  analysis  touches  on  a  few  of  these  issues  –  pa.ent  sickness,  SES,  payer,  access  to  and  u.liza.on  of  outpa.ent  care  

•  Addi*onal  presenta*ons,  breakout  sessions:      Data  will  s.mulate  discussion  that  leads  to  ac.on  

Questions?  

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among  pa.ents  with  diabetes.  Am  J  Manag  Care.  Oct  2010;16(10):760-­‐767.  q  Joynt  KE,  Orav  EJ,  Jha  AK.  Thirty-­‐day  readmission  rates  for  Medicare  beneficiaries  by  race  and  site  

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