Safety-Net Hospitals, Neighborhood Disadvantage, and Readmissions Under Maryland's All-Payer Program: An Observational Study

Ann Intern Med. 2019 Jul 16;171(2):91-98. doi: 10.7326/M16-2671. Epub 2019 Jul 2.

Abstract

Background: Safety-net hospitals have higher-than-expected readmission rates. The relative roles of the mean disadvantage of neighborhoods the hospitals serve and the disadvantage of individual patients in predicting a patient's readmission are unclear.

Objective: To examine the independent contributions of the patient's neighborhood and the hospital's service area to risk for 30-day readmission.

Design: Retrospective observational study.

Setting: Maryland.

Participants: All Maryland residents discharged from a Maryland hospital in 2015.

Measurements: Predictors included the disadvantage of neighborhoods for each Maryland resident (area disadvantage index) and the mean disadvantage of each hospital's discharged patients (safety-net index). The primary outcome was unplanned 30-day hospital readmission. Generalized estimating equations and marginal modeling were used to estimate readmission rates. Results were adjusted for clinical readmission risk.

Results: 13.4% of discharged patients were readmitted within 30 days. Patients living in neighborhoods at the 90th percentile of disadvantage had a readmission rate of 14.1% (95% CI, 13.6% to 14.5%) compared with 12.5% (CI, 11.8% to 13.2%) for similar patients living in neighborhoods at the 10th percentile. Patients discharged from hospitals at the 90th percentile of safety-net status had a readmission rate of 14.8% (CI, 13.4% to 16.1%) compared with 11.6% (CI, 10.5% to 12.7%) for similar patients discharged from hospitals at the 10th percentile of safety-net status. The association of readmission risk with the hospital's safety-net index was approximately twice the observed association with the patient's neighborhood disadvantage status.

Limitations: Generalizability outside Maryland is unknown. Confounding may be present.

Conclusion: In Maryland, residing in a disadvantaged neighborhood and being discharged from a hospital serving a large proportion of disadvantaged neighborhoods are independently associated with increased risk for readmission.

Primary funding source: National Institute on Minority Health and Health Disparities and Maryland Health Services Cost Review Commission.

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Female
  • Humans
  • Male
  • Maryland
  • Middle Aged
  • Patient Readmission / economics*
  • Poverty Areas
  • Residence Characteristics*
  • Retrospective Studies
  • Risk Factors
  • Safety-net Providers*