新作坊

Thirty-Day Readmission Rates for Medicare Beneficiaries by Race and Site of Care

摘要：

Context Understanding whether and why there are racial disparities in readmissions has implications for efforts to reduce readmissions. Objective 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. Design Using national Medicare data, we examined 30-day readmissions after hospitalization for acute myocardial infarction (MI), congestive heart failure (CHF), and pneumonia. We categorized hospitals in the top decile of proportion of black patients as minority-serving. We determined the odds of readmission for black patients compared with white patients at minority-serving vs non–minority-serving hospitals. Setting and Participants Medicare Provider Analysis Review files of more than 3.1 million Medicare fee-for-service recipients who were discharged from US hospitals in 2006-2008. Main Outcome Measure Risk-adjusted odds of 30-day readmission. Results Overall, black patients had higher readmission rates than white patients (24.8% vs 22.6%, odds ratio [OR], 1.13; 95% confidence interval [CI], 1.11-1.14; P < .001); patients from minority-serving hospitals had higher readmission rates than those from non–minority-serving hospitals (25.5% vs 22.0%, OR, 1.23; 95% CI, 1.20-1.27; P < .001). Among patients with acute MI and using white patients from non−minority-serving hospitals as the reference group (readmission rate 20.9%), black patients from minority-serving hospitals had the highest readmission rate (26.4%; OR, 1.35; 95% CI, 1.28-1.42), while white patients from minority-serving hospitals had a 24.6% readmission rate (OR, 1.23; 95% CI, 1.18-1.29) and black patients from non−minority-serving hospitals had a 23.3% readmission rate (OR, 1.20; 95% CI, 1.16-1.23; P < .001 for each); patterns were similar for CHF and pneumonia. The results were unchanged after adjusting for hospital characteristics including markers of caring for poor patients. Conclusion Among elderly Medicare recipients, black patients were more likely to be readmitted after hospitalization for 3 common conditions, a gap that was related to both race and to the site where care was received. Racial disparities in health care are well documented,1 and eliminating them remains a national priority.2 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. While at least one study has found that in aggregate, across all conditions, black patients have slightly increased odds of readmission,3 others have found no such association.4 We are unaware of prior work on racial disparities in readmission rates at the national level for common medical conditions. Beyond simply describing whether disparities exist, there is also an increasing urgency to understand why these disparities exist. One possibility is that site of care plays a role. Prior studies have found that care for minorities is highly concentrated: a small number of hospitals provide a disproportionate share of the care for minority patients, and these hospitals appear to have worse performance on processes of care,5- 8 although data on outcomes are mixed.4,9,10 Thus, if black patients have higher readmission rates than white patients, it may be because these patients receive care at low-quality hospitals rather than because of race itself. Understanding whether, and why, black patients have higher readmission rates for common, publicly reported conditions can help improve the design of interventions that target the most vulnerable patients and hospitals. Therefore, we sought to answer 3 questions: first, are there disparities in readmission rates between elderly black and white patients admitted for acute myocardial infarction (MI), congestive heart failure (CHF), or pneumonia? Second, if these disparities exist, are they related primarily to race itself or primarily to the site where care is provided? And finally, if disparities based on the site of care do exist, are they associated with particular structural features of the hospitals that disproportionately care for minorities (such as size or teaching status), or markers of financial stress, such as public ownership or disproportionately caring for the poor?