Patient characteristics influence readmissions after colorectal surgery

Old sick lady lying in hospital bed (Wavebreakmedia)

- When patients wind up back in the hospital in the months following surgery, it may reflect more than just the quality of the hospital, a recent study suggests.

Instead, individual patient factors such as race, income and insurance status could be more likely to influence whether people get readmitted to the hospital within 30 or 90 days after procedures, a study of colorectal surgery patients suggests.

"We already know that minority-serving hospitals have higher mortality and readmission rates than non-minority serving hospitals after several surgical procedures including colorectal procedures," said senior study author Dr. Waddah Al-Refaie, director of the MedStar-Georgetown Surgical Outcomes Research Center in Washington, D.C.

"However, this study (finds) that patient-level factors, social determinants of health, race, and income contribute more to readmission than hospital-related factors such as hospital volume and bed size," Al-Refaie added by email.

The Hospital Readmission Reduction Program (HRRP), put in place in 2012 by the U.S. Centers for Medicare and Medicaid Services (CMS), penalizes hospitals for higher-than-expected readmission rates for six conditions: heart attacks, heart failure, pneumonia, chronic obstructive pulmonary disorder and hip and knee replacement, researchers note in the journal Surgery.

To date, this program has penalized more than half of the nation's hospitals for failing to meet expectations, imposing more than $500 million in fines, the authors write.

Some health policy experts have argued that hospitals treating a large number of socially disadvantaged patients - individuals who may not be able to afford their medications or lack a supportive social environment - shouldn't be penalized the same way as hospitals treating more affluent communities, the researchers point out.

But CMS holds all hospitals to the same standard when it comes to readmissions.

For the current study, researchers set out to look at outcomes in colorectal surgery, a common procedure in the U.S. each year as treatment for conditions including colorectal cancer and inflammatory bowel disease. This procedure has a high risk for postoperative complications and hospital readmissions within 30 days of discharge.

The researchers examined outcomes and patient factors in more than 168,000 colorectal surgery patients treated in 374 California hospitals from 2004 to 2011.

Forty-seven of these hospitals were considered minority-serving hospitals for having a high percentage of minority patients. Hispanic and black patients comprise 63 percent of the patient population in minority-serving hospitals, compared with 17 percent in other hospitals.

After accounting for patients' age, sex, other health conditions, and the year and type of procedure, the researchers found that, overall, 30-day, 90-day and repeated remission rates were 11.6 percent, 17.4 percent and 3.0 percent, respectively.

The rates in minority-serving hospitals, in comparison, were 13.6 percent, 20.1 percent and 4.0 percent, respectively.

Inpatient deaths were also significantly higher at minority-serving hospitals (4.9 percent) compared to non-minority-serving hospitals (3.8 percent).

Patient factors such as race, low income and insurance status accounted for up to 65 percent of the observed increase in odds for readmission at minority-serving hospitals, the study also found, while hospital-level factors such as procedure volume and procedure type accounted for up to 40 percent.

One limitation of the study is that researchers didn't look at certain hospital characteristics that could influence readmissions, such as urban versus rural locations or nonprofit versus for-profit status, the authors note.

Even so, the findings suggest that CMS should take individual patient characteristics into account in setting readmission policies, the authors argue.

Larger hospitals and teaching hospitals also had lower readmission rates than other places in the study, suggesting that patients seeking elective procedures may still want to consider hospital characteristics, said Elizabeth Habermann, a researcher at the Mayo Clinic College of Medicine in Rochester, Minnesota, who wasn't involved in the study.

"Patients with other underlying health conditions, or comorbidities, were more likely than patients with none to face readmissions; therefore, it is important to make sure chronic conditions such as diabetes or hypertension are adequately controlled prior to surgery," Habermann added by email.

"Patients in this study who underwent emergency surgery had greater odds of readmissions than the patients who were admitted electively; this points to seeking medical care prior to an issue becoming an emergency, when possible," Habermann added.