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Association of Social Determinants With Children's Hospitals' Preventable Readmissions Performance
Marion R Sills1, Matt Hall2, Jeffrey D Colvin3
1Department of Pediatrics, University of Colorado School of Medicine, Aurora.
Insights
Risk adjustment for social determinants of health (SDH) impacts hospital readmissions penalties. Incorporating SDH data in pay-for-performance (P4P) measures ensures fairer assessments of hospital quality.
Area of Science:
- Healthcare policy
- Health equity
- Hospital performance measurement
Background:
- Pay-for-performance (P4P) measures, particularly those related to hospital readmissions, impose significant financial penalties on hospitals.
- Social determinants of health (SDH) are known to influence individual patient readmission risk.
- The impact of risk adjusting for SDH on hospital P4P penalties remains unclear.
Purpose of the Study:
- To assess whether risk adjustment for common SDH measures alters the readmissions-based P4P penalty status for children's hospitals.
- To evaluate the effect of incorporating SDH data into risk adjustment models for hospital performance metrics.
Main Methods:
- A retrospective cohort study analyzed 2013 data from 43 children's hospitals in the Pediatric Health Information System database.
- Two risk-adjustment models were compared: a baseline model (severity of illness) and an SDH-enhanced model (severity of illness plus race, ethnicity, payer, and median household income).
- Changes in penalty status were determined based on an observed-to-expected readmissions ratio threshold.
Main Results:
- The study included 179,400 hospital discharges; median SDH percentages indicated significant patient diversity.
- Adjustment for SDH led to changes in penalty status for several hospitals: 3 hospitals within 15 days and 5 within 30 days.
- These changes included hospitals no longer exceeding the penalty threshold and some newly penalized.
Conclusions:
- Risk adjustment for SDH demonstrably altered hospital penalty status for readmissions-based P4P measures.
- Failure to adjust for SDH in P4P measures may result in penalties that unfairly reflect patient socioeconomic factors rather than hospital quality.
- Incorporating SDH into performance measures is crucial for equitable evaluation of healthcare providers.
Importance:
Performance-measure risk adjustment is of great interest to hospital stakeholders who face substantial financial penalties from readmissions pay-for-performance (P4P) measures. Despite evidence of the association between social determinants of health (SDH) and individual patient readmission risk, the effect of risk adjusting for SDH on readmissions P4P penalties to hospitals is not well understood.
Objective:
To determine whether risk adjustment for commonly available SDH measures affects the readmissions-based P4P penalty status of a national cohort of children's hospitals.
Design, Setting, And Participants:
Retrospective cohort study of 43 free-standing children's hospitals within the Pediatric Health Information System database in the calendar year 2013. We evaluated hospital discharges from 2013 that met criteria for 3M Health Information Systems' potentially preventable readmissions measure for calendar year 2013. The analysis was conducted from July 2015 to August 2015.
Exposures:
Two risk-adjustment models: a baseline model adjusted for severity of illness and an SDH-enhanced model that adjusted for severity of illness and the following 4 SDH variables: race, ethnicity, payer, and median household income for the patient's home zip code.
Main Outcomes And Measures:
Change in a hospital's potentially preventable readmissions penalty status (ie, change in whether a hospital exceeded the penalty threshold) using an observed-to-expected potentially preventable readmissions ratio of 1.0 as a penalty threshold.
Results:
For the 179,400 hospital discharges from the 43 hospitals meeting inclusion criteria, median (interquartile range [IQR]) hospital-level percentages for the SDH variables were 39.2% nonwhite (n = 71,300; IQR, 28.6%-54.6%), 17.9% Hispanic (n = 32,060; IQR, 6.7%-37.0%), and 58.7% publicly insured (n = 106,116; IQR, 50.4%-67.8%). The hospital median household income for the patient's home zip code was $ 40,674 (IQR, $ 35,912-$ 46,190). When compared with the baseline model, adjustment for SDH resulted in a change in penalty status for 3 hospitals within the 15-day window (2 were no longer above the penalty threshold and 1 was newly penalized) and 5 hospitals within the 30-day window (3 were no longer above the penalty threshold and 2 were newly penalized).
Conclusions And Relevance:
Risk adjustment for SDH changed hospitals' penalty status on a readmissions-based P4P measure. Without adjusting P4P measures for SDH, hospitals may receive penalties partially related to patient SDH factors beyond the quality of hospital care.
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