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Adding Social Determinant Data Changes Children's Hospitals' Readmissions Performance
Marion R Sills1, Matthew Hall2, Gretchen J Cutler3
1Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
Insights
Risk adjustment using social determinants of health (SDH) significantly altered hospital rankings for pediatric readmissions. Including SDH in models improves accuracy and is recommended for performance measures and research.
Area of Science:
- Health Services Research
- Pediatric Healthcare Quality
- Health Equity
Background:
- The Pediatric All-Condition Readmission (PACR) measure is crucial for assessing hospital performance.
- Understanding how social determinants of health (SDH) influence readmission rates is essential for accurate performance evaluation.
- Current risk adjustment models may not fully capture the impact of SDH on pediatric readmissions.
Purpose of the Study:
- To evaluate if incorporating social determinants of health (SDH) into risk adjustment modifies hospital performance on the 30-day Pediatric All-Condition Readmission (PACR) measure.
- To determine if SDH risk adjustment enhances the accuracy and fit of discharge-level predictive models for pediatric readmissions.
Main Methods:
- A retrospective cohort study analyzed 458,686 pediatric hospital discharges from 2014 across 47 hospitals.
- Four nested regression models were developed, progressively adding chronic condition indicators, patient factors, and SDH variables (electronic health record-derived and zip code-linked).
- Changes in hospital decile rank for readmissions and model fit/accuracy were assessed for each model.
Main Results:
- Factors associated with higher readmission rates included young age, female sex, chronic conditions, Medicaid insurance, higher median household income, and single-parent households.
- Risk adjustment for SDH resulted in small but significant improvements in the fit and accuracy of discharge-level PACR models.
- Hospital-level performance rankings changed for 17 out of 47 hospitals after SDH adjustment, indicating a notable impact.
Conclusions:
- Risk adjustment for social determinants of health (SDH) demonstrably alters hospital readmission rate rankings.
- The financial implications of these performance changes underscore the importance of accurate risk adjustment.
- Findings support the inclusion of SDH variables in risk adjustment for pay-for-performance measures and related research in pediatric healthcare.
Objectives:
To determine whether social determinants of health (SDH) risk adjustment changes hospital-level performance on the 30-day Pediatric All-Condition Readmission (PACR) measure and improves fit and accuracy of discharge-level models.
Study Design:
We performed a retrospective cohort study of all hospital discharges meeting criteria for the PACR from 47 hospitals in the Pediatric Health Information database from January to December 2014. We built four nested regression models by sequentially adding risk adjustment factors as follows: chronic condition indicators (CCIs); PACR patient factors (age and sex); electronic health record-derived SDH (race, ethnicity, payer), and zip code-linked SDH (families below poverty level, vacant housing units, adults without a high school diploma, single-parent households, median household income, unemployment rate). For each model, we measured the change in hospitals' readmission decile-rank and assessed model fit and accuracy.
Results:
For the 458 686 discharges meeting PACR inclusion criteria, in multivariable models, factors associated with higher discharge-level PACR measure included age <1 year, female sex, 1 of 17 CCIs, higher CCI count, Medicaid insurance, higher median household income, and higher percentage of single-parent households. Adjustment for SDH made small but significant improvements in fit and accuracy of discharge-level PACR models, with larger effect at the hospital level, changing decile-rank for 17 of 47 hospitals.
Conclusions:
We found that risk adjustment for SDH changed hospitals' readmissions rate rank order. Hospital-level changes in relative readmissions performance can have considerable financial implications; thus, for pay for performance measures calculated at the hospital level, and for research associated therewith, our findings support the inclusion of SDH variables in risk adjustment.
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