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Social, Economic Factors Strong Influence on Hospital Readmissions

ANN ARBOR, MI — Despite facing penalties for high readmission rates, hospitals actually have little control over many of the factors bringing patients back to them, according to a new study.

The study, published recently in the Journal of General Internal Medicine, points out that specific social, economic, disability, and personal-care factors can make a significant difference in who gets readmitted after recent hospitalization for heart failure, pneumonia, or a heart attack.

The problem, according to the researchers from the University of Michigan Medical School and Institute for Healthcare Policy and Innovation, and the VA Ann Arbor Healthcare System, is that predicting which patients will return to the hospital, potentially resulting in a readmission penalty, is much more difficult than government policymakers seem to realize.

For the retrospective cohort study of Medicare patients, the study team used Health and Retirement Study-Medicare claims data (HRS-CMS) and Healthcare Cost and Utilization Project State Inpatient Databases for Florida and Washington, linked with ZIP code-level measures from the Census American Community Survey (ACS-HCUP).

Readmissions 30 days or less after hospitalization for pneumonia, heart failure, or acute myocardial infarction were the primary outcomes measured based on 10 measures of disability.

Across the models, results indicate the following:

  • increased readmission for pneumonia in patients with three or more activities of daily living (ADL) difficulties and prior home healthcare needs as well as ADL difficulties and “other” race,
  • lower readmission for heart failure among those with children or greater wealth, but increased readmission for those who are black or “other” race, and
  • increased readmission for acute myocardial infarction among nursing home patients. Whether the hospital cared for a high percentage of minority patients also was a factor.

Study authors noted that Medicare now adjusts its penalties based only on how sick a hospital's patients are — the more severely ill, the lower the penalty — but fails to take social determinants into account.

"The relationship between socioeconomic status, functional status, and use of healthcare is not a simple or straightforward as people might think," explained first author Jennifer Meddings, MD, MSc. "The impact is different depending on condition. We hope these findings will inform future adjustments in the models for readmission."

Meddings added that the National Academy of Sciences has convened a committee to evaluate evidence on the topic and present it to Centers for Medicare & Medicaid Services.

"In many ways, hospitals these days are being held accountable for the failures of the social safety net, as policies have been developed and implemented to evaluate the performance of hospitals and tie payment to that," she said. "As these programs are refined, understanding the impact of social determinants of health will be crucial."