0

The full content of Annals is available to subscribers

Subscribe/Learn More  >
Original Research |

Neighborhood Socioeconomic Disadvantage and 30-Day Rehospitalization: A Retrospective Cohort StudyNeighborhood Socioeconomic Disadvantage and 30-Day Rehospitalization

Amy J.H. Kind, MD, PhD; Steve Jencks, MD, MPH; Jane Brock, MD, MSPH; Menggang Yu, PhD; Christie Bartels, MD; William Ehlenbach, MD, Msc; Caprice Greenberg, MD; and Maureen Smith, MD, MPH, PhD
[+] Article, Author, and Disclosure Information

From University of Wisconsin School of Medicine and Public Health, Geriatric Research, Education and Clinical Center, William S. Middleton Veterans Affairs Hospital, and School of Nursing and School of Pharmacy, University of Wisconsin–Madison, Madison, Wisconsin, and Telligen, Englewood, Colorado.

Disclaimer: The contents of this article do not reflect Centers for Medicare & Medicaid Services policy.

Acknowledgment: The authors thank Peggy Munson for Institutional Review Board assistance; Katie Ronk for data management assistance; Bill Buckingham for map creation; and Brock Polnaszek, Jacquelyn Porter, Melissa Hovanes, and Colleen Brown for help with manuscript formatting.

Grant Support: By the National Institute on Aging (Paul D. Beeson Career Development Award [K23AG034551]), the American Federation for Aging Research, the John A. Hartford Foundation, The Atlantic Philanthropies, and The Starr Foundation. Dr. Kind's time was also partially supported by the University of Wisconsin School of Medicine and Public Health from the Wisconsin Partnership Program. Additional support was provided by the University of Wisconsin School of Medicine and Public Health's Health Innovation Program, the Community–Academic Partnerships core of the University of Wisconsin Institute for Clinical and Translational Research, and the Clinical and Translational Science Award program of the National Center for Research Resources, National Institutes of Health (grant 1UL1RR025011). Dr. Brock's time was partially supported by the Integrating Care for Populations & Communities National Coordinating Center at Colorado Foundation for Medical Care, under contract with the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-2946.

Reproducible Research Statement:Study protocol, statistical code, and data set: Available from Dr. Kind (email, ajk@medicine.wisc.edu).

Requests for Single Reprints: Amy J.H. Kind, MD, PhD, Geriatric Research Education and Clinical Center, William S. Middleton Veterans Affairs Hospital, 2500 Overlook Terrace, Madison, WI 53705; e-mail, ajk@medicine.wisc.edu.

Current Author Addresses: Dr. Kind: Geriatric Research Education and Clinical Center, William S. Middleton Veterans Affairs Hospital, 2500 Overlook Terrace, Madison, WI 53705.

Dr. Jencks: 8 Midvale Road, Baltimore, MD 21210.

Dr. Brock: Telligen, Colorado Foundation for Medical Care, 23 Inverness Way East, Suite 100, Englewood, CO 80112.

Dr. Yu: University of Wisconsin School of Medicine and Public Health, 1685 Highland Avenue, Madison, WI 53705.

Dr. Bartels: University of Wisconsin School of Medicine and Public Health, Rheumatology, Room 4132, Medical Foundation Centennial Building, 1685 Highland Avenue, Madison, WI 53705.

Dr. Ehlenbach: University of Wisconsin School of Medicine and Public Health, Room 5245 Medical Foundation Centennial Building, 1685 Highland Avenue, Madison, WI 53705.

Dr. Greenberg: University of Wisconsin School of Medicine and Public Health, BX7375 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792.

Dr. Smith: University of Wisconsin School of Medicine and Public Health, Room 210-31, 800 University Bay Drive, Madison, WI 53705.

Author Contributions:Conception and design: A.J.H. Kind, S. Jencks, J. Brock, C. Greenberg, M. Smith.

Analysis and interpretation of the data: A.J.H. Kind, S. Jencks, J. Brock, M. Yu, C. Bartels, W. Ehlenbach, C. Greenberg, M. Smith.

Drafting of the article: A.J.H. Kind, S. Jencks, J. Brock.

Critical revision of the article for important intellectual content: A.J.H. Kind, S. Jencks, J. Brock, M. Yu, C. Bartels, W. Ehlenbach, C. Greenberg, M. Smith.

Final approval of the article: A.J.H. Kind, S. Jencks, J. Brock, C. Bartels, C. Greenberg, M. Smith.

Statistical expertise: A.J.H. Kind, M. Yu.

Obtaining of funding: A.J.H. Kind, M. Smith.

Administrative, technical, or logistic support: A.J.H. Kind, M. Smith.

Collection and assembly of data: A.J.H. Kind, C. Greenberg, M. Smith.


Ann Intern Med. 2014;161(11):765-774. doi:10.7326/M13-2946
Text Size: A A A

Background: Measures of socioeconomic disadvantage may enable improved targeting of programs to prevent rehospitalizations, but obtaining such information directly from patients can be difficult. Measures of U.S. neighborhood socioeconomic disadvantage are more readily available but are rarely used clinically.

Objective: To evaluate the association between neighborhood socioeconomic disadvantage at the census block group level, as measured by the Singh validated area deprivation index (ADI), and 30-day rehospitalization.

Design: Retrospective cohort study.

Setting: United States.

Patients: Random 5% national sample of Medicare patients discharged with congestive heart failure, pneumonia, or myocardial infarction between 2004 and 2009 (n = 255 744).

Measurements: Medicare data were linked to 2000 census data to construct an ADI for each patient's census block group, which were then sorted into percentiles by increasing ADI. Relationships between neighborhood ADI grouping and 30-day rehospitalization were evaluated using multivariate logistic regression models, controlling for patient sociodemographic characteristics, comorbid conditions and severity, and index hospital characteristics.

Results: The 30-day rehospitalization rate did not vary significantly across the least disadvantaged 85% of neighborhoods, which had an average rehospitalization rate of 21%. However, within the most disadvantaged 15% of neighborhoods, rehospitalization rates increased from 22% to 27% with worsening ADI. This relationship persisted after full adjustment, with the most disadvantaged neighborhoods having a rehospitalization risk (adjusted risk ratio, 1.09 [95% CI, 1.05 to 1.12]) similar to that of chronic pulmonary disease (adjusted risk ratio, 1.06 [CI, 1.04 to 1.08]) and greater than that of uncomplicated diabetes (adjusted risk ratio, 0.95 [CI, 0.94 to 0.97]).

Limitation: No direct markers of care quality or access.

Conclusion: Residence within a disadvantaged U.S. neighborhood is a rehospitalization predictor of magnitude similar to chronic pulmonary disease. Measures of neighborhood disadvantage, such as the ADI, could potentially be used to inform policy and care after hospital discharge.

Primary Funding Source: National Institute on Aging and University of Wisconsin School of Medicine and Public Health's Institute for Clinical and Translational Research and Health Innovation Program.

Figures

Grahic Jump Location
Figure 1.

Unadjusted relationship between ADI percentile of a Medicare patient's neighborhood and 30-day rehospitalization.

ADI = area deprivation index; AMI = acute myocardial infarction; CHF = congestive heart failure; PNA = pneumonia.

* On the ADI percentile range shown, 0 is the least socioeconomically disadvantaged group of neighborhoods ranging sequentially by equally sized neighborhood groupings up to 100 as the most disadvantaged group of neighborhoods. Mean lines represent the mean relationship over each ADI percentile.

Grahic Jump Location
Grahic Jump Location
Figure 2.

Locations of the 15% most disadvantaged neighborhoods based on census block group ADI score.

Urban block groups or neighborhoods must be viewed at greater magnification because they are composed of smaller geographic areas than their rural counterparts. Enlargements of sample urban areas are offered to demonstrate. ADI = area deprivation index.

Grahic Jump Location

Tables

References

Letters

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Comments

Submit a Comment/Letter
Submit a Comment/Letter

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

Toolkit

Buy Now for $32.00

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Advertisement
Related Articles
Related Point of Care
Topic Collections
PubMed Articles
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.
(Required)
(Required)