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Considering the Role of Socioeconomic Status in Hospital Outcomes MeasuresConsidering the Role of Socioeconomic Status in Hospital Outcomes Measures

Harlan M. Krumholz, MD, SM; and Susannah M. Bernheim, MD, MHS
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From Yale University School of Medicine, New Haven, Connecticut, and Yale-New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Connecticut.

Grant Support: Dr. Krumholz is supported by the National Heart, Lung, and Blood Institute Center for Cardiovascular Outcomes Research at Yale University (grant U01 HL105270-05).

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-2308.

Requests for Single Reprints: Harlan M. Krumholz, MD, SM, Yale University School of Medicine, 1 Church Street, Suite 200, New Haven, CT 06510; e-mail, harlan.krumholz@yale.edu.

Current Author Addresses: Drs. Krumholz and Bernheim: Yale University School of Medicine, 1 Church Street, Suite 200, New Haven, CT 06510.

Ann Intern Med. 2014;161(11):833-834. doi:10.7326/M14-2308
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In this issue, Kind and Keyhani and their colleagues evaluated the effects of neighborhood and individual socioeconomic status and clinical factors on 30-day rehospitalization rates and hospital performance. The editorialists discuss these studies and stress that quality assessment should reflect how well hospitals care for their patients regardless of financial circumstances.

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Submit a Comment/Letter
Posted on December 16, 2014
Alan M Zaslavsky, Ph.D., Ashish K. Jha, MD, MPH
Harvard School of Public Health
Conflict of Interest: None Declared

Krumhoz and Bernheim (henceforth KB) propose several arguments against adjustment of quality measures for socioeconomic (SES) factors that might affect outcomes.(1) First, socioeconomic effects are not large compared to overall quality differences among hospitals or the potential for improvement. Although this may be true in many cases, this is the wrong standard: adjustment, or the failure to adjust, could still have significant implications, especially for hospitals with large proportions of disadvantaged patients. Second, KB argue that acquisition and analysis of data required for SES adjustment may be difficult. While there are certainly challenges involved in collecting such data, its importance is increasingly recognized and progress is being made.(2) Furthermore, research reported in the same issue shows that readily available area measures of concentrated disadvantage linked to patient residential addresses can be highly predictive of outcomes(3); these are likely to be indicative of the SES composition of patients entering a hospital from the surrounding area.
KB’s main argument on principle is that SES adjustment obscures differences in quality between hospitals used by advantaged and disadvantaged patients. We would find this argument more compelling if such differences in quality were in fact evident in unadjusted performance reports. In fact, the same unadjusted performance could represent inferior quality at hospitals serving disadvantaged patients, or equally inferior outcomes for disadvantaged patients relative to others at all hospitals with some hospitals simply having a higher proportion of disadvantaged populations.(4) The nature of the underlying disparities can only be revealed by further systematic analysis; indeed the disaggregated data and analytic methods required to adjust reported measures are closely tied to those required to describe disparities and properly attribute responsibility for them. Furthermore, the same incentives to improvement operate with unadjusted and adjusted reporting.
Unadjusted measures have their uses, especially in providing a straightforward description of shortcomings for internal use to target quality improvement. However, for distribution of performance incentives and informing patient choice, a well-considered adjustment can enhance the value of data for patients and providers.


1. Krumholz HM, Bernheim SM. Considering the Role of Socioeconomic Status in Hospital Outcomes Measures. Ann Intern Med. 2014;161(11):833-4.

2. Perrin E, Ver Ploeg M. Eliminating Health Disparities: Measurement and Data Needs: National Academies Press; 2004.

3. Kind AJH, Jencks S, Brock J, Yu M, Bartels C, Ehlenbach W, et al. Neighborhood Socioeconomic Disadvantage and 30-Day Rehospitalization: A Retrospective Cohort Study. Ann Intern Med. 2014;161(11):765-74.

4. Jha AK, Zaslavsky AM. Quality reporting that addresses disparities in health care. JAMA. 2014;312(3):225-6.

Author's Response
Posted on February 23, 2015
Harlan M Krumholz, MD, Susannah M. Bernheim, MD, MHS
Yale Universtiy School of Medicine
Conflict of Interest: None Declared
There is much in common between the letter writers and us. We all agree that this a complex area in which causal pathways influence decisions about adjustment and there is important work remaining to understand the interaction of SES and outcomes. Our main point remains that we can either assume that differences based on socioeconomic status are unrelated to hospital quality and adjust them away, or allow that they might have a relationship to hospital quality, and that hospitals are likely to be able to mitigate any disparities and not adjust the differences away. Given our nation’s history and a large volume of studies showing a relationship between sociodemographic factors and quality, as well as the challenges and limitations we discussed, we believe that it is not appropriate to assume that black patients and poor patients intrinsically have higher risks of post-hospital outcomes in ways that cannot be modified by the hospital itself or by the hospital collaborating with its community in constructive ways. Also, we agree with MedPAC that payment policy must seek not to impose penalties on hospitals that treat vulnerable populations, have precarious finances, and would be better served by other strategies to incentivize and help promote improvement. In the end, we favor showing disparities in outcomes where they exist and challenging policymakers to devise wise approaches to promote performance improvements where we need them most, regardless of the cause.
Harlan M. Krumholz, MD, SM and Susannah M. Bernheim, MD, MHS
Yale University School of Medicine
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