Stephen F. Jencks, MD, MPH; Alyson Schuster, PhD, MPH, MBA; Geoff B. Dougherty, PhD, MPH; Sule Gerovich, PhD; Jane E. Brock, MD, MSPH; Amy J.H. Kind, MD, PhD
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the U.S. Department of Veterans Affairs, the MHSCRC, or Telligen Colorado.
Acknowledgment: The authors thank Bill Buckingham for assistance with the ADI, Carol Hermann for assistance with manuscript formatting, and Talia Pindyck for critiquing the manuscript.
Financial Support: This project was supported by a National Institute on Minority Health and Health Disparities of the National Institutes of Health Award (R01MD010243 [principal investigator, Dr. Kind]. Drs. Jencks and Brock did not receive support for this work. Drs. Schuster, Dougherty, and Gerovich were employed by the MHSCRC. This material is the result of work also supported with resources and the use of facilities at the William S. Middleton Memorial Veterans Hospital Geriatric Research, Education and Clinical Center in Madison, Wisconsin (GRECC-Manuscript 2016-010), and the University of Wisconsin Department of Medicine.
Disclosures: Dr. Jencks reports personal fees and nonfinancial support from the MHSCRC during the conduct of the study and personal fees and nonfinancial support from the American College of Cardiology outside the submitted work. Dr. Brock reports contracts from the Centers for Medicare & Medicaid Services, and grants from the Patient-Centered Outcomes Research Institute outside the submitted work. Dr. Kind reports grants from the National Institutes of Health during the conduct of the study and grants from the Commonwealth Fund and the U.S. Department of Veterans Affairs outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-2671.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Catharine B. Stack, PhD, MS, Deputy Editor, Statistics, reports that she has stock holdings in Pfizer, Johnson & Johnson, and Colgate-Palmolive. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Reproducible Research Statement:Study protocol: See the Methods section of the text. Statistical code: Available from Dr. Schuster (e-mail, alyson.schuster@maryland.gov). Data set: Hospital-level data are largely available from the Maryland Health Services Cost Review Commission Web site (www.hscrc.state.md.us/pages/default.aspx). Census block group–level ADI estimates are available from reference 18. Person-level data are available only by special application to the MHSCRC.
Corresponding Author: Stephen F. Jencks, MD, MPH, 8 Midvale Road, Baltimore, MD 21210; e-mail, steve.jencks@comcast.net.
Current Author Addresses: Dr. Jencks: 8 Midvale Road, Baltimore, MD 21210.
Drs. Schuster and Dougherty: Maryland Health Services Cost Review Commission, 4160 Patterson Avenue, Baltimore, MD 21215.
Dr. Gerovich: Mathematica Policy Research, 7102 Ambassador Road, Suite 100, Woodlawn, MD 21244.
Dr. Brock: Telligen, 7730 East Belleview Avenue, Suite 300, Greenwood Village, CO 80111.
Dr. Kind: Geriatric Research Education and Clinical Center (GRECC), William S. Middleton Hospital, 2500 Overlook Terrace, Madison, WI 53705.
Author Contributions: Conception and design: S.F. Jencks, A. Schuster, S. Gerovich, J.E. Brock, A.J.H. Kind
Analysis and interpretation of the data: S.F. Jencks, A. Schuster, G.B. Dougherty, S. Gerovich, J.E. Brock, A.J.H. Kind
Drafting of the article: S.F. Jencks, J.E. Brock, A.J.H. Kind
Critical revision of the article for important intellectual content: S.F. Jencks, G.B. Dougherty, S. Gerovich, J.E. Brock, A.J.H. Kind
Final approval of the article: S.F. Jencks, A. Schuster, G.B. Dougherty, S. Gerovich, J.E. Brock, A.J.H. Kind
Provision of study materials or patients: A.J.H. Kind
Statistical expertise: S.F. Jencks, A. Schuster, G.B. Dougherty, S. Gerovich, A.J.H. Kind
Obtaining of funding: A.J.H. Kind
Administrative, technical, or logistic support: A. Schuster, J.E. Brock, A.J.H. Kind
Collection and assembly of data: A. Schuster, A.J.H. Kind
Safety-net hospitals have higher-than-expected readmission rates. The relative roles of the mean disadvantage of neighborhoods the hospitals serve and the disadvantage of individual patients in predicting a patient's readmission are unclear.
To examine the independent contributions of the patient's neighborhood and the hospital's service area to risk for 30-day readmission.
Retrospective observational study.
Maryland.
All Maryland residents discharged from a Maryland hospital in 2015.
Predictors included the disadvantage of neighborhoods for each Maryland resident (area disadvantage index) and the mean disadvantage of each hospital's discharged patients (safety-net index). The primary outcome was unplanned 30-day hospital readmission. Generalized estimating equations and marginal modeling were used to estimate readmission rates. Results were adjusted for clinical readmission risk.
13.4% of discharged patients were readmitted within 30 days. Patients living in neighborhoods at the 90th percentile of disadvantage had a readmission rate of 14.1% (95% CI, 13.6% to 14.5%) compared with 12.5% (CI, 11.8% to 13.2%) for similar patients living in neighborhoods at the 10th percentile. Patients discharged from hospitals at the 90th percentile of safety-net status had a readmission rate of 14.8% (CI, 13.4% to 16.1%) compared with 11.6% (CI, 10.5% to 12.7%) for similar patients discharged from hospitals at the 10th percentile of safety-net status. The association of readmission risk with the hospital's safety-net index was approximately twice the observed association with the patient's neighborhood disadvantage status.
Generalizability outside Maryland is unknown. Confounding may be present.
In Maryland, residing in a disadvantaged neighborhood and being discharged from a hospital serving a large proportion of disadvantaged neighborhoods are independently associated with increased risk for readmission.
National Institute on Minority Health and Health Disparities and Maryland Health Services Cost Review Commission.
Jencks SF, Schuster A, Dougherty GB, Gerovich S, Brock JE, Kind AJ. Safety-Net Hospitals, Neighborhood Disadvantage, and Readmissions Under Maryland's All-Payer Program: An Observational Study. Ann Intern Med. [Epub ahead of print 2 July 2019]171:91–98. doi: 10.7326/M16-2671
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© 2019
Published: Ann Intern Med. 2019;171(2):91-98.
DOI: 10.7326/M16-2671
Published at www.annals.org on 2 July 2019
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