Higher mortality rates seen for white patients, but readmissions higher for minorities, report finds
Race plays a role in how patients fare on some of the outcome measures included in Medicare's pay-for-performance programs.
That was a key finding of an in-depth analysis from Truven Health Analytics' Center for Healthcare Analytics, released exclusively to Modern Healthcare. Specifically, Truven Health found that as a hospital's proportion of white patients increases, so does its 30-day mortality rate for heart failure. But they did not find a significant relationship between the proportion of white patients at a hospital and 30-day mortality rates for heart attack and pneumonia.
Conversely, as a hospital's proportion of blacks—or, to a lesser extent, other minorities—increases, so does its rate of 30-day readmissions for heart failure, heart attack and pneumonia.
To arrive at those findings, Truven researchers analyzed data in two steps. They looked at hospital-level data from the CMS website, Hospital Compare. They divided patients into three categories: white, black and other—a small percentage of the total population, including Hispanics, North American Natives, Asians and others.
This is where researchers found the correlation between the racial composition of a hospital's patient population and its performance on 30-day mortality and readmission rates.
Researchers then analyzed discharge-level data, using Medicare Provider Analysis and Review data from the third quarter of 2007 through the second quarter of 2010 to analyze 30-day mortality rates, and 2010 data from the CMS' Standard Analytical Files to track 30-day readmissions. What they found: Whites had a higher rate of 30-day mortality for heart failure than blacks or other minorities, while blacks and other minorities had higher rates of 30-day readmission for heart attack, heart failure and pneumonia than whites.
But the finding on 30-day mortality for congestive heart failure puzzled researchers. Given the impact of racial disparities in healthcare, they expected blacks to die at a faster rate. U.S. Census data revealed a possible explanation: Blacks had higher overall death rates than whites between ages 35 to 84. By the time blacks are old enough to qualify for Medicare, their numbers have been depleted. Meanwhile, the death rate for whites catches up because “in the end, everybody dies,” says David Foster, lead scientist at Truven's Center for Healthcare Analytics.
Truven's findings come on the heels of a similar study published last year in the Journal of the American Medical Association. In that study, Harvard University researchers found that elderly blacks had higher rates of 30-day readmission for heart attack, heart failure and pneumonia than elderly whites.
Their work also revealed that patients discharged from minority-serving hospitals—institutions in the top 10% based on the proportion of blacks in the total patient population—had higher rates of readmission. Like Truven, they also analyzed Medicare administrative data.
The findings from both studies add fuel to an ongoing debate about whether to incorporate race into the risk-adjustment methodology that the CMS uses to calculate outcome measures, such as 30-day mortality and readmission rates. While the CMS models include risk adjustments to account for the impact of age, severity of illness and case mix, the agency does not adjust for race.
Truven's Foster says the lack of risk adjustment for race is unfair because some hospitals will fare worse on 30-day readmission or mortality rates based solely on the racial composition of their patients “That is the whole point of doing the adjustments—it levels the playing field and takes those differences out,” he says.
The issue has gotten more attention lately because the CMS plans to implement performance-based reimbursement programs that include these outcome measures. This October, the CMS will launch the hospital readmissions reduction program, which assesses penalties for excessive readmissions. In October 2013, the agency plans to add 30-day mortality to the methodology it uses to assess hospitals' performance as part of the value-based purchasing program, which debuts in October 2012.
That is why the American Hospital Association has publicly commented on the CMS' risk-adjustment methodologies. For example, in a letter last year, the AHA urged Dr. Donald Berwick, who was the CMS administrator at the time, to include race and limited English proficiency in the risk-adjustment methodology for the hospital readmissions reduction program.
The AHA also has expressed concern about the impact of dual-eligibles, or those enrolled in both Medicare and Medicaid, and a group that is often a proxy for socio-economic status in research studies. Socio-economic status and race “tend to go together. It is hard to separate the two,” says Nancy Foster, the AHA's vice president of quality and patient-safety policy.
Nonetheless, officials at the CMS rejected the idea of adjusting readmission measures to account for disparities in outcomes based on race in its final rule for the hospital readmissions reduction program. To explain their decision, CMS officials wrote, “Differences in the quality of healthcare received by certain racial and ethnic groups may be obscured if the measures risk-adjust for race and ethnicity. Also, risk-adjusting for patient race, for instance, may suggest that hospitals with a high proportion of minority patients are held to different standards of quality than hospitals treating fewer minority patients.”
What does the CMS' current stance on the issue mean for hospital executives? “Adjusting for race and understanding racial disparities is a complex topic,” says Dr. Anthony Slonim, executive vice president and chief medical officer at West Orange, N.J.-based Barnabas Health, which includes two hospitals on this year's 100 Top list: Community Medical Center in Toms River, N.J., and Clara Maass Medical Center in Belleville, N.J. “There is so much confounding that goes on when you are looking at something generic like white vs. black that you need more context to make it actionable. What it requires for me is to dig deeply into my context of care and better understand the circumstances.”
At Barnabas, he adds, “Race has not been a major category for us. I could set up a program for African-Americans, but that does me less good than identifying the health literacy problem and making sure that all patients, regardless of race, know how to take their medicines.”
Health literacy figures prominently into a program Barnabas launched this year to reduce readmissions among patients with congestive heart failure. All heart failure patients receive at least one phone call after discharge; those at higher risk for readmission get additional phone calls and, in some cases, home-care visits.
The focus of all of the personalized attention is to ensure that patients understand their disease and all of their discharge instructions, including their medication regimen.
Barnabas launched the program at Community Medical Center and Kimball Medical Center, Lakewood, N.J. Clara Maass Medical Center is scheduled to roll out the program next.
Health literacy will figure prominently into a program Clara Maass Medical Center is planning to roll out.
Executives at Advocate Health Care, Oak Brook, Ill., developed an electronic tool to assess the impact of race and other factors on patients' risk of being readmitted within 30 days.
Advocate has three hospitals on the current 100 Top list: Advocate Illinois Masonic Medical Center, Chicago; Advocate Christ Medical Center, Oak Lawn; and Advocate Good Samaritan Hospital, Downers Grove.
Advocate analyzed 200,000 patients' medical records to develop the tool, which includes 25 variables across broad categories, such as demographics, medications, medical resource utilization and medical morbidities.
Within demographics, one of the variables they found was, indeed, race. “African-Americans were at an increased risk of being readmitted,” says Dr. Rishi Sikka, vice president of clinical transformation at Advocate. Other demographic variables associated with an increased risk of readmission include patients who are admitted from a skilled-nursing facility or have Medicare as their primary payer.
In the other categories, risk factors include medications, such as warfarin and insulin, and certain diseases, such as heart failure and cancer. Patients who were hospitalized within the past 12 months or used a lot of medical services also were considered at higher risk.
A program at Community Medical Center aims to reduce readmissions among patients with congestive heart failure.
Sikka says patients' risk of readmission is evaluated using the tool at the beginning of their hospital stay and periodically thereafter. Patients earn a total score based on the number of points they accumulate for various risk factors. Patients deemed to be at risk for readmission qualify for a series of interventions, including the newest: a transition coach. The coaches, who are not yet available at all of the system's hospitals, follow patients assigned to them for 30 days after discharge with phone calls and home visits.
“It is probably not possible to give a program to everybody because some of the interventions to improve a patient's transition in care can be expensive. You really need a way to be able to say: Who is at the greatest risk? Let's target those patients who are at the greatest risk,” Sikka says.