Readmission rates at children's hospitals influenced by patients' characteristics

In the most comprehensive study to date of state Medicaid readmission pay-for-performance policies and social determinants of health, the researchers found that pay-for-performance measures may disproportionately penalize hospitals that serve children who are poor, ethnic or racial minorities or publicly insured.

The results of the study are reported in an article, "Association of Social Determinants with Children's Hospitals' Preventable Readmissions Performance," published online on Feb. 15, by JAMA Pediatrics. The lead author is Marion Sills, MD, MPH, associate professor of pediatrics at the University of Colorado School of Medicine.

"Studies like ours show that patients who are poorer or are minorities are readmitted at higher rates than other patients, which raises concern that the readmissions penalties punish hospitals for the type of patients that they serve, rather than purely for the quality of care they provide," Sills said.

They conclude that without adjusting for social determinants of health, "hospitals that care for more vulnerable patients may receive penalties in part related to patient factors beyond the control of the hospital and unrelated to the quality of hospital care."

Previous studies have found that several "social determinants of health," including race and ethnicity, public insurance and median household income, were predictors of higher risk of pediatric readmission. Such factors are thought to affect health by impairing patients' access to care and are associated with barriers to adherence to health care recommendations.

Yet even with evidence that some children's hospitals could be unfairly penalized in a shift to pay for performance, policymakers have recommended further study before adopting risk adjustment factors that would reduce penalties for hospitals that care for more patients with social determinants of health risk factors.

Sills and her colleagues reviewed 179,400 hospital discharges from 43 hospitals across the country. The hospital discharges occurred in 2013 and the analysis was conducted in July-August 2015.

In their analysis, the researchers used 15-day and 30-day readmission rates to measure the hospitals. In baseline studies, 22 hospitals were penalized when patients were readmitted within the 15-day window and 23 were penalized for readmissions within the 30-day window. When adjusting for social determinants of health, researchers found differences in penalty rates. Considering those factors, the penalty status changed for three hospitals in the 15-day timeframe: two were no longer penalized and one was newly penalized. For the 30-day timeframe, the penalty status changed for five hospitals, with three no longer penalized and two newly penalized.

"The financial effect of P4P [pay for performance] penalties is substantial, can worsen the financial challenges already facing safety net hospitals, and can lead to unintended consequences such as hospital closure," Sills and her co-authors wrote.