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Original Investigation |

Effect of Hospital Safety-Net Burden on Cost and Outcomes After Surgery

Richard S. Hoehn, MD1; Koffi Wima, MS1; Matthew A. Vestal, MHA2; Drew J. Weilage, MHA3; Dennis J. Hanseman, PhD1; Daniel E. Abbott, MD1; Shimul A. Shah, MD, MHCM1
[+] Author Affiliations
1Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
2Sg2 Health Care and Hospital System Consultancy, Chicago, Illinois
3Centura Health, Denver, Colorado
JAMA Surg. 2016;151(2):120-128. doi:10.1001/jamasurg.2015.3209.
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Importance  Safety-net hospitals provide broad services for a vulnerable population of patients and are financially at risk owing to impending reimbursement penalties and policy changes.

Objective  To determine the effect of patient and hospital factors on surgical outcomes and cost at safety-net hospitals.

Design, Setting, and Participants  Hospitals in the University HealthSystem Consortium database from January 1, 2009, through December 31, 2012 (n = 231), were grouped according to their safety-net burden, defined as the proportion of Medicaid and uninsured patient charges for all hospitalizations during that time (n = 12 638 166). Nine cohorts, based on a variety of surgical procedures, were created and examined with regard to preoperative characteristics, postoperative outcomes, and resource utilization. Multiple logistic regression was performed to analyze the effect of patient and center factors on outcomes. Hospital Compare data from the Centers for Medicare & Medicaid Services were linked and used to characterize and compare the groups of hospitals.

Main Outcomes and Measures  Postoperative mortality, 30-day readmissions, and total direct cost.

Results  For all 9 procedures examined in 231 hospitals comprising 12 638 166 patient encounters, patients at hospitals with high safety-net burden (HBHs) (vs hospitals with low and medium safety-net burdens) were most likely to be young, to be black, to be of the lowest socioeconomic status, and to have the highest severity of illness and the highest cost for surgical care (P < .01 for all). For 7 of 9 procedures, HBHs had the highest proportion of emergent cases and longest length of stay (P < .01 for all). After adjusting for patient characteristics and center volume, HBHs still had higher odds of mortality for 3 procedures (odds ratios [ORs], 1.81-2.08; P < .05), readmission for 2 procedures (ORs, 1.19-1.30; P < .05), and the highest cost of care associated with 7 of 9 procedures (risk ratios, 1.23-1.35; P < .05). Analysis of Hospital Compare data found that HBHs had inferior performance on Surgical Care Improvement Project measures, higher rates of surgical complications, and inferior markers of emergency department timeliness and efficiency (all P < .05).

Conclusions and Relevance  These data suggest that intrinsic qualities of safety-net hospitals lead to inferior surgical outcomes and increased cost across 9 elective surgical procedures. These outcomes are likely owing to hospital resources and not necessarily patient factors. In addition, impending changes to reimbursement may have a negative effect on the surgical care at these centers.

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Figure 1.
Hospital Groups According to Safety-Net Burden

Graph depicts the quartiles of safety-net burden. HBH indicates high-burden hospital; LBH, low-burden hospital; and MBH, medium-burden hospital.

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Figure 2.
Adjusted Likelihood of Study Outcomes by Surgical Procedure

Odds ratios (ORs) (diamond markers) for mortality and readmission in high-burden hospitals and risk ratios (RRs) (diamond markers) for cost after adjusting for patient factors and hospital volume are given with 95% CIs. CABG indicates coronary artery bypass graft.

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