Understanding Readmissions after Cancer Surgery in Vulnerable Hospitals

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Understanding Readmissions after Cancer Surgery in Vulnerable Hospitals Waddah B. Al-Refaie, MD, FACS John S. Dillon and Chief of Surgical Oncology MedStar Georgetown University Hospital Lombardi Comprehensive Cancer Center MedStar-Georgetown Surgical Outcomes Research Center

No disclosures to report

Hospital Readmissions and Surgery Reducing readmissions have become policy and clinical priority to improve quality of health care and control cost. Penalized hospitals will assess up to 3% for higher than average readmission rates for medical conditions. Financial penalties have since been expanded for orthopedic procedures. These penalties will likely expand to other surgical procedures in the near future. Fontanarosa PB. JAMA. 2012 Weber SM. Surgery. 2014

Surgical Concerns about ACA Readmissions Differences in surgical vs. medical patients Drivers of readmissions after surgical procedures (complications and multi-morbidity) are different from chronic medical Health conditions (e.g. care coordination, poly pharmacy..etc) Social determinants are not considered (SES, race) Financial penalties will likely strain already vulnerable hospitals (minority-serving, safety net or high-medicaid hospitals) Most readmission reduction interventions are evolving and of questionable benefit Weber et al. Surgery 2014 Neuhausen K. et al. NEJM 2013 Sommers B. et al. Int J Health Serv. 2015

Vulnerable Hospitals and Readmissions in the US MSH were twice as likely to be penalized compared with non-msh for higher readmissions (61% vs. 32%) MSH vs. non-msh readmission penalties are projected to be $112M vs. $41M X2 higher operative mortality rates at MSH Little is known about cancer surgery readmission patterns across vulnerable hospitals in the US Tsai TC Ann Surg 2014 Jha Ak. JAHA 2014

Minority Serving Hospitals and Cancer Surgery Readmissions: A Reason for Concern Young Hong, Chaoyi Zheng, Russell C. Langan, Elizabeth Hechenbleikner, Erin C. Hall, Nawar M. Shara, Lynt B. Johnson, Waddah B. Al-Refaie To be presented at 2015 American College of Surgeons

Objectives Minority Serving Hospital (MSH): Hospitals that ranked in the top 25% for the proportion of black and Hispanic patients served Aims: Primary Quantify the impact of Minority Serving Hospitals on readmission rates after major cancer surgery Secondary Identify possible hospital and/or patient factors associated with variations in hospital readmissions

Data Source and Cohort Use of 2 complimentary data sources: 2004 2011 State Inpatient Database of California: Large and racially diverse population Linked to Annual Survey Database of American Hospital Association: Rich in hospital factors Patient selection: 110,857 patients in 355 hospitals in California Operative procedures: Resections of lung, esophageal, gastric, pancreatic, hepatobiliary, rectal, and kidney cancers.

Statistical Methods Minority-Serving Hospital: Top quartile in % of Black/Hispanic patients Covariates: HRRP adjustment: age, sex, comorbidity, procedure type, year Patient factors: race/ethnicity, insurance, income Emergency status Hospital factors: bed size, teaching status, case volume, cancer program, ownership

Statistical Methods Outcome (dependent) variables: 30-day (ACA priority) 90-day and repeated readmissions (clinical relevance) Multivariate analyses: MSH and readmission rates (Hierarchical model with adjustment for case mix) Blockwise regression analyses by sequentially adding patient, procedure and hospital factors Repeated sensitivity analyses using different MSH proportional (top tertile or decile)

Results

Vulnerable Hospitals in California Performing Major Cancer Surgery (n=355) Non-Vulnerable Hospitals (n=189) Minority Serving Hospital (Top 25%) Minority Serving Hospital (MSH) (n=111) High Medicaid Hospitals (HMH) (n=36) Safety Net Hospital (SNH) (n=19) High Medicaid Hospital (Top 10%) Safety Net Hospital (California Association of Public Hospital and Health System)

Minority Serving Hospital 76 33 9 4 2 Safety Net Hospital 5 Relative Overlap Within California Vulnerable Hospitals High Medicaid Hospital 10 13

MSH Performing Major Cancer Surgery Distribution of Major Cancer Surgery Performed in California 18% 82% MSH Non-MSH

MSH Patients were Younger, Multi-morbid, and Underwent Emergent Surgery! Non-MSH (%) MSH (%) P-Value Age 18-49 50-64 65-74 75+ 18.2 31.4 26.9 23.5 19.7 36.4 24.4 19.5 <0.0001 Charlson Index 0 1 2+ 59.5 26.2 14.3 56.0 26.7 17.3 < 0.0001 Emergency Status 0 1 92.36 7.64 83.69 16.31 <0.0001

MSH vs. non-msh Attributes Non-MSH (%) MSH (%) P-Value Primary Insurance Medicare Medicaid Private Other 50.49 5.09 41.08 3.34 43.05 16.43 32.17 8.36 <0.0001 Procedure Volume (in tertiles/yr) Low Medium High 28.63 32.09 39.28 53.33 37.78 8.89 <0.0001 Teaching Status Designated Cancer Program Teaching 17.5 31.0 0.0061 Yes 38.9 21.0 0.0016

Comparable Readmission Diagnosis Non-MSH (%) MSH (%) Septicemia 4.92 5.83 Intestinal Obstruction without hernia 4.61 4.14 Pneumonia 4 3.74 Complication of device; implant or graft 3.33 3.19 Hypovolemia 3.02 2.36 Acute and unspecified renal failure 2.27 1.77 Urinary tract infections 2.17 2.13

Higher Adjusted Readmissions Rates at Minority Serving Hospitals % Minority Served at Hospital 30-Day Readmission OR (95% CI) 90-Day Readmission OR (95% CI) Repeated Readmissions OR (95% CI) 2nd Quartile (vs. Q1) 1.05 (0.96-1.14) 1.06 (0.98-1.15) 1.06 (0.92-1.23) 3rd Quartile (vs. Q1) 1.13 (1.04-1.22)** 1.14 (1.06-1.22)*** 1.20 (1.05-1.38)** 4th Quartile (MSH) (vs. Q1) 1.16 (1.05-1.29)** 1.18 (1.08,1.29)** 1.28 (1.10,1.50)** After adjusting for age, sex, comorbidity, type of procedure, race, and yr of admission. ** p < 0.01; *** p < 0.001.

Readmission Predominately Driven by Patient Factors Q4 vs. Q1-3 30-Day Readmission OR (95% CI) % Change 90-Day Readmission OR (95% CI) % Change Repeated Readmissions OR (95% CI) % Change Unadjusted 1.15 (1.06,1.24) 1.16 (1.09,1.25) 1.21 (1.09,1.34) + HRRP 1.13 (1.04,1.23) 11.8% 1.15 (1.07,1.24) 9.0% 1.16 (1.05,1.29) 21.9% + Patient Factors 1.06 (0.96,1.16) 50.9% 1.05 (0.96,1.15) 59.0% 1.06 (0.93,1.22) 47.8% + Hospital Factors 1.06 (0.96,1.15) 0.0% 1.06 (0.97,1.15) -4.5% 1.08 (0.96,1.22) -9.4% Sensitivity Analysis using top decile and top tertile demonstrated comprable estimates

Readmission Predominately Driven by Patient Factors Q4 vs. Q1-3 30-Day Readmission OR (95% CI) % Change 90-Day Readmission OR (95% CI) % Change Repeated Readmissions OR (95% CI) % Change Unadjusted 1.15 (1.06,1.24) 1.16 (1.09,1.25) 1.21 (1.09,1.34) + HRRP 1.13 (1.04,1.23) 11.8% 1.15 (1.07,1.24) 9.0% 1.16 (1.05,1.29) 21.9%

Readmission Predominately Driven by Patient Factors Q4 vs. Q1-3 30-Day Readmission OR (95% CI) % Change 90-Day Readmission OR (95% CI) % Change Repeated Readmissions OR (95% CI) % Change Unadjusted 1.15 (1.06,1.24) 1.16 (1.09,1.25) 1.21 (1.09,1.34) + HRRP 1.13 (1.04,1.23) 11.8% 1.15 (1.07,1.24) 9.0% 1.16 (1.05,1.29) 21.9% + Patient Factors 1.06 (0.96,1.16) 50.9% 1.05 (0.96,1.15) 59.0% 1.06 (0.93,1.22) 47.8%

Readmission Predominately Driven by Patient Factors Q4 vs. Q1-3 30-Day Readmission OR (95% CI) % Change 90-Day Readmission OR (95% CI) % Change Repeated Readmissions OR (95% CI) % Change Unadjusted 1.15 (1.06,1.24) 1.16 (1.09,1.25) 1.21 (1.09,1.34) + HRRP 1.13 (1.04,1.23) 11.8% 1.15 (1.07,1.24) 9.0% 1.16 (1.05,1.29) 21.9% + Patient Factors 1.06 (0.96,1.16) 50.9% 1.05 (0.96,1.15) 59.0% 1.06 (0.93,1.22) 47.8% + Hospital Factors 1.06 (0.96,1.15) 0.0% 1.06 (0.97,1.15) -4.5% 1.08 (0.96,1.22) -9.4% Sensitivity Analysis using top decile and top tertile demonstrated comprable estimates

Readmissions Predominately Driven by Patient Factors Q4 vs. Q1-3 30 Day Readmissions OR (95% CI) % Change 90 Day Readmissions OR (95% CI) % Change Repeated Readmission OR (95% CI) % Change Unadjusted 1.15 (1.06,1.24) 1.16 (1.09,1.25) 1.21 (1.09,1.34) + HRRP 1.13 (1.04,1.23) 11.8% 1.15 (1.07,1.24) 9.0% 1.16 (1.05,1.29) 21.9% + Hospital Factors 1.12 (1.04,1.21) 6.0% 1.15 (1.07,1.24) -0.4% 1.19 (1.08,1.32) -11.8% + Patient Factors 1.06 (0.96,1.15) 44.8% 1.06 (0.97,1.15) 55.0% 1.08 (0.96,1.22) 50.2% Sensitivity Analysis using top decile/top tertile and order of block regression demonstrated similar outcomes.

Vulnerable Hospitals and Cancer Surgery Readmissions: Insights into the unintended consequences of the Patient Protection and Affordable Care Act (PPACA) Young Hong MD, Chaoyi Zheng MS, Elizabeth Hechenbleikner MD, Lynt B. Johnson MD, Nawar Shara PhD, Waddah B. Al-Refaie MD, FACS To be Presented at 2015 Western Surgical Association

Definitions Safety Net Hospitals: Identified by the California Association of Public Hospitals and Health Systems High Medicaid Hospitals: Hospitals with highest decile of Medicaid patients (Top 10%)

Vulnerable Hospitals Have Higher Adjusted 30-day Readmission Rates Vulnerable Hospital Type 30-Day Readmissions OR (95% CI) 90-Day Readmissions OR (95% CI) Repeated Readmissions OR (95% CI) Safey Net vs. Non- Safety Net Hospital 1.29 (1.17-1.42) 1.24 (1.14-1.35) 1.30 (1.15-1.47) High Medicaid vs. Low Medicaid Hospital 1.12 (1.00-1.25) 1.26 (1.15-1.39) 1.28 (1.05-1.55) a After adjusting for age, sex, comorbidity, type of procedure and year of admission. b Defined as 1 readmission within 60 days from first index readmission.

Higher Adjusted 90-day Readmission Rates Vulnerable Hospital Type 30-Day Readmissions OR (95% CI) 90-Day Readmissions OR (95% CI) Repeated Readmissions OR (95% CI) Safey Net vs. Non- Safety Net Hospital 1.29 (1.17-1.42) 1.24 (1.14-1.35) 1.30 (1.15-1.47) High Medicaid vs. Low Medicaid Hospital 1.12 (1.00-1.25) 1.26 (1.15-1.39) 1.28 (1.05-1.55) a After adjusting for age, sex, comorbidity, type of procedure and year of admission. b Defined as 1 readmission within 60 days from first index readmission.

.. And Higher Repeated Readmission Rates Vulnerable Hospital Type 30-Day Readmissions OR (95% CI) 90-Day Readmissions OR (95% CI) Repeated Readmissions OR (95% CI) Safey Net vs. Non- Safety Net Hospital 1.29 (1.17-1.42) 1.24 (1.14-1.35) 1.30 (1.15-1.47) High Medicaid vs. Low Medicaid Hospital 1.12 (1.00-1.25) 1.26 (1.15-1.39) 1.28 (1.05-1.55) a After adjusting for age, sex, comorbidity, type of procedure and year of admission. b Defined as 1 readmission within 60 days from first index readmission.

Conclusions Vulnerable hospitals experience higher readmission rates after major cancer surgery compared to non-vulnerable hospitals. These findings validate current concerns about unintended consequences of PPACA penalties on financially strained hospitals. Our results have policy implications for amendments of penalties by PPACA to vulnerable hospitals given diminishing reimbursements.

Do Hospital Factors Contribute to Readmissions after Colorectal Procedures? Elizabeth Hechenbleikner, Chaoyi Zheng, Young Hong, Nawar M. Shara, Lynt B. Johnson, Waddah B. Al-Refaie

Objectives Minority Serving Hospital (MSH): Hospitals that ranked in the top decile for the proportion of black and Hispanic patients served (top 10%) Aims: Primary Quantify the impact of Minority Serving Hospitals on readmission rates after colorectal surgery Secondary Identify possible hospital and/or patient factors associated with variations in hospital readmissions

Do Hospital Factors Contribute to Readmission? MSH have higher readmission rates Which hospital factors drive readmissions after colorectal resections (as a proxy for common surgical procedures) performed at MSH in the context of patient- and procedure-related factors? Contribution of hospital factors not well understood

Data source and cohort Use of 2 complimentary Data sources: 2004 2011 State Inpatient Database of California: Large and racially diverse population Linked to Annual Survey Database of American Hospital Association: Rich in hospital factors Patient selection: 168,590 patients in 374 hospitals in California Operative procedures: Colon and rectal procedures for benign and malignant conditions.

Statistical methods Constructed variables: Patient: age, race/ethnicity, insurance, region, multimorbidity, yr Procedure status: urgent Hospitals: bed size, teaching status, volume, RN: bed, ICU, rehab, or cancer center Readmission diagnosis

Statistical methods Outcome (dependent) variables: 30-day (ACA priority) 90-day and repeated readmissions (clinical relevance) Multivariate analyses: MSH and readmission rates (Hierarchical model with adjustment for case mix) Blockwise regression analyses by sequentially adding patient, procedure and hospital factors Repeated sensitivity analyses using different MSH proportional (top tertile or quartiles)

Odds Ratios for Readmissions at MSH v. Non-MSH STEPWISE MODEL 30-Day Readmission 90-Day Readmission Repeated Readmission Odds Ratio (95% CI) % Change in OR Odds Ratio (95% CI) % Change in OR Odds Ratio (95% CI) % Change in OR Model 1 = Unadjusted Model 1.22 (1.09,1.36)*** - 1.21 (1.12,1.32)*** - 1.38 (1.15,1.65)*** - Model 2 = Model 1 + Patient Factors 1.06 (0.94,1.19) 71.7% 1.09 (0.99,1.20) 59.0% 1.11 (0.91,1.36) 70.6% Top Decile vs Decile 1-9 Model 3 = Model 2 + Procedure Factors 1.06 (0.94,1.19) 2.2% 1.08 (0.98,1.19) 2.2% 1.11 (0.91,1.36) 0.5% Model 4 = Model 3 + Hospital Factors 1.02 (0.90,1.15) 16.2% 1.04 (0.94,1.15) 20.1% 1.05 (0.88,1.26) 14.8%

Patient Factors Contributed More.. Odds Ratios for Readmissions at MSH v. Non-MSH STEPWISE MODEL 30-Day Readmission 90-Day Readmission Repeated Readmission Odds Ratio (95% CI) % Change in OR Odds Ratio (95% CI) % Change in OR Odds Ratio (95% CI) % Change in OR Model 1 = Unadjusted Model 1.22 (1.09,1.36)*** - 1.21 (1.12,1.32)*** - 1.38 (1.15,1.65)*** - Model 2 = Model 1 + Patient Factors 1.06 (0.94,1.19) 71.7% 1.09 (0.99,1.20) 59.0% 1.11 (0.91,1.36) 70.6% Top Decile vs Decile 1-9 Model 3 = Model 2 + Procedure Factors 1.06 (0.94,1.19) 2.2% 1.08 (0.98,1.19) 2.2% 1.11 (0.91,1.36) 0.5% Model 4 = Model 3 + Hospital Factors 1.02 (0.90,1.15) 16.2% 1.04 (0.94,1.15) 20.1% 1.05 (0.88,1.26) 14.8%

Procedure Factors Contributed Far Less.. Odds Ratios for Readmissions at MSH v. Non-MSH STEPWISE MODEL 30-Day Readmission 90-Day Readmission Repeated Readmission Odds Ratio (95% CI) % Change in OR Odds Ratio (95% CI) % Change in OR Odds Ratio (95% CI) % Change in OR Model 1 = Unadjusted Model 1.22 (1.09,1.36)*** - 1.21 (1.12,1.32)*** - 1.38 (1.15,1.65)*** - Model 2 = Model 1 + Patient Factors 1.06 (0.94,1.19) 71.7% 1.09 (0.99,1.20) 59.0% 1.11 (0.91,1.36) 70.6% Top Decile vs Decile 1-9 Model 3 = Model 2 + Procedure Factors 1.06 (0.94,1.19) 2.2% 1.08 (0.98,1.19) 2.2% 1.11 (0.91,1.36) 0.5% Model 4 = Model 3 + Hospital Factors 1.02 (0.90,1.15) 16.2% 1.04 (0.94,1.15) 20.1% 1.05 (0.88,1.26) 14.8%

Hospital Factors Contributed Less than Patient Factors! Odds Ratios for Readmissions at MSH v. Non-MSH STEPWISE MODEL 30-Day Readmission 90-Day Readmission Repeated Readmission Odds Ratio (95% CI) % Change in OR Odds Ratio (95% CI) % Change in OR Odds Ratio (95% CI) % Change in OR Model 1 = Unadjusted Model 1.22 (1.09,1.36)*** - 1.21 (1.12,1.32)*** - 1.38 (1.15,1.65)*** - Model 2 = Model 1 + Patient Factors 1.06 (0.94,1.19) 71.7% 1.09 (0.99,1.20) 59.0% 1.11 (0.91,1.36) 70.6% Top Decile vs Decile 1-9 Model 3 = Model 2 + Procedure Factors 1.06 (0.94,1.19) 2.2% 1.08 (0.98,1.19) 2.2% 1.11 (0.91,1.36) 0.5% Model 4 = Model 3 + Hospital Factors 1.02 (0.90,1.15) 16.2% 1.04 (0.94,1.15) 20.1% 1.05 (0.88,1.26) 14.8%

Only Few Hospital Factors Contributed.. Hospital Volume (in tertile) Bedsize Teaching Hospital Cancer program ICU Wound Center Rehabilitation Center Nurse Bed Ratio MSH v. Non-MSH Effect 30-DAY READMISSION FULL REGRESSION MODEL 90-DAY READMISSION REPEATED READMISSION OR (95% CI) OR (95% CI) OR (95% CI) Low (38/period) 1.05 (0.99,1.12) 1.01 (0.90,1.14) 1.32 (1.18,1.48)*** Med (39-104/period) 1.02 (0.95,1.08) 0.98 (0.88,1.10) 1.28 (1.14,1.43)*** High (>104/period) 1-99 0.75 (0.66,0.87)*** 0.71 (0.57,0.88)** 0.67 (0.54,0.84)*** 100-399 0.90 (0.83,0.97)** 0.92 (0.81,1.04) 0.94 (0.83,1.07) 400+ No 0.91 (0.85,0.97)** 0.83 (0.76,0.92)*** 0.97 (0.89,1.07) Yes No 0.98 (0.93,1.04) 1.03 (0.93,1.13) 0.96 (0.87,1.06) Yes Yes 0.94 (0.85,1.05) 1.09 (0.84,1.43) 1.23 (1.00,1.52) No No 0.95 (0.88,1.03) 1.10 (0.97,1.23) 1.02 (0.90,1.16) Yes No 1.07 (1.00,1.15)* 1.12 (1.01,1.25)* 0.98 (0.86,1.10) Yes 1-2 0.99 (0.90,1.08) 0.96 (0.82,1.12) 1.02 (0.85,1.23) >=2 1.00 (0.92,1.10) 1.02 (0.88,1.18) 1.04 (0.88,1.25) 0-1 Black/Hispanic T10 vs. 1.04 (0.94,1.15) 1.05 (0.88,1.26) 1.09 (0.91,1.31) Black/Hispanic T1-9

Conclusions Patient-level factors appeared to dominate the increased readmission risk following colorectal resections performed at MSH while hospital factors were less contributory. These findings need to be further validated to shape quality improvement interventions to decrease readmissions.

Thank you! wba6@georgetown.edu

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