Medical Research: What is the background for this study? What are the main findings?
Dr. Hoehn: Safety-net hospitals are hospitals that either have a stated purpose of maintaining an “open door policy” to all patients, regardless of their ability to pay, or simply have a significantly high burden of patients with Medicaid or no insurance. As healthcare policy and reimbursement change to focus on both “quality” metrics as well as cost containment, these hospitals may find themselves in a precarious situation. Current literature suggests that increased safety-net burden corresponds to inferior surgical outcomes. If this is true, safety-net hospitals will have inferior outcomes and suffer more financial penalties than other centers. This decrease in resources may adversely affect patient care, leading to even worse outcomes and further financial penalties, potentially creating a downward spiral that exacerbates disparities in surgical care that already exist in our country.
Medical Research: What are the main findings?
Dr. Hoehn: Our study analyzed 9 major surgical operations using the University HealthSystem Consortium clinical database, which represents 95% of academic medical centers in the United States. We sought to determine the effect of patient and hospital characteristics on the inferior outcomes at safety-net hospitals. As expected, we found that safety-net hospitals had higher rates of patients who were of black race, of lowest socioeconomic status, had government insurance, had extreme severity of illness, and needed emergent operations. They also had the highest rates of post-operative mortality, 30-day readmissions, and highest costs associated with care.
Next we performed a multivariate analysis controlling for patient age, race, socioeconomic status, and severity of illness, as well as hospital procedure-specific volume. Using this model, we found that the increased mortality and readmission rates at safety-net hospitals were somewhat reduced, but the increased costs were not affected. Safety-net hospitals still provided surgical care that was 23-35% more expensive, despite controlling for patient characteristics. This suggests that intrinsic hospital characteristics may be responsible for the increased costs at safety-net hospitals.
To further investigate this finding, we analyzed Medicare Hospital Compare data and found that safety-net hospitals performed worse on Surgical Care Improvement Project (SCIP) measures, had higher rates of reported surgical complications, and also had much slower measures of emergency department throughput (time from arrival to evaluation, treatment, admission, etc). This corresponded with our finding that hospital characteristics may be driving increased costs at safety-net hospitals.
Medical Research: What should clinicians and patients take away from your report?
Dr. Hoehn: Safety-net hospitals have a unique patient population with decreased resources and advanced illness. These hospitals also have inferior surgical outcomes and increased costs of care that are not simply a result of their patient characteristics. Safety-net hospitals perform worse on SCIP measures, which may be due to either worse care or worse documentation, and they have slower emergency department throughput, which may indicate differences in staffing or efficiency at these centers. The mission of these hospitals, to treat all patients regardless of payment or disease burden, prevents them from rationalizing services and streamlining care in order to be more cost-effective. Future changes in healthcare policy must consider the special situation regarding safety-net hospitals that are already overworked, understaffed, and providing for a vulnerable group of patients.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Hoehn: The next step is to gain a more detailed perspective of the hospital characteristics driving surgical outcomes and cost. We must better characterize the needs and weaknesses of these centers in order to affect policy in a way that strengthens, rather that penalizes, safety-net hospitals.
Richard S. Hoehn, MD (2015). Mission of Safety Net Hospitals Prevents Streamlining Health Care