Abstract
Objective
To determine whether neighborhood socioeconomic disadvantage, as determined by the
Area Deprivation Index, increases 30-day hospital re-observation risk.
Participants and Methods
This retrospective study of 20% Medicare fee-for-service beneficiary observation stays
from January 1, 2014, to November 30, 2014, included 319,980 stays among 273,308 beneficiaries.
We evaluated risk for a 30-day re-observation following an index observation stay
for those living in the 15% most disadvantaged compared with the 85% least disadvantaged
neighborhoods.
Results
Overall, 4.5% (270,600 of 6,080,664) of beneficiaries had index observation stays,
which varied by disadvantage (4.3% [232,568 of 5,398,311] in the least disadvantaged
85% compared with 5.6% [38,032 of 682,353] in the most disadvantaged 15%). Patients
in the most disadvantaged neighborhoods had a higher 30-day re-observation rate (2857
of 41,975; 6.8%) compared with least disadvantaged neighborhoods (13,543 of 278,005;
4.9%); a 43% increased risk (unadjusted odds ratio [OR], 1.43; 95% CI, 1.31 to 1.55).
After adjustment, this risk remained (adjusted OR, 1.13; 95% CI, 1.04 to 1.22). Discharge
to a skilled nursing facility reduced 30-day re-observation risk (OR, 0.63; 95% CI,
0.57 to 0.69), whereas index observation length of stay of 4 or more days (3 midnights)
conferred increased risk (OR, 1.29; 95% CI, 1.09 to 1.52); those living in disadvantaged
neighborhoods were less likely to discharge to skilled nursing facilities and more
likely to have long index stays. Beneficiaries with more than one 30-day re-observation
(chronic re-observation) had progressively greater disadvantage by number of stays
(adjusted incident rate ratio, 1.08; 95% CI, 1.02 to 1.14). Observation prevalence
varied nationally.
Conclusion
Thirty-day re-observation, especially chronic re-observation, is highly associated
with socioeconomic neighborhood disadvantage, even after accounting for factors such
as race, disability, and Medicaid eligibility. Beneficiaries least able to pay are
potentially most vulnerable to costs from serial re-observations and challenges of
Medicare observation policy, which may discourage patients from seeking necessary
care.
Abbreviations and Acronyms:
ADI (Area Deprivation Index), C-APC (Comprehensive Ambulatory Payment Classification), CMS (Centers for Medicare & Medicaid Services), COPD (chronic obstructive pulmonary disease), ED (emergency department), OR (odds ratio), Q (quartile), SNF (skilled nursing facility)To read this article in full you will need to make a payment
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Article info
Footnotes
For editorial comment, see page 2589
Grant Support: This project was supported by a National Institute on Minority Health and Health Disparities Award (R01MD010243 [PI Kind]). This material is the result of work also supported with the resources and use of facilities at the University of Wisconsin Department of Medicine Health Services and Care Research Program. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funding source had no role in study design; collection, analysis, and interpretation of the data; writing of the report; or the decision to submit the article for publication.
Potential Competing Interests: Dr Sheehy served as pro bono expert witness for the plaintiffs in Alexander v Azar, US District Court of Connecticut, regarding beneficiary rights to appeal to Medicare when placed under observation.
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Access this article on ScienceDirectLinked Article
- Unintended Consequences of Observation Stay Use May Disproportionately Burden Medicare Beneficiaries in Disadvantaged NeighborhoodsMayo Clinic ProceedingsVol. 95Issue 12
- PreviewGeographic variation in health care access, utilization, and quality—and health outcomes—is well documented. This evidence suggests that policy interventions should potentially target specific geographic locations identified on the basis of need. Since 1970, residential segregation by income in the United States has increased—accelerating even faster after 2000—and bolstering the argument for neighborhood-focused health policy intervention.1 There have been several efforts to identify communities with high socioeconomic disadvantage and to assess whether such disadvantages can be linked to adverse health outcomes.
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