Hoehn et al
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SAFETY-NET BURDEN AFFECTS COST AND OUTCOMES AT ACADEMIC HOSPITALS
Richard S Hoehn MD1, Koffi Wima MS1, Matthew A Vestal MHA2, Drew J Weilage MHA3, Daniel E
Abbott MD1, Shimul A Shah MD MHCM1
1
Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Department of Surgery, University of
Cincinnati School of Medicine, Cincinnati, OH 2Sg2 Health Care and Hospital System Consultancy,
Chicago, IL 3Centura Health, Denver, CO
PURPOSE: Hospital safety-net burden is known to correlate with inferior patient outcomes. The aim of
this study was to assess the influence of patient and hospital factors on these outcomes. METHODS:
Patients undergoing 9 major surgical procedures from 2009-2012 were queried using the University
HealthSystem Consortium. Hospitals (n=231) were grouped according to safety-net burden (proportion of
Medicaid/uninsured charges for all 12,638,166 patient encounters). Surgical procedure patient cohorts
were examined for preoperative characteristics, postoperative outcomes, and resource utilization. Gamma
regression was used to analyze the effect of patient and center characteristics on surgical outcomes and
costs. Medicare Hospital Compare data was used to characterize the groups of hospitals. RESULTS: For
all procedures examined, patients at high safety-net burden hospitals (HBH) were most likely of youngest
age, black race, lowest socioeconomic status, highest severity of illness, and highest cost for surgical care
(all p<0.05). For most procedures, HBH also had the most emergent cases, longest length of stay, highest
mortality, and highest readmissions. After adjusting for patient characteristics and hospital procedurespecific volume, HBH were still 6-26% more expensive than low safety-net burden hospitals (all
p<0.001). Analysis of Medicare data found HBH had worse performance on SCIP measures, more
surgical complications, and inferior markers of emergency department timeliness and efficiency.
CONCLUSIONS: These data suggest that intrinsic qualities of safety-net hospitals lead to inferior
surgical outcomes and increased cost. This is likely due to hospital resources, and impending changes to
reimbursement may further affect the quality of surgical care at these centers.