Cancer Surgery Readmission among Vulnerable Populations:
Insights into the Medicare Hospital Readmission Reduction Program
Russell C. Langan MD1,2, Chaoyi Zheng MS1,2, Yewande Alimi MD1,2, Erin Hall MD1,2, Chukwuemeka
Ihemelandu2,3, Nawar Shara PhD2,5, Lynt B. Johnson MD, MBA, FACS1,2,4 Waddah B. Al-Refaie MD, FACS1,2,4
1
Department of Surgery at Georgetown University Hospital, 2MedStar-Georgetown Surgical Outcomes Research
Center, 3Department of Surgery at Washington Hospital Center, 4Lombardi Comprehensive Cancer Center, 5Medstar
Health Research Institute
Supported by the MedStar-Georgetown Partnership Award
Background: Concerns have arisen about the applicability of the Medicare Hospital Readmission Reduction
Program (HRRP) to surgical readmission including its lack of risk adjustment for vulnerable populations who are
typically at risk for poorer operative outcomes. Such knowledge is particularly relevant to minority-serving US
hospitals. In this study, we sought to assess the extent to which race/ethnicity, among other factors, affect
unplanned readmissions (including to non-indexed hospitals) within a large and racially diverse cohort of
gastrointestinal (GI) cancer surgery patients.
Methods: We identified 49,755 adults who underwent 1 of 6 major GI cancer surgeries (esophagectomy, distal
gastrectomy, total gastrectomy, pancreatectomy, hepatectomy, proctectomy) between 2004 and 2011 from the
California State Inpatient Database. Multivariable logistic regression analyses were conducted to examine the effect
of race/ethnicity on all-cause 30- and 90-day readmission after GI cancer surgery while controlling for relevant
patient-, procedure-, complication-, hospital-, and region-related factors.
Results: Our sample had 16.6% Hispanics, 13.2% Asian/Pacific Islanders and 5.3% Blacks. Overall 30- and 90-day
readmission rates to index-hospitals were 12.4% and 22.3%, respectively and 10.2% and 17.7% to non-index
hospitals. Black race predicted 22% and 18% higher odds of 30- and 90-day readmission to index hospitals than
whites, respectively (Table 1 Model 1). Additionally, Hispanic ethnicity predicted 10% higher odds of 90-day
readmission to index hospitals than NHW. These risks remained elevated even after adjusting for comorbidity, inhospital complication, insurance type and hospital volume (Table 1 Model 2).
Conclusion: In this large and racially diverse population-based study, Black and Hispanic race predicted higher
readmission rates. Our findings reinforce previous concerns about HRRP lacking adjustment for patient
characteristics, and thus placing hospitals serving vulnerable populations at risk for higher penalties.
Table 1. Adjusted Odds Ratios Associated with Race for 30- and 90-Day Readmission after Complex Alimentary
Tract Cancer Surgery, California Inpatient Database 2004-2011.
Readmission to Index Hospitals
30-day
N = 45,322
OR (95% CI)
Readmission to Any Hospital in
California (non-index)
30-day
90-day
N = 45,322
N = 46,890
OR (95% CI)
OR (95% CI)
90-day
N = 46,890
OR (95% CI)
Model 1a
Blackc
1.22 (1.08-1.39)
1.18 (1.06-1.31)
1.20 (1.06 -1.35)
1.11 (1.01-1.23)
Hispanicc
1.07 (0.98-1.16)
1.10 (1.03-1.17)
1.02 (0.95 -1.10)
1.05 (0.99-1.12)
Asian/Pacific Islanderc 0.95 (0.87-1.05)
0.95 (0.88-1.02)
0.89 (0.81-0.97)
0.88 (0.83-0.95)
Model 2b
Blackc
1.18 (1.03-1.34)
1.12 (1.01-1.24)
1.14 (1.01-1.29)
1.05 (0.95-1.15)
Hispanicc
1.05 (0.96-1.14)
1.07 (1.00-1.14)
1.01 (0.93-1.09)
1.03 (0.97-1.09)
Asian/Pacific Islanderc 0.96 (0.88-1.06)
0.96 (0.89-1.03)
0.90 (0.83-0.99)
0.90 (0.84-0.97)
a
Adjusted for year of admission, age at admission, sex, patient residence (rural/urban), region, procedure type. bAdjusted for all
covariates in Model 1, plus comorbidity, in-hospital complication, insurance type and hospital volume. cReference group: nonHispanic Whites.