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Racial Disparities in Postoperative Readmission May Be Reduced by Improving Nurse-to-Patient Staffing

The Cross-Sectional Study Analyzed Data from 107,000 Medicare Patients in Nearly 500 US Hospitals.

October 31, 2016

A new study from the University of Pennsylvania School of Nursing’s Center for Health Outcomes and Policy Research (CHOPR) shows that older black adults are not only more likely to be readmitted following an elective hip/knee replacement, than otherwise similar white patients – they may also be more adversely affected by insufficient hospital nurse staffing. The results are set for publication in a future issue of the Journal of the American Geriatrics Society, but are available now online here. The cross-sectional study analyzed data of nearly 107,000 Medicare patients in 483 US hospitals and points to improving nurse-to-patient staffing ratios as a strategy for reducing racial disparities in postoperative readmissions.

After accounting for patient factors such as patient acuity, age, and socioeconomic status, as well as characteristics of the hospital where patients receive care, older black adults have a 30 percent increased likelihood of readmission compared with their white counterparts. “Patients have multiple risk factors, such as older age or comorbidity, which predispose them to re-hospitalization. Our findings suggest that an individual’s race is one such risk factor for poorer health outcomes,” says the study’s lead investigator Karen Lasater PhD, RN, and a Postdoctoral Fellow at CHOPR. Racial disparities in readmission outcomes are widely recognized and remain unabated despite numerous efforts in the public and private sectors.  
The study points to hospital nurse staffing as a likely mechanism for reducing readmissions in this postsurgical group and further demonstrates the added value for older minority adults. Every additional patient in a nurse’s workload was associated with eight percent increased odds of readmission among older white patients and 15 percent increased odds among older black patients.

“What is striking about these findings is that we find this relationship even in a cohort of relatively healthy adults undergoing an elective surgery. The protective benefit of higher nurse-to-patient staffing for minorities may be related to gaps in health care access, financial flexibility, and social support systems. If individuals lack resources to mobilize ongoing support following discharge, the quality and intensity of care received during the hospitalization may help to address such gaps,” says Lasater.

Since 2010, hospitals have been financially penalized for high readmission rates under the Centers for Medicare and Medicaid Services Hospital Readmission Reduction Program.  Safety-net hospitals, those serving a disproportionate share of low-income and under-served patients, are more likely to experience financial penalties and have demonstrated slower improvements in curbing readmission rates overtime, compared to better resourced hospitals. These study findings provide insight into one potential mechanism that may help alleviate readmission disparities observed across various patient populations.

This study shows nurse staffing is important for the health outcomes of all patients, but may have a more protective effect for black patients. While the study does not demonstrate causation, it suggests a focus on supporting front line providers can improve readmissions for high-risk groups.

Matthew McHugh, PhD, JD, MPH, RN, Associate Director of CHOPR, served as co-lead investigator for this research. This study was supported by grants from the National Institute of Nursing Research (R01-NR04513, T32-NR0714 and R01-AG041099-01), and from the Robert Wood Johnson Foundation Nurse Faculty Scholars Program.

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