Our study reveals that in 2008, Black Medicare beneficiaries with heart failure, AMI, and pneumonia were more likely than Whites to be readmitted following an initial hospitalization. Hispanic beneficiaries had significantly higher odds of readmission for AMI. These effects remained significant even after controlling for patient comorbidities and hospital characteristics such as teaching status, bed size, and technological status. Other studies have examined readmissions in minority patients and have noted no differences in readmission between Blacks, Hispanics and Whites (Deswal, Petersen, Souchek, Ashton, & Wray, 2004
; Yancy et al., 2008
). Our study, however, is consistent with previous research, which found that race was an important determinant of readmission in chronic conditions (Curtis et al., 2008
; Friedman & Basu, 2004
; Jiang et al., 2005
; Philbin & DiSalvo, 1998
; Rathore et al., 2003
Readmissions are common, represent high costs (Friedman & Basu, 2004
), and in some respects indicate clinical tasks and interventions left undone (Ashton, Del Junco, Souchek, Wray, & Mansyur, 1997
). Early readmissions may (conversely) reflect complex underlying problems such as unobserved factors that are unrelated to care processes but equally influence admission rates. In the case of hospitals serving large communities of minority patients, the use of readmission rates as an outcome for value-based purchasing policies raises concerns because it may fail to account for several factors related to the specific health care practices and community attributes of minority patients. Though not entirely conclusive (Baker, Stevens, & Brook, 1994
; Gaskin et al., 2007
), studies have found that Black and Hispanic patients are more likely to rely on hospitals as the most convenient and reliable source of care (Baker et al., 1994
; Fuda & Immekus, 2006
; LaCalle & Rabin, 2010
). This utilization pattern may arise due to a number of underlying structural, political, and economic factors that contribute to limited access to regular primary care providers in minority communities (Mayberry, Mili, & Ofili, 2000
; Williams & Rucker, 2000
). Continuity of care may be further fragmented if minorities are seen routinely by a range of different health care providers (Hargraves & Hadley, 2003
). Physicians servicing large proportions of minority patients have reported that coordination of care, ability to spend adequate time with patients during office visits, and obtaining specialty care is more difficult in these practices (Reschovsky & O’Malley, 2008
). The confluence of access issues and physician constraints threaten care continuity and may influence readmission rates in hospitals serving minority communities. Our findings suggest that further study and additional consideration should be given to whether including patient demographics, the clustering of hospitals in specific regions, differences in patient utilization patterns, access to providers, or other socioeconomic factors in risk-standardized statistical models of readmissions is appropriate (Bhalla & Kalkut, 2010
The inclusion of race in risk adjustment models can be controversial and there are justifiable reasons for not including race as a factor in risk adjustment. One of the foremost reasons is that the adjustment may mask important racial disparities that would otherwise indicate biases in care and not patient differences. Another important issue is measurement. Although data quality has improved, race has been measured differently over time and the quality of data varies significantly by source (Arispe, Holmes, & Moy, 2005
; Kaplan & Bennett, 2003
; LaVeist, 1994
). Continued evaluation of the most appropriate models for use in implementing the readmissions policies will be important for researchers going forward.
Despite the difficulties of implementation of the CMS policies, the focus on hospitals as a source of disparities in readmissions is justified. In its landmark report, the Institute of Medicine (2002)
highlighted the presence of inequitable hospital care quality as a concerning source of racial and ethnic health disparities. A number of studies have found that differences between hospitals contribute significantly to disparities in a number of outcomes (Gaskin et al., 2008
; Hasnain-Wynia et al., 2010
). Nursing in particular has a prominent role to play in ensuring that quality initiatives are successful in improving care and reducing disparities. Regarding readmissions, nurses provide critical in-hospital care, deliver essential patient teaching and discharge instructions, and work with families and outside institutions to ensure smooth transitions and prevent readmissions. Nurses are also in key positions in postacute care settings where they can provide and manage transitional care to prevent readmission to the acute care hospital.
Many other value-based purchasing initiatives that will be implemented as part of health reform focus not only on readmissions but on patient safety and satisfaction; measures directly influenced by nursing care (Kutney-Lee et al., 2009
). To the extent that the results of quality initiatives affect hospital ratings and revenue, the role of nurses and particularly those employed in hospitals serving minority communities will be critical to understand. Nurses must continue to make the business case that the bedside care, surveillance, discharge teaching, transitional care, and multidisciplinary team services they participate in are cost-effective in light of these new initiatives (Sochalski et al., 2009
). Continuing to provide up-to-date evidence regarding cost-effective organizational interventions including appropriate nurse staffing levels and work environments supportive of professional nursing practice will be important as value-based purchasing initiatives are implemented more widely (Aiken, Clarke, Sloane, Lake, & Cheney, 2008
; Dall, Chen, Seifert, Maddox, & Hogan, 2009
; Mark, Lindley, & Jones, 2009
; Rothberg, Abraham, Lindenauer, & Rose, 2005
). This may be particularly important in underresourced institutions that could be caught in the spiral of poor outcomes and limited resources to improve performance, which may ultimately lead to lower reimbursement and continued poor outcomes.
Nurse-led coordinated care management models are currently in practice across the country and hold promise for cost effectively managing patients with chronic illness. The Transitional Care Model for instance emphasizes the role of advanced practice nurses in providing critical care to patients transitioning from the hospital to the home setting (Naylor et al., 1999
). Similarly, the Care Transitions intervention for patients discharged from hospitals relies on nurses (called transition coaches) who provide necessary services for patients with chronic illness (Coleman, Parry, Chalmers, & Min, 2006
). These models have been associated with significant reductions in emergency department visits, lower hospital costs, and decreased readmission days in clinical studies.
Addressing current trends in readmissions cannot rest solely on nurses. Management of complex disease processes such as heart failure and acute medical illness such as AMI requires the coordinated care services of a host of health care professionals and community resources. Comprehensive care management through nurse-led transitional care interventions, home health services and patient activation programs geared to engage patients in improved symptom management offers an important tool to avert early readmissions. These types of approaches are increasingly important as the health care system moves toward more multidisciplinary and integrated models of care such as the patient-centered medical home and accountable care organizations (Fisher & Shortell, 2010
; Rittenhouse & Shortell, 2009
). Further research should evaluate the effect of these integrated care approaches on reducing disparities. The attention to multidisciplinary care across settings also presents a window of opportunity for research examining the specific role of nurses in collaborative teams and the linkages between acute, ambulatory, and other community agencies (e.g., Public Health Departments, Community Health Centers, and Visiting Nursing Associations).