Rates of readmission to hospitals after complex cancer surgeries are usually higher in vulnerable hospitals that serve as safety nets in their communities or in hospitals with a large number of Medicaid-insured patients. The reasons for these higher rates of readmission are complex, involving socioeconomic and hospital institutional characteristics.1

Financial penalties tied to readmissions do not reflect these socioeconomic factors and could cause unintended consequences in hospitals that are already financially strained.

“Patient conditions and hospital infrastructure make vulnerable hospitals prone to higher readmissions from the outset. Policymakers need to be aware of the drivers that lead to higher readmissions at these hospitals so payment penalties do not push financially strained hospitals into further hardship,” said Young Hong, MD, MedStar-Georgetown Surgical Outcomes Research Center and Georgetown University Medical Center, Washington, DC, and first author of the study.

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This study, published in the Journal of the American College of Surgeons, assessed the care of 110 857 adult patients who underwent 1 of 7 major or complex cancer operations between January 2004 and September 2011 at 355 hospitals in California.

Of the hospitals, 311 were considered nonvulnerable, 13 were considered safety net hospitals, 31 had a high number of Medicaid-insured patients, and 5 were both safety net hospitals and had high numbers of Medicaid-insured patients.

Patients underwent cancer resection procedures for the removal of the esophagus, stomach, pancreas, liver, prostate, lung, or kidney.

Readmission rates at 30 days were 11% for nonvulnerable hospitals, 14% for safety net hospitals, 13% for high Medicaid hospitals, and 14% for hospitals that were both safety net and high Medicaid facilities. Readmission rates at 90 days were 17% for nonvulnerable hospitals, 20% for safety net hospitals, 22% for high Medicaid hospitals, and 21% for hospitals that were both safety net and high Medicaid facilities.

Patients undergoing cancer procedures at vulnerable hospitals were more likely to live in low-income areas (28% vs 17%), be insured by Medicaid (27% vs. 5%), and be admitted through the emergency department for the index procedure (15% vs 9%) than patients undergoing operations at nonvulnerable hospitals.

Demographics of patients also differed depending on the type of vulnerable hospital. For example, the proportion of Hispanic patients was much higher (41%) at high Medicaid hospitals than at safety net (24%) or high Medicaid and safety net facilities (25%).

Most safety net (85%) and all safety net plus high Medicaid hospitals (100%) were teaching institutions, while only 47% of high Medicaid hospitals were teaching institutions.

The American College of Surgeons encourages incorporation of socioeconomic variables in the determination of Hospital Readmission Reduction Program payments, and the results from this study support that stance.


1. Hong Y, Zheng C, Hechenbleikner E, Johnson LB, Shara N, Al-Refaie WB. Vulnerable hospitals and cancer surgery readmissions: insights into the unintended consequences of the Patient Protection and Affordable Care Act [published online May 6, 2016]. J Am Coll Surg. doi:10.1016/j.jamcollsurg.2016.04.042.