What works at hospitals with many privately insured patients may not work at facilities serving the poor and uninsured.
Disparities in surgical outcomes at safety net hospitals (SNH)—both real and perceived—are the result of a complex series of factors, say three Boston Medical Center surgeons in a paper published in the current JAMA Surgery.
Underfunding, Understaffing Hobble Outcomes at Safety Net Hospitals
Outcomes at these hospitals are influenced by factors at the individual, organizational, and policy levels, said Ryan Macht, MD, David McAneny, MD, and Gerard Doherty, MD.
At the individual level, risk-adjustment models used to evaluate quality fail to account for numerous factors that can influence outcomes at SNHs.
These include:
- Language and cultural barriers
- Social support
- Environmental characteristics
- Trust in the healthcare system
- Substance abuse
- Psychiatric diagnoses
"It is easy to appreciate that the risk for certain complications, such as a readmission for dehydration after a new ileostomy, differs between an illiterate, non–English-speaking patient with poorly controlled schizophrenia and a highly functioning patient," they wrote.
Why and How Safety Net Hospitals are Marketing Themselves
Efforts to improve quality metrics that work at some hospitals may not work at safety-net hospitals. For example, it can be too costly for SNHs to address the risk of venous thromboembolism among high-risk patients with postoperative prophylaxis.
Some SNHs have set up such programs, but it takes "significant institutional resources" to ensure that uninsured and Medicaid patients receive prophylaxis regimens on discharge, consistent with the standards for all patients and regardless of ability to pay, the authors stated.
In addition, the authors noted that SNHs have limited resources to improve pay-for-performance metrics. The authors advocated changing policies that disproportionately penalize these institutions