The Vivien T. Thomas Symposium – The 3rd STS Achieving Equity in Clinical Care and Education Summit
A "Vulnerable" Patient-Intensified Protocol to Reduce Coronary Artery Bypass Grafting (CABG) Readmission Disparities: Importance of Social Determinants of Health (SDOH), Insurance, and Race/Ethnicity
Friday, January 24, 2025
2:55pm – 3:05pm PT
Location: 404AB
R. Mosca1, B. Aydin2, R. Ynfante2, T. Rhett2, M. Liao2, E. Grossi31NYU Langone Health, New York, New York 2Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York 3New York University Medical Center, New York, New York
Disclosure(s):
Ralph Mosca, MD, MBA: No financial relationships to disclose
Purpose: Equity metrics for readmission disparities and the availability of CABG readmission prevention programs impacting reimbursement and rankings were recently instituted. Knowledge gaps exist in the practical implementation and efficacy of such programs. We evaluated a social-risk informed quality initiative to identify vulnerable patients and associations among race/ethnicity, insurance, and SDOH.
Methods: Consecutive patients admitted to an urban medical center for isolated CABG from 10/2023-4/2024 (N=152) completed a standardized clinician-assisted SDOH questionnaire adapted from billing Z codes. An SDOH+ screen was defined as 2/9 yes responses. Race/ethnicity was determined by EHR; missing data were imputed from chart review and categorized using current CMS recommendations. Medicaid beneficiaries and those with dual eligibility (DE) for Medicare were deemed high risk for readmission. These patients and those with SDOH+ screen were assigned to a Vulnerable Patient Intensified Protocol (VPIP) pre-op that focused on enhancing connections to hospital and community social services, targeted educational interventions, and increased frequency of follow-up. Non-VPIP patients continued their usual care. Distributions and univariate associations among race/ethnicity, insurance status, SDOH, VPIP status, and 30-day readmissions were analyzed with chi-square (OR +/-95% CI). Independent associations between race/ethnicity, insurance status, and SDOH adjusted for age and gender were evaluated with stepwise logistic regression.
Results: Among 152 isolated CABG patients, 53% were >65 years, 80% male, 45% White, 24% had Medicaid, 13% DE. The most prevalent SDOH+ responses were: need for interpreter (34%), low health literacy (20%), transportation issues (20%), and < high school education (18%). Overall, 39% had two or more social risk factors. Patients with any SDOH risk factor were 7X more likely to have Medicaid or DE (p <.0001). Among Asians, 63% were SDOH+ c/w 37% of Whites (OR=6.0, p<.0001). African Americans/Blacks had 2X the odds to screen SDOH+ c/w Whites, but owing to the small sample, it was not significant. Whites were 80% less likely to screen SDOH+ c/w all minorities (OR=.20, p=.0004). Odds of an SDOH+ screen were significantly higher among patients with Medicaid vs. commercial insurance (OR=10.6, p<.0001), as was Medicaid/DE status c/w other insurance (OR=7.1, p<.0001). Among Asians without Medicaid/DE, 41% were SDOH+, and among African Americans/Blacks, 50% had no Medicaid/DE and were SDOH negative. Multivariable logistic regression showed Asian race was an independent predictor of SDOH+ status (OR=3.4, CI, 1.5-8.0). The strongest predictor of SDOH+ was Medicaid/DE vs. other insurance (OR=6.3, CI, 2.9-13.7). Overall, 30-day readmission rates were low but higher in VPIP (8%) than non-VPIP patients (2%).
Conclusion: Identifying vulnerable patients pre-op to refer to a CABG readmission prevention program was feasible via clinician-assisted standardized social risk factor documentation in the EHR. Our findings suggest that insurance status may be a better proxy than race to identify high-risk patients and may depend on the local populations served. Systematic evaluation of SDOH may help identify missed opportunities to prevent CABG readmissions. These findings may help inform healthcare organizations to develop and tailor quality initiatives in response to new requirements by the Centers for Medicare & Medicaid Services to document SDOH, reduce readmission disparities, and, most importantly, improve patient care.
Identify the source of the funding for this research project: None