Residence within a disadvantaged U.S. neighborhood is a substantial predictor for re-hospitalization and that measures of such disadvantage, such as the Gopal Singh-developed area deprivation index (ADI), could potentially be used to inform policy and care after hospital discharge, according to a study published Dec. 2 in Annals of Internal Medicine.

Current data shows that thirty-day re-hospitalization affects one in five hospitalized Medicare patients, costs more than $17 billion annually, and results in hospital-based Medicare payment penalties for congestive heart failure, pneumonia and acute myocardial infarction re-hospitalizations. While specific hospital programs could potentially be used to support vulnerable patients during the high-risk period after hospital discharge, the targeting of these programs is often stymied because important contributing factors, such as socioeconomic disadvantage, are not well-measured.

A complex theoretical concept, socioeconomic disadvantage is described as the state of being challenged by low income, limited, education and substandard living conditions for both the person and his or her neighborhood or social network. As such information is rarely available in an individual patient’s medical record, creating a unique care plan after hospital discharge is incredibly challenging.

In an effort to gain a better understanding of socioeconomic disadvantage and its potential effect on re-hospitalization tactics, Amy Kind, MD, PhD, Geriatric Research Education and Clinical Center, Madison, WI, and her co-authors examined a national sample of Medicare patients (random five percent) discharged with congestive heart failure, pneumonia, or myocardial infarction between 2004 and 2009 (n=255,744). Linking patients’ Medicare data to 2000 census data to construct an ADI for each patient’s census block group, sorting them into percentiles by increasing ADI, relationships between neighborhood ADI grouping and 30-day re-hospitalization were evaluated using multivariate logistic regression models, controlling for patient sociodemographic characteristics, comorbid conditions and severity, and index hospital characteristics.

Results showed that the 30-day re-hospitalization rate did not vary significantly across the least disadvantaged 85 percent, which accrued an average re-hospitalization rate of 21 percent. Within the most disadvantaged 15 percent however, re-hospitalization rates increased from 22 percent to 27 percent as ADI worsened. After full adjustment, this relationship continued, with the most disadvantaged neighborhoods having a re-hospitalization risk (adjusted risk ratio, 1.09 [95 percent CI, 1.05 to 1.12]) similar to that of chronic pulmonary disease (adjusted risk ratio, 1.06 [CI, 1.04 to 1.08]) and greater than that of uncomplicated diabetes (adjusted risk ratio, 0.95 [CI, 0.94 to 0.97]).

“Our findings suggest that neighborhood disadvantage is associated with a threshold effect, with strong and increasing risk for re-hospitalization for residents of the most disadvantaged 15 percent,” write the authors. “This threshold effect conforms with fundamental theories of social disadvantage that indicate that there is generally some point beyond which persons can no longer compensate and additional disadvantage leads to increasingly adverse outcomes. A wealth of social science research demonstrates that ‘areas of concentrated poverty’ place additional burdens on poor families that live within them, beyond the effect of the families’ individual circumstances. It is clear that social support and a patient’s environment can influence clinical outcomes, including re-hospitalizations.”

Keywords: Censuses, Heart Failure, Hospitalization, Social Conditions, Medicare, Myocardial Infarction, Pneumonia, Residence Characteristics, Risk, Social Support, United States, Vulnerable Populations

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