DOI: 10.1111/jocs.

14738

ORIGINAL ARTICLE

The impact of hospital safety‐net burden on mortality and

readmission after CABG surgery

Marguerite M. Hoyler MD1 | Christopher W. Tam MD1 | Richard Thalappillil MD1 |

Silis Jiang PhD2 | Xiaoyue Ma MS3 | Briana Lui BS2 | Robert S. White MD, MS1,2

1
Department of Anesthesiology, New York‐
Presbyterian/Weill Cornell Medical Center,
New York, New York
2 Background and Aim: Safety‐net hospitals (SNHs) serve high proportions of unin-
Department of Anesthesiology, Center for
Perioperative Outcomes, New York‐
Presbyterian/Weill Cornell Medical Center,
New York, New York
3
Department of Healthcare Policy and
Research, Weill Cornell Medicine, New York,
New York
Correspondence
Marguerite M. Hoyler, MD, Department of
Anesthesiology, New York‐Presbyterian/Weill
Cornell Medical Center, 525 East 68th Street,
Box 124, New York, NY 10065.
Email: mam9508@nyp.org
Abstract
sured and Medicaid patients. Data conflict as to the impact of hospital safety‐net
status on perioperative complications. Our goal was to assess the effect of hospital
safety‐net burden on mortality and readmission following coronary artery bypass
graft (CABG) surgery.
Methods: A retrospective analysis was performed using five State Inpatient
Databases (2007‐2014) for isolated CABG surgery. High, medium, and low
burden hospitals were those with the highest, middle, and lowest tertiles of
uninsured and Medicaid admissions, respectively. We compared patient
demographics and hospital characteristics by safety‐net status. Multivariable
logistic regression models assessed adjusted odds of in‐hospital mortality and
30‐ and 90‐day readmission.
Results: About 304 080 patients were included in our analysis. On univariate ana-
lysis, high burden hospitals had higher inpatient mortality (2.06% vs 1.71%; P < .001)
and 30 day‐ (16.3% vs 15.3%; P < .001) and 90‐day readmission rates (24.6% vs
23.0%; P < .001). On multivariate analysis, high‐burden status was not associated
with significantly increased adjusted odds of inpatient mortality (OR, 1.047; 95% CI,
0.878‐1.249), or readmission at 30 (OR, 1.035; 95% CI, 0.958‐1.118) or 90 days (OR,
1.040; 95% CI, 0.968‐1.117).
Conclusion: SNHs do not have worse mortality and readmission outcomes
following CABG, after adjusting for patient and hospital characteristics. These
findings are reassuring regarding the quality of cardiac surgery care provided to
underinsured patient groups. More research is needed to further elucidate trends
in outcomes.

KEYWORDS

CABG, mortality and readmission, safety‐net burden, socioeconomic status, surgical outcomes

1 | BACKGROUND procedures.1 Although postoperative outcomes continue to improve,2

CABG is still associated with frequent postoperative complications,
Coronary artery bypass grafting (CABG) is the most common cardiac including in‐hospital mortality up to 2%3 and readmission rates
operation performed in the United States, with over 370 000 annual between 8% and 20%.4 Among CABG patients, markers of low

J Card Surg. 2020;1–10. wileyonlinelibrary.com/journal/jocs © 2020 Wiley Periodicals LLC | 1

2 |
socioeconomic status, such as Medicaid and uninsured status, corre-
late to increased risk of postoperative mortality and readmission,
among other commonly utilized metrics of quality of care.3,4 Similarly,
a growing body of research links lower socioeconomic status to
increased mortality and other adverse outcomes following orthopedic,
vascular, and general surgery procedures.3,5‐9
Safety‐net hospitals (SNHs) serve high proportions of uninsured
and Medicaid patients and provide a significant portion of care to pa-
10
tients regardless of their ability to pay. Although there are no official
criteria for designating safety‐net hospital status,10 the relative per-
centages of uninsured and Medicaid patients cared for in these in-
stitutions is a commonly utilized indicator. Safety‐net hospitals are thus
often referred to as “high burden” hospitals (HBHs) due to the elevated
burden of uninsured and Medicaid patients they serve; in the medical
11,12
literature, these terms are often used interchangeably.
In spite of the association between socioeconomic markers and
postoperative complications, data are conflicting regarding the im-
pact of hospital safety net status on perioperative mortality and
morbidity.13 Previous studies have demonstrated increased rates of
14 15,16
readmission and perioperative mortality among surgical pa-
tients treated at SNHs, while other research suggests that HBHs may
achieve comparable surgical treatment outcomes to “low burden”
hospitals (LBHs).17,18 Among cardiac disease patients, HBHs have
been associated with increase mortality following ST‐elevation
myocardial infarction19 and elevated rates of “failure to rescue”
following cardiac surgery.20 However, recent data indicate that aortic
valve replacement (AVR) outcomes may be comparable across high‐
11
and low‐burden institutions. Data are particularly limited regarding
the relationship between hospital safety‐net status and adverse
clinical outcomes following CABG.
The goal of this study was to assess the effect of hospital safety‐
net burden on adverse outcomes following CABG. We hypothesized
that high‐burden hospitals would have elevated rates of inpatient
mortality and readmission following isolated CABG procedures.
HOYLER ET AL.
2 | METHO DS
2.1 | Study database and populations
A retrospective review was performed on data from California,
Florida, New York, Maryland, and Kentucky from the State Inpatient
Databases (SID), Healthcare Cost and Utilization Project (HCUP),
Agency for Healthcare Research and Quality from 2007 to 2014.21
California data was only available 2007 to 2011. No readmissions
data were available for Kentucky, and Maryland lacked readmissions
data from 2007 to 2011.
The study population consisted of patients more than equal to 18
years of age who underwent isolated CABG. Patients were excluded
if demographic data (eg, age, sex, and insurance status) were absent
(Figure 1).
The SID contains all‐payer inpatient data from nonfederal, non-
psychiatric hospitals and is verified by quality control measures es-
tablished by the HCUP for validity and internal consistency.21 All
study activities were approved by the Weill Cornell Medicine In-
stitutional Review Board.
2.2 | Variables and outcomes
Variables extracted for each admission and readmission included
patient demographic information (eg, age, sex, and race/ethnicity),
ICD‐9‐CM diagnoses and procedure codes, insurance type or ex-
pected payer, surgical type as indicated (elective, urgent, or emergent
operative status), and median household income by zip code, strati-
fied by the state into quartiles. Hospital volume quartiles were cal-
culated based on the total volume of CABG procedures performed at
each institution. Case volume ranges per quartile were 1 to 271
(quartile 1), 272 to 649 (quartile 2), 560‐1367 (quartile 3) and more
than equal to 1368 (quartile 4) total CABG procedures.
FIGURE 1 CONSORT Diagram
HOYLER ET AL.
Hospitals were cohorted into tertiles based on the proportion of
inpatient cases billed to Medicaid or identified as unpaid (the latter
labeled as uninsured). The lowest tertile (“low burden hospitals,” or
LBH) had less than 16.8% Medicaid or uninsured patients, the middle
tertile (“medium burden hospitals,” or MBH) between 16.9% and
30.4% Medicaid or uninsured patients, and the highest (“high burden
hospitals,” or HBH) served at least 30.5% Medicaid or uninsured
among all inpatient cases.
Present‐on‐admission (POA) comorbid diagnostic codes (ICD‐9‐CM)
were categorized according to the Elixhauser Comorbidity Index.22
Patients were grouped by insurance type or expected payer into the
following cohorts: Medicare, Medicaid, Uninsured (eg, no‐charge
reported or “self‐pay” status), Other (eg, Worker's Compensation,
CHAMPUS, CHAMPVA), and Private Insurance. Patients were grouped
by self‐reported race/ethnicity as white, black, Hispanic, other, or “coded
as missing.”
Patients who underwent isolated CABG were identified using
International Classification of Disease, 9th Revision, Clinical Mod-
ification (ICD‐9‐CM) procedure codes. ICD‐9‐CM procedure codes
for CABG include 361, 3610, 3611, 3612, 3613, 3614, 3615, and
3616. Patients were excluded if they underwent concomitant cardiac
valve operations.
2.3 | Outcomes
The primary outcome of this study was mortality during the index
hospitalization. Secondary outcomes included 30‐ and 90‐ day
readmission. Exploratory outcomes include rates of perioperative
complications.
2.4 | Statistical analyses
Demographic characteristics and POA comorbidities were compared
for all patients who underwent isolated CABG. χ analysis or Fisher's
2
exact test was used to test statistical significance for categorical
variables, including insurance status, readmission rates, readmission
diagnoses, and demographic data. Continuous variables were ana-
lyzed with analysis of variance or Kruskal‐Wallis tests, for non-
normally distributed variables, as appropriate. All P‐values were
two‐sided with statistical significance evaluated at an α level of .05.
Multivariate logistic regression analyses were used to estimate
odds ratios (OR) with 95% confidence intervals for mortality during
the index hospitalization and 30‐ and 90‐day readmissions for each
burden tertile, while controlling for other demographic variables,
comorbidities, postoperative complications, hospital length of stay
(LOS), discharge disposition status, and other potential confounders.
These models were clustered at the hospital level to account for
intrainstitutional practice patterns and interinstitutional practice
differences. Length of stay, discharge disposition, and total charges of
index hospitalization was incorporated into the model for read-
missions outcomes only, to adjust for initial hospitalization course.
| 3
Models included variables with an alpha level of 0.25 or lower in
bivariate analyses, or variables selected a priori as potential con-
founders. To handle missing data complete case analysis was
performed.
The discrimination of each previously described model was
measured with the C‐statistic. Statistical tests and analyses were
performed using SAS version 9.3 (SAS Institute, Cary, NC).
3 | RE SU LTS
About 304 080 adult patients underwent CABG between 2007 and
2014 in the aforementioned five states and met inclusion criteria, as
depicted in Figure 1. Patient characteristics, stratified by hospital
burden status, are presented in Table 1.
3.1 | Demographic and clinical characteristics
Relative to LBH, patients treated at HBH were younger (64.7 vs 66.5
years; P < .001) and less predominantly male (72.8% vs 75.2%;
P < .001). They were more likely to have pre‐existing comorbidities,
including congestive heart failure (CHF), hypertension with chronic
complications, and obesity. Patients treated at medium burden hos-
pitals were least likely to have diabetes with chronic complications.
Patients treated at HBH were more likely to be in the lowest and
second‐lowest income quartiles by zip code (31.6% vs 15.0%;
P < .001; 27.9% vs 21.0%; P < .001), and more likely to be Hispanic
(16.3% vs 6.11%; P < .001) or of black race/ethnicity (8.29% vs
4.57%; P < .001).
3.2 | Postoperative outcomes
The overall in‐hospital mortality rate was 1.87%. Overall 30‐ and 90‐
day readmission rates were 15.8% and 23.7%, respectively. HBH had
higher unadjusted inpatient mortality (2.06% vs 1.71%; P < .001) and
30 day‐ (16.3% vs 15.3%; P < .001) and 90‐ day readmission (24.6% vs
23.0%; P < .001).
The overall complication rate was 37.4%. On univariate analysis,
complication rates were significantly different across hospital groups,
with the lowest rates observed in medium‐burden institutions (38.4%
v. 36.1% vs 37.4%, P < .001 for HBH, MBH, and LBH, respectively).
HBH had higher rates of postoperative infectious (6.09% v. 4.65%,
P < 0.001) and pulmonary complications (27.4% vs 26.0%, P < .001),
but lower rates of cardiovascular complications (14.9% v. 17.4%,
P < 0.001). The median length of stay was similar across groups, but
longer lengths of stay were observed in HBH patients relative to
other tertiles.
On multivariate analysis, high‐burden status was not associated
with increased odds of inpatient mortality (OR, 1.047; 95% CI, 0.878‐
1.249), or readmission at 30 days (OR, 1.035; 95% CI, 0.958‐1.118)
or 90 days (OR, 1.040; 95% CI, 0.969‐1.118).
4 | HOYLER ET AL.

T A B L E 1 Baseline characteristics of patients undergoing isolated CABG, stratified by hospital safety‐net burden
Low burden Medium burden; High burden;
Total N = 304 080 N = 72 468 N = 151 254 N = 80 358 P value

Age, y, mean ± SD 65.6 ± 10.7 66.5 ± 10.7 65.7 ± 10.7 64.7 ± 10.7 <.001

Died 5699 (1.87%) 1238 (1.71%) 2802 (1.85%) 1659 (2.06%) <.001

Readmitted (30 d) 37194 (15.8%) 8058 (15.3%) 18763 (15.7%) 10 373 (16.3%) <.001

Readmitted (90 d) 55 768 (23.7%) 12 133 (23.0%) 27 988 (23.5%) 15 647 (24.6%) <.001

Sex (female) 80 381 (26.4%) 17 961 (24.8%) 40 580 (26.8%) 21 840 (27.2%) <.001

Race/ethnicity <.001

Black 17 856 (5.87%) 3313 (4.57%) 7884 (5.21%) 6659 (8.29%)

Hispanic 28 886 (9.50%) 4429 (6.11%) 11 388 (7.53%) 13 069 (16.3%)
Other 9615 (3.16%) 1265 (1.75%) 4827 (3.19%) 3523 (4.38%)
White 27 573 (9.07%) 7029 (9.70%) 10 397 (6.87%) 10 147 (12.6%)

Coded as “Missing” 11 371 (3.74%) 3455 (4.77%) 5322 (3.52%) 2594 (3.23%)

State <.001
CA 68 896 (22.7%) 20 965 (28.9%) 18 530 (12.3%) 29 401 (36.6%)
FL 10 6245 (34.9%) 17 547 (24.2%) 64 379 (42.6%) 24 319 (30.3%)
KY 33 323 (11.0%) 12 012 (16.6%) 16 725 (11.1%) 4586 (5.71%)
MD 21 630 (7.11%) 4068 (5.61%) 9686 (6.40%) 7876 (9.80%)
NY 73 986 (24.3%) 17 876 (24.7%) 41 934 (27.7%) 14 176 (17.6%)

Patient zip code income quartile, lowest to highest <.001

First 77 031 (25.3%) 10 899 (15.0%) 40 770 (27.0%) 25 362 (31.6%)
Second 81 711 (26.9%) 15 190 (21.0%) 44 113 (29.2%) 22 408 (27.9%)
Third 77 922 (25.6%) 19 316 (26.7%) 40 119 (26.5%) 18 487 (23.0%)
Fourth 67 416 (22.2%) 27 063 (37.3%) 26 252 (17.4%) 14 101 (17.5%)

Insurance status <.001

Medicaid 23 642 (7.77%) 3240 (4.47%) 10 051 (6.65%) 10 351 (12.9%)
Medicare 163 979 (53.9%) 39 782 (54.9%) 84 037 (55.6%) 40160 (50.0%)
Other 9615 (3.16%) 1265 (1.75%) 4827 (3.19%) 3523 (4.38%)
Private insurance 94 245 (31.0%) 26 194 (36.1%) 45 909 (30.4%) 22 142 (27.6%)
Self‐pay/uninsured 12 599 (4.14%) 1987 (2.74%) 6430 (4.25%) 4182 (5.20%)

Operative urgency <.001

Elective 10 0134 (32.9%) 21 995 (30.4%) 58 032 (38.4%) 20 107 (25.0%)
Emergent 80 762 (26.6%) 18 211 (25.1%) 42 606 (28.2%) 19 945 (24.8%)
Urgent 53 695 (17.7%) 11 275 (15.6%) 31 603 (20.9%) 10 817 (13.5%)
Other/trauma center <91 (<0.03%) <11 (<0.02%) 49 (0.03%) 31 (0.04%)
Coded As “Missing” 69 401 (22.8%) 20 979 (28.9%) 18 964 (12.5%) 29 458 (36.7%)

Comorbidities present on admissiona

CHF 39 924 (13.1%) 9440 (13.0%) 17 544 (11.6%) 12 940 (16.1%) <.001
Peripheral cascular disease 34308 (11.3%) 8804 (12.1%) 16 481 (10.9%) 9023 (11.2%) <.001
Diseases of the pulmonary 7238 (2.38%) 1731 (2.39%) 3254 (2.15%) 2253 (2.80%) <.001
circulation
HTN, uncomplicated 140 291 (46.1%) 34 627 (47.8%) 67 294 (44.5%) 38 370 (47.7%) <.001
HTN, complicated 35 694 (11.7%) 9021 (12.4%) 15 923 (10.5%) 10 750 (13.4%) <.001
Obesity 41 860 (13.8%) 9660 (13.3%) 20 713 (13.7%) 11 487 (14.3%) <.001
Chronic pulmonary disease 48 830 (16.1%) 11 377 (15.7%) 24 268 (16.0%) 13 185 (16.4%) <.001
Diabetes, with chronic complications 16035 (5.27%) 4375 (6.04%) 7060 (4.67%) 4600 (5.72%) <.001
Diabetes, without chronic 74 099 (24.4%) 16 923 (23.4%) 34 822 (23.0%) 22 354 (27.8%) <.001
complications
Renal failure 33 130 (10.9%) 8678 (12.0%) 14 538 (9.61%) 9914 (12.3%) <.001
Liver disease 2791 (0.92%) 755 (1.04%) 1155 (0.76%) 881 (1.10%) <.001
HOYLER ET AL. | 5

TABLE 1 (Continued)

Low burden Medium burden; High burden;

Total N = 304 080 N = 72 468 N = 151 254 N = 80 358 P value

Coagulopathy 9836 (3.23%) 2476 (3.42%) 4344 (2.87%) 3016 (3.75%) <.001
Deficiency anemia 28 185 (9.27%) 6686 (9.23%) 12413 (8.21%) 9086 (11.3%) <.001
Blood loss anemia 1534 (0.50%) 315 (0.43%) 603 (0.40%) 616 (0.77%) <.001
Alcohol abuse 6598 (2.17%) 1259 (1.74%) 3212 (2.12%) 2127 (2.65%) <.001
Drug abuse 3063 (1.01%) 496 (0.68%) 1262 (0.83%) 1305 (1.62%) <.001

Complications
Any complication 113 611 (37.4%) 28 093 (38.8%) 54 658 (36.1%) 30 860 (38.4%) <.001
Intraoperative 8400 (2.76%) 2138 (2.95%) 3802 (2.51%) 2460 (3.06%) <.001
Gastrointestinal 2216 (0.73%) 520 (0.72%) 1099 (0.73%) 597 (0.74%) .836
Cardiovascular 46 917 (15.4%) 12 642 (17.4%) 22 321 (14.8%) 11 954 (14.9%) <.001
Infectious 14 657 (4.82%) 3369 (4.65%) 6391 (4.23%) 4897 (6.09%) <.001
Pulmonary 78 869 (25.9%) 18 849 (26.0%) 37 987 (25.1%) 22 033 (27.4%) <.001

Length of stay (d; IQR) 8 (6‐11) 8 (6‐11) 8 (6‐11) 8(6‐12) <.001

Disposition
Routine discharge 104 375 (34.3%) 22 122 (30.5%) 51 641 (34.1%) 30 612 (38.1%) <.001
Home health care 136 243 (44.8%) 35 320 (48.7%) 67 396 (44.6%) 33 527 (41.7%) <.001
Short term hospital 2678 (0.88%) 738 (1.02%) 1047 (0.69%) 893 (1.11%) <.001
Other transfer/AMA/Unknown 55 085 (18.1%) 13 050 (18.0%) 28 368 (18.8%) 13 667 (17.0%) <.001

Abbreviations: AMA, against medical advice; CABG, coronary artery bypass graft; IQR, interquartile range.
a
Partial list of comorbidities.

On exploratory analyses, it was noted that mortality odds were
similar across states. California demonstrated significantly reduced
readmission odds (30‐day OR, 0.855 [0.789‐0.925]; 90‐day OR, 0.864
[0.801‐0.931]). Results of multivariate analyses are presented in
Table 2.
The most common readmission diagnoses were consistent at
time periods of 30‐ and 90‐days, but prevalence varied significantly
across burden tertiles. HBH patients were significantly more likely to
be readmitted with diagnoses of pneumonia or myocardial infarction;
LBH patients were more likely to be readmitted with atrial fibrilla-
tion. Present‐on‐readmission diagnoses are presented in Table 3.
4 | D I S C U S SI O N
This retrospective analysis of 304 080 CABG patients in five states
over 8 consecutive years found increased rates of in‐patient mor-
tality and 30‐ and 90‐day readmission among patients treated at
HBH. However, after statistical adjusting for hospital and patient
characteristics, HBH status was not associated with significantly in-
creased in‐patient mortality or readmission odds. These findings
suggest that the care provided to CABG patients at HBH may be
comparable to care provided in hospitals that treat fewer Medicaid
and uninsured patients, as indicated by the established quality me-
trics of readmission and in‐patient mortality.
The results of this study were contrary to our hypothesis, which
anticipated worse mortality and readmission outcomes at SNHs, and
was based on prior research demonstrating inferior postoperative
mortality and morbidity for surgical patients at SNHs.14,15 For in-
stance, in an analysis of over two million cases from the National
Inpatient Databases, Sanaiha et al.20 found that HBH status was
associated with “failure to rescue” after elective CABG and/or car-
diac valve operations (OR, 1.12, 95% CI, 1.01‐1.23). Inferior mortal-
ity, morbidity and readmission outcomes have also been reported
following open AAA repair,12 total hip arthroplasty,15 head and neck
oncologic surgery,23 and neurosurgical management of traumatic
brain injury,24 among other operations.13
Nonetheless, the findings of the current study are not without
precedent. In a retrospective review of 85 441 surgical AVR patients
from the NIS databases, Ando et al11 found that in‐hospital mortality
rates were significantly higher at high‐burden SNHs, but that mor-
tality odds were not significantly elevated after adjusting for patient
demographic factors and comorbidities, as well as hospital factors
including size and case volume (OR: 1.08; 95% CI: 0.85‐1.36).11
Similarly, a retrospective analysis of patients undergoing CABG and
other major surgery in New York State, Glance et al.25 reported
increased readmission odds for patients treated at high‐burden
SNHs, before risk adjustment. In that study, however, mortality odds
were less elevated after adjusting for patient demographics and co-
morbidities, and became statistically comparable across hospital
burden groups after accounting for patient socioeconomic status
(OR, 1.08; 95% CI: 0.95‐1.23). Finally, a study of over 12 million
thoracic, orthopedic, and general surgery patients captured in the
University HealthSystem Consortium database found no increased
risk of in‐hospital mortality or 30‐day readmission among CABG
patients treated at HBHs.13
6 | HOYLER ET AL.

T A B L E 2 Results of multivariable generalized estimating equations for inpatient mortality and 30‐ and 90‐d readmission
Independent variables In‐hospital mortality 30‐d Readmission 90‐d Readmission

(Odds ratios with 95% confidence intervals)

Age (per 1 year increase)

1.035 (1.031‐1.039)**** 1.000 (0.998‐1.001) 0.998 (0.997‐1.000)*

Female sex (reference: male)

1.321 (1.248‐1.399)**** 1.244 (1.214 – 1.275)**** 1.250 (1.222‐1.278)****

Hospital burden (reference: low burden)

Medium 1.084 (0.932‐1.260) 1.007 (0.935‐1.084) 0.995 (0.928‐1.067)
High 1.047 (0.878‐1.249) 1.035 (0.958‐1.118) 1.040 (0.969‐1.118)

Payer status (reference: private Insurance)

Medicaid 1.452 (1.278‐1.650) **** 1.429 (1.365‐1.496)**** 1.452 (1.392‐1.514)****
Medicare 1.190 (1.094‐1.296) **** 1.272 (1.227‐1.319)**** 1.307 (1.264‐1.351)****
Other 1.098 (0.883‐1.365) 1.028 (0.939‐1.126) 1.031 (0.954‐1.115)
Self‐Pay/no charge/uninsured 1.595 (1.346‐1.889) **** 1.067 (0.963‐1.183) 1.084 (0.997‐1.180)

Race/Ethnicity (reference: White)

Black 1.076 (0.966‐1.199) 1.197 (1.142‐1.254)**** 1.210 (1.161‐1.262)****
Hispanic 0.936 (0.853‐1.026) 1.153 (1.101‐1.207)**** 1.159 (1.109‐1.211)****
Other 0.993 (0.895‐1.102) 0.971 (0.927‐1.016) 0.927 (0.880‐0.966)****
Coded as “Missing” 1.746 (1.480‐2.060)**** 0.747 (0.679‐0.820)**** 0.770 (0.706‐0.840)d

Median income level per Zip Code (reference: first quartile)

Second quartile 0.920 (0.851‐0.995)* 0.984 (0.950‐1.019) 0.978 (0.947‐1.010)
Third quartile 0.883 (0.805‐0.968)** 0.983 (0.942‐1.025) 0.960 (0.924‐0.997)*
Fourth quartile 0.848 (0.776‐0.927)*** 0.939 (0.897‐0.982)** 0.926 (0.888‐0.964)***

Hospital volume (reference: first quartile)

Second quartile 0.791 (0.601‐1.042) 0.970 (0.864‐1.088) 0.999 (0.891‐1.119)
Third quartile 0.769 (0.577‐1.023) 0.926 (0.820‐1.045) 0.964 (0.857‐1.083)
Fourth quartile 0.773 (0.574‐1.043) 0.933 (0.827‐1.053) 0.984 (0.873‐1.108)

State (reference: Florida)

California 1.109 (0.917‐1.342) 0.855 (0.789‐0.926)**** 0.864 (0.801‐0.931)***
Kentuckya 1.074 (0.858‐1.346) … …
Maryland 0.915 (0.683‐1.224) 0.978 (0.858‐1.116) 0.990 (0.886‐1.106)
New York 0.924 (0.782‐1.091) 1.033 (0.958‐1.113) 1.013 (0.983‐1.094)

Year (reference: 2007)

2008 0.719 (0.650‐0.795)**** 1.047 (1.001‐1.095) 1.027 (0.989‐1.067)
2009 0.622 (0.562‐0.689)**** 0.999 (0.995‐1.045) 0.990 (0.953‐1.028)
2010 0.628 (0.560‐0.704)**** 0.943 (0.894‐0.994)* 0.938 (0.892‐0.986)*
2011 0.602 (0.536‐0.675)**** 0.895 (0.851‐0.941)**** 0.901 (0.863‐0.941)****
2012 2.071 (1.736‐2.471)**** 1.100 (1.033‐1.171)*** 1.155 (1.090‐1.223)****
2013 2.089 (1.772‐2.463)**** 1.022 (0.957‐1.092) 1.067 (1.007‐1.131)*
2014 1.836 (1.548‐2.179)**** 1.044 (0.975‐1.118) 1.099 (1.033‐1.687)***

Elixhauser comorbidity index category (reference: category 1)

Category 2 1.329 (1.171‐1.507)**** 0.823 (0.788‐0.860)**** 0.823 (0.792‐0.855)****
Category 3 2.103 (1.882‐2.351)**** 1.191 (1.145‐1.239)**** 1.305 (1.262‐1.349)****
b
Length of stay (log‐transformed)
… 1.552 (1.480‐1.627)**** 1.622 (1.551−1.696)****
b
Total hospital charges (log‐transformed)
… 1.199 (1.135‐1.266)**** 1.197 (1.139‐1.258)****

Postoperative complications (Reference: no complications)

Intraoperative 2.661 (2.398‐2.953)**** 1.078 (1.007‐1.154)* 0.997 (0.939‐1.059)
Cardiovascular 1.194 (1.108‐1.285) **** 1.040 (1.009‐1.073)* 1.040 (1.014‐1.067)***
HOYLER ET AL. | 7

TABLE 2 (Continued)

Independent variables In‐hospital mortality 30‐d Readmission 90‐d Readmission

Gastrointestinal 1.628 (1.298‐2.041)**** 0.903 (0.809‐1.008) 0.909 (0.808‐1.023)

Infectious 3.538 (3.251‐3.845)**** 0.970 (0.921‐1.023) 0.992 (0.944‐1.043)
Pulmonary 6.145 (5.552‐6.798)**** 1.014 (0.982‐1.047) 1.006 (0.977‐1.037)
b
Discharge disposition (reference: routine discharge)
Home health care … 1.135 (1.088‐1.184)**** 1.123 (1.086‐1.161)****
Short‐term hospital … 1.126 (0.952‐1.332) 1.364 (1.198‐1.554)****
Other transfer/AMA/Unknown … 1.5578 (1.478‐1.641)**** 1.647 (1.576‐1.721)****

Abbreviation: AMA, against medical advice.

a
Readmission data are unavailable for Kentucky.
b
Length of stay (LOS), total hospital charges, and discharge dispositions were included as markers of index hospitalization course complexity; they were
excluded from the multivariable model for in‐hospital mortality.
*P < .05; **P < .01; ***P < .001; ****P < .0001.

Comparable surgical outcomes at high‐burden hospitals have
also been reported in noncardiac surgery literature. An analysis of
over 300,000 patients who received surgical treatment for carotid
stenosis, peripheral arterial disease and AAAs found that, while HBH
patients were younger and presented with more comorbidities and
more advanced vascular disease, HBH status did not yield a sig-
nificantly increased odds of in‐hospital mortality.26 Similarly, a ret-
rospective review of 11,047 liver transplant patients found that
safety‐net hospitals had higher rates of in‐hospital mortality but
achieved noninferior rates of long‐term patient and graft survival.17
Comparable long‐term outcomes have also been described among
27 18
patients treated surgically for pancreatic and rectal cancers.
Several explanations may account for the findings of the current
study. Most notably, our findings suggest that patient‐level clinical
and demographic factors, as opposed to hospital‐level factors, in-
cluding safety‐net status, are the primary determinants of in‐hospital
mortality and postoperative readmission following CABG, even high‐
burden institutions. In the current study, markers of lower socio-
economic status had a particularly strong impact on postoperative
mortality and readmission: patients treated at HBH were more likely
to reside in lower‐income zip‐codes and to be uninsured or Medicaid
status and these markers of low SES were independently associated
with inferior outcomes.
The association between lower socioeconomic status and in-
3,5‐9
ferior postoperative outcomes is well‐documented. Pre‐existing
chronic disease is often posited as a factor connecting social dis-
advantage to worse postoperative outcomes.25,28 Patients of lower
SES tend to have more numerous and more severe comorbidities
than more affluent patient groups,9,29 as well as higher rates of to-
bacco use and other modifiable mortality risk factors.30,31 Limited
healthcare literacy and cultural and linguistic barriers may further
compromise the management of chronic medical conditions in so-
cially disadvantaged populations.32,33 Uninsured and underinsured
patients may be less likely to seek out preventative care and may
defer necessary medical treatment for financial reasons.34 In the
current study, patients treated at HBH were more likely to have
comorbidities such as CHF, hypertension with chronic complications,
and obesity. The significantly different rates of readmission diag-
noses (eg, myocardial infarction, pneumonia) and index hospitaliza-
tion LOS across burden tertiles, as observed in this study, may also
reflect differences in the underlying health status of patients from
different socioeconomic strata. In the current study, increasing co-
morbidity burden was independently associated with increased odds
of in‐hospital mortality and 30‐ and 90‐day readmission across hos-
pital burden tertiles.
An alternate explanation for the comparable mortality and
readmissions odds observed in this study reflects close national
oversight of CABG outcomes, as well as powerful financial incentives
for the provision of high‐quality care. CABG is one of a small number
of operations targeted by the Centers for Medicare and Medicaid

T A B L E 3 Most common 30‐ and 90‐day readmission diagnoses, by Hospital Burden Tertile

30‐d Readmissions n (%) 90‐d Readmissions n (%)

Diagnosis Low burden Medium burden High Burden P value Low burden Medium burden High burden P value

Atrial fibrillation 2237 (30.2%) 5468 (29.2%) 2442 (23.6%) <.001 3061 (27.3%) 7369 (26.3%) 3270 (20.9%) <.001

Pleural effusion 1593 (21.5%) 4449 (23.7%) 2191 (21.1%) <.001 1942 (17.3%) 5412 (19.3%) 2665 (17.0%) <.001

Wound Infection 1309 (17.7%) 3176 (16.9%) 1807 (17.4%) .291 1628 (14.5%) 3942 (14.1%) 2235 (14.3%) .503

Pneumonia 827 (11.2%) 2543 (13.6%) 1422 (13.7%) <.001 1072 (9.57%) 3313 (11.8%) 1834 (11.7%) <.001

Myocardial Infarction 849 (11.5%) 2423 (12.9%) 1373 (13.3%) .001 1088 (9.72%) 3033 (10.8%) 1745 (11.2%) <.001
8 |
(CMS) Hospital Readmissions Reduction Program, which applies fi-
nancial penalties to institutions with elevated CABG readmissions
35 1
rates. In addition, a mean hospital charge of over $180,000, CABG
procedures may represent a significant source of hospital revenue.36
These fiscal considerations may be a notable impetus for both high‐
and low‐burden hospitals to prioritize the care of CABG patients and
may help explain the comparable mortality and readmission odds we
observed.
Furthermore, CABG is the most common cardiac operation
performed in the US,1 and an overall high procedural volume may
contribute to the comparable mortality and readmission odds seen in
this study. Across a wide range of surgical specialties, high volume
centers have been shown to achieve superior operative outcomes
compared to low volume centers.37,38 In the context of safety‐net
institutions, differences in operative volume may help explain why
HBH achieves comparable mortality and morbidity outcomes fol-
lowing relatively common procedures, such as appendectomy,39 but
inferior outcomes following more rare operations, such as open AAA
repair.12 In the current study, hospital volume quartiles were not
associated with readmission or mortality odds, potentially indicating
an overall sufficient CABG case volume to support equivalent out-
comes regardless of burden status. In a related fashion, only a subset
of US hospitals, including HBHs, are capable of offering cardiac
14
surgery ; hospitals with the resources to sustain the complex
technical and staffing requirements for open heart operations may be
systematically different from institutions that lack these resources.
Finally, increased standardization of postoperative care may help
account for the outcomes of this study. Enhanced recovery after
surgery protocols are increasingly recommended across surgical
disciplines, including cardiac surgery.40,41 In theory, these care
pathways may play a significant role in reducing disparities across
42
socioeconomic lines, , and in ensuring high‐quality care at institu-
tions with fewer resources, such as high‐burden hospitals.
5 | LIMITATIONS
Our study is subject to several limitations, including its retrospective
and observational nature and the absence of granular clinical data
available in the administrative billing data we queried. In particular,
the HCUP‐SID databases do not stratify comorbid disease severity or
provide pre‐ or intra‐operative data (eg, immediate preoperative
clinical status, cardiopulmonary bypass time, or transfusion require-
ments). These and similar data may indicate both surgical and patient
43
clinical complexity and increased risk of complications.
In addition, although our study includes five geographically and
culturally diverse states, our results may not be generalizable to the
entire US population. The included states could in some way be dif-
ferent in terms of patient demographics, as well as healthcare re-
sources and practice patterns, relative to the 45 states not included.
In particular, our study may not fully account for differences in
Medicaid coverage across states. Our model was not structured to
identify interstate differences as a primary outcome; the state‐based
HOYLER ET AL.
outcomes reported here (including decreased odds of readmission on
California) should be regarded as preliminary and hypothesis‐
generating.
The utilization of tertile thresholds to indicate burden status may
also affect the results of this study. There are no universally accepted
criteria for the designation of safety‐net or “high burden” status10 in
terms of volume or percentages of underinsured patients cared for, and
prior studies have utilized highest burden quartiles12 and quintiles11 to
designate HBH. However, our decision to use tertiles, as opposed to
comparisons across smaller and more widely stratified groups, biases
towards the null hypothesis and thus strengthens the findings of the
current study. Our data set includes admissions through the year 2014;
it is possible that clinical practice patterns, and also complication rates,
have changed in the intervening 6 years, and that the results of our
study do not reflect the current state of CABG outcomes. Finally, our
study captures only mortality during the index hospitalization, and thus
offers an incomplete picture of the overall mortality risk associated
with HBH status.
Due to its retrospective nature, this study cannot elucidate the
causal mechanisms by which HBH achieve post‐CABG mortality and
readmission rates comparable to LBH. However, it may inform hy-
potheses for future inquiry. These future studies could be used to
help elevate the quality of care, and improve the clinical outcomes,
for patients undergoing other procedures as HBH, particularly those
demonstrated to have increased mortality and morbidity risk at
safety‐net institutions.
The strengths of this study include large statistical power and
external validity, as our sample included over 304 080 patients from
five diverse states for 8 consecutive years (2007‐2014). An addi-
tional strength of this study is a robust mixed‐effect multivariate
analysis including patient clinical and demographic data, as well as
hospital factors (eg, case volume, local institutional practice pat-
terns), known to influence surgical outcomes.
6 | C O N CL U S I O N
Our study indicates that high burden hospitals, serving the greatest
percentages of uninsured and Medicaid patients, do not have worse
adjusted mortality and readmission outcomes following CABG pro-
cedures, after accounting for patient and other hospital character-
istics. These findings are reassuring regarding the quality of cardiac
surgery care provided to underinsured patient populations. Addi-
tional research is needed to identify the mechanisms by which HBH
achieves comparable post‐CABG outcomes. Such inquiry may help to
perpetuate high‐quality CABG care at safety‐net institutions, and
may also be leveraged to help improve postoperative outcomes
across surgical specialties and across safety‐net hospitals.
AC KNO WL EDG M EN T
This research was previously presented at the New York State
Society of Anesthesiologists Postgraduate Assembly (poster) on
15 December 2019 in New York City, NY.
HOYLER ET AL.
CO NFLICT OF I NTERE STS
The authors declare that there are no conflict of interests.
A UT HO R C ONT RI BU TIO NS
Concept/Design: RW, SJ, and XM; Statistics: RW, SJ, and XM; Data
analysis/interpretation: MH, RW, SJ, and XM; Drafting article: MH;
Critical revision of article: BL, CT, RT, and RW.
OR CID
Marguerite M. Hoyler http://orcid.org/0000-0002-3561-3347
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How to cite this article: Hoyler MM, Tam CW, Thalapallil R,
et al. The impact of hospital safety‐net burden on mortality
and readmission after CABG surgery. J Card Surg. 2020;1–10.
https://doi.org/10.1111/jocs.14738