Analysis of Emergency Surgery Patients in Safety Net Hospitals Reveals Disparities in Healthcare-Associated Infections

Author(s):
Chelsea Spector; Joshua Parreco; Luis Quintero; Lisa Ngo

Background:

Recently, focus on hospital-acquired conditions has intensified, particularly within the framework of value-based care programs. The financial repercussions imposed on hospitals for healthcare-associated infections (HAIs) by payers have underscored the urgency of understanding and addressing these issues. Safety net hospitals, dedicated to caring for vulnerable populations at the highest risk for these infections, have borne the brunt of severe penalties.

Hypothesis:

The purpose of this study was to perform a comprehensive comparison of HAIs in safety net hospitals throughout the US.

Methods:

The Nationwide Readmissions Database for 2016-2020 was queried for all patients aged 18 years or older and undergoing non-elective gastrointestinal surgery. Safety net hospitals were identified as publicly funded, metropolitan academic, and large by bed size per region of the country. Propensity matching was performed one to one for safety net patients to non-safety net patients using predictors for age, gender, anatomic location, 38 comorbidities, household income, and insurance status. The primary outcome was a diagnosis of a healthcare-associated infection including: surgical site infection (SSI), ventilator associated pneumonia (VAP), catheter associated urinary tract infection (CAUTI), or a central line associated bloodstream infection (CLABSI).

Results:

There were 1,738,382 patients meeting inclusion criteria and 97,949 (5.6%) were treated in safety net hospitals. There were 126,414 patients included in the outcome analysis who were successfully matched across all predictors. There were 1,627 (1.3%) patients who had a HAI and the risk was increased in safety net hospitals (OR 1.18 [1.07-1.30] p<0.01). There were 1,441 (1.1%) patients with a SSI and the risk was increased in safety net hospitals (OR 1.13 [1.02-1.26] p=0.02). There were 142 (0.1%) patients who developed a VAP with an increased risk found in safety net hospitals (OR 2.02 [1.41-2.93] p<0.01). There were 34 (0.03%) patients with a CAUTI and 20 (0.02%) patients with a CLABSI. There was no significant difference in risk of CAUTI or CLABSI in safety net hospitals.

Conclusions:

Despite controlling for comorbidities and socioeconomic confounders, safety net hospitals demonstrate an increased risk for healthcare associated infections. The unintended consequence of value-based care programs potentially exacerbating disparities underscores the need for a more nuanced and empathetic approach to ensure fairness in penalizing safety net hospitals.