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Health system characteristics and rates of readmission after acute myocardial infarction in the United States.

ABSTRACT: Interventions to reduce early readmissions have focused on patient characteristics and the importance of early follow-up; however, less is known about the characteristics of health systems, including quality, capacity, and intensity, and their influence on readmission rates in the United States. Therefore, we examined the association of hospital patterns of medical care with rates of 30-day readmission.Medicare beneficiaries hospitalized for an AMI (n=188 611) between 2008 and 2009 in 1088 hospitals in the United States were included in our cohort. We tested the association between hospital patterns of medical care quality (discharge planning care quality), capacity (hospital size measured as the number of beds, hospital-level Medicare all medical admission rates, supply of primary care physicians and cardiologists), and intensity (measures of care during the last 6 months of life) on CMS risk-adjusted rates of 30-day readmission using Poisson multilevel mixed-effects models adjusting for patient- and hospital-level covariates. There were 38 350 readmissions at 30-days (20.3%) AMI discharges. Controlling for patient characteristics, measures of hospital care associated with higher rates of readmission included higher hospital-level rates for all medical admissions, per capita primary care physicians and cardiologists, and last 6 months of life care intensity measures including increased number of hospital days, number of ICU days, number of physician visits, and 10 or more different physicians seen during the last 6 months of life. Better discharge quality and larger hospitals were associated with lower rates of readmission.In addition to quality of care, high 30-day readmission rates are associated with hospital-level measures of capacity and intensity. Efforts to reduce readmission rates may need to address these broader patterns of medical care.

SUBMITTER: Brown JR

PROVIDER: S-EPMC4309053 | biostudies-literature | 2014 May

REPOSITORIES: biostudies-literature

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Health system characteristics and rates of readmission after acute myocardial infarction in the United States.

Brown Jeremiah R JR Chang Chiang-Hua CH Zhou Weiping W MacKenzie Todd A TA Malenka David J DJ Goodman David C DC

Journal of the American Heart Association 20140520 3

<h4>Background</h4>Interventions to reduce early readmissions have focused on patient characteristics and the importance of early follow-up; however, less is known about the characteristics of health systems, including quality, capacity, and intensity, and their influence on readmission rates in the United States. Therefore, we examined the association of hospital patterns of medical care with rates of 30-day readmission.<h4>Methods and results</h4>Medicare beneficiaries hospitalized for an AMI ...[more]

PMID: 24847032

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Project description:Background Important administrative-based measures of hospital quality, including those used by Centers for Medicare and Medicaid Services, may not adequately account for patient illness and social factors that vary between hospitals and can strongly affect outcomes. Do-not-resuscitate (DNR) order on admission (within the first 24 hours) is one such factor that may reflect higher preadmission illness burden as well as patients' desire for less-intense therapeutic interventions and has been shown to vary widely between hospitals. We sought to evaluate how accounting for early DNR affected hospital quality measures for acute myocardial infarction. Methods AND RESULTS We identified all patients admitted with acute myocardial infarction using the California State Inpatient Database, which captures early DNR use within 24 hours of admission. We generated hospital risk-standardized mortality and readmissions using random-effects logistic regression, before and after including early DNR status, to examine changes in overall model fit and hospital outlier designations. We included 109?521 patients from 289 hospitals and found that 8.5% (9356) patients had early DNR. Early DNR use varied widely, with median (interquartile range) hospital rates of 7.9% (4.1%-14.0%). Including early DNR in models used to assess hospital quality resulted in improvement in the mortality model (C statistics from 0.754 [0.748-0.759] to 0.784 [0.779-0.789]) but not the readmissions model. Of the hospitals designated high outliers for mortality and readmissions by the Centers for Medicare/Medicaid Services model, and therefore destined for a financial penalty, 6/25 (24%) were reclassified as nonoutliers for mortality and 2/14 (14.3%) for readmissions after including DNR status. Agreement in outlier status between the models before and after inclusion of early DNR status was moderate for mortality (?, 0.603 [0.482-0.724]; P<0.001) and high for readmissions (?, 0.888 [0.800-0.977]; P<0.001). Conclusions Including early DNR status in risk-adjustment models significantly improved model fit and resulted in substantial reclassification of hospital performance rankings for mortality and moderate reclassification for readmissions. DNR status at hospital admission should be considered when reporting risk-standardized hospital mortality.

Project description:BACKGROUND:This study aimed to assess the risk factors and impact of acute myocardial infarction on in-hospital treatments, complications, outcomes, and resource utilization in hospitalized patients for heat stroke in the United States. METHODS:Hospitalized patients with a principal diagnosis of heat stroke were identified in the National Inpatient Sample dataset from the years 2003 to 2014. Acute myocardial infarction was identified using the hospital International Classification of Diseases, Ninth Revision (ICD-9), diagnosis of 410.xx. Clinical characteristics, in-hospital treatment, complications, outcomes, and resource utilization between patients with and without acute myocardial infarction were compared. RESULTS:A total of 3372 heat stroke patients were included in the analysis. Of these, acute myocardial infarction occurred in 225 (7%) admissions. Acute myocardial infarction occurred more commonly in obese female patients with a history of chronic kidney disease, but less often in male patients aged <20 years with a history of hypothyroidism. The need for mechanical ventilation, blood transfusion, and renal replacement therapy were higher in patients with acute myocardial infarction. Acute myocardial infarction was associated with rhabdomyolysis, metabolic acidosis, sepsis, gastrointestinal bleeding, ventricular arrhythmia or cardiac arrest, renal failure, respiratory failure, circulatory failure, liver failure, neurological failure, and hematologic failure. Patients with acute myocardial infarction had 5.2-times greater odds of in-hospital mortality than those without myocardial infarction. The length of hospital stay and hospitalization cost were also higher when an acute myocardial infarction occurred while hospitalized. CONCLUSION:Acute myocardial infarction was associated with worse outcomes and higher economic burden among patients hospitalized for heat stroke. Obesity and chronic kidney disease were associated with increased risk of acute myocardial infarction, while young male patients and hypothyroidism were associated with decreased risk.

Project description:BackgroundReducing hospital readmission after acute myocardial infarction (AMI) has the potential to both improve quality and reduce costs. As such, readmission after AMI has been a target of financial penalties through Medicare. However, substantial concern exists about potential adverse effects and efficacious readmission-reduction strategies are not well validated.Methods and resultsWe started an AMI readmissions reduction program in November 2017. Between July 2016 and February 2019, hospital billing data were queried to detect all inpatient hospitalizations at the Massachusetts General Hospital for AMI. Thirty-day readmission was identified through hospital billing data, and mortality was extracted from our electronic health record. The data set was merged with claims data for patients in accountable care organizations to detect readmission at other hospitals. We performed segmented linear regression, adjusting for secular trend and case mix, to assess the independent association of our program on both outcome variables. After inclusion and exclusion criteria were applied, the study population included 2020 patients. The overall 30-day readmission rate was higher before the intervention than after the intervention (15.5% versus 10.7%, P=0.002). The overall 30-day mortality rate was similar in both time periods (1.8% versus 1.4%, P=0.457). The program was associated with initial reduction in 30-day readmission (-9.8%, P=0.0002) and 30-day mortality (-2.6%, P=0.041). The program did not change trend in 30-day readmission (+0.19% readmissions/mo, P=0.554) and trend in 30-day mortality (-0.21% deaths/mo, P=0.119).ConclusionsAn AMI readmissions reduction program that increases outpatient and emergency department (ED) access to cardiology care is associated with reduced 30-day readmission and 30-day mortality. Similar statistical techniques can be used to conduct a rigorous, mechanistic program evaluation of other quality improvement initiatives.

Project description:Background There are limited contemporary data on the use of emergent coronary artery bypass grafting (CABG) in acute myocardial infarction. Methods and Results Adult (aged >18 years) acute myocardial infarction admissions were identified using the National (Nationwide) Inpatient Sample (2000-2017) and classified by tertiles of admission year. Outcomes of interest included temporal trends of CABG use; age-, sex-, and race-stratified trends in CABG use; in-hospital mortality; hospitalization costs; and hospital length of stay. Of the 11 622 528 acute myocardial infarction admissions, emergent CABG was performed in 1 071 156 (9.2%). CABG utilization decreased overall (10.5% [2000] to 8.7% [2017]; adjusted odds ratio [OR], 0.98 [95% CI, 0.98-0.98]; P<0.001), in ST-segment-elevation myocardial infarction (10.2% [2000] to 5.2% [2017]; adjusted OR, 0.95 [95% CI, 0.95-0.95]; P<0.001) and non-ST-segment-elevation myocardial infarction (10.8% [2000] to 10.0% [2017]; adjusted OR, 0.99 [95% CI, 0.99-0.99]; P<0.001), with consistent age, sex, and race trends. In 2012 to 2017, compared with 2000 to 2005, admissions receiving emergent CABG were more likely to have non-ST-segment-elevation myocardial infarction (80.5% versus 56.1%), higher rates of noncardiac multiorgan failure (26.1% versus 8.4%), cardiogenic shock (11.5% versus 6.4%), and use of mechanical circulatory support (19.8% versus 18.7%). In-hospital mortality in CABG admissions decreased from 5.3% (2000) to 3.6% (2017) (adjusted OR, 0.89; 95% CI, 0.88-0.89 [P<0.001]) in the overall cohort, with similar temporal trends in patients with ST-segment-elevation myocardial infarction and non-ST-segment-elevation myocardial infarction. An increase in lengths of hospital stay and hospitalization costs was seen over time. Conclusions Utilization of CABG has decreased substantially in acute myocardial infarction admissions, especially in patients with ST-segment-elevation myocardial infarction. Despite an increase in acuity and multiorgan failure, in-hospital mortality consistently decreased in this population.

Dataset Information

Health system characteristics and rates of readmission after acute myocardial infarction in the United States.

Publications

Health system characteristics and rates of readmission after acute myocardial infarction in the United States.

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