Rethinking Thirty-Day Hospital Readmissions: Shorter Intervals Might Be Better Indicators Of Quality Of Care.
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ABSTRACT:
SUBMITTER: Chin DL
PROVIDER: S-EPMC5457284 | biostudies-literature | 2016 Oct
REPOSITORIES: biostudies-literature
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Rethinking Thirty-Day Hospital Readmissions: Shorter Intervals Might Be Better Indicators Of Quality Of Care.
Chin David L DL Bang Heejung H Manickam Raj N RN Romano Patrick S PS
Health affairs (Project Hope) 20161001 10
Public reporting and payment programs in the United States have embraced thirty-day readmissions as an indicator of between-hospital variation in the quality of care, despite limited evidence supporting this interval. We examined risk-standardized thirty-day risk of unplanned inpatient readmission at the hospital level for Medicare patients ages sixty-five and older in four states and for three conditions: acute myocardial infarction, heart failure, and pneumonia. The hospital-level quality sign ...[more]
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Project description:Risk-adjusted 30-day hospital readmission rate is a commonly used benchmark for hospital quality of care and for Medicare reimbursement. Persons living with HIV (PLWH) may have high readmission rates. This study compared 30-day readmission rates by HIV status in a multi-state sample with planned subgroup comparisons by insurance and diagnostic categories.Data for all acute care, nonmilitary hospitalizations in nine states in 2011 were obtained from the Healthcare Costs and Utilization Project. The primary outcome was readmission for any cause within 30 days of hospital discharge. Factors associated with readmission were evaluated using multivariate logistic regression.A total of 5?484?245 persons, including 33?556 (0.6%) PLWH, had a total of 6?441?695 index hospitalizations, including 45?382 (0.7%) among PLWH. Unadjusted readmission rates for hospitalizations of HIV-uninfected persons and PLWH were 11.2% [95% confidence interval (CI) 11.2, 11.2%] and 19.7% (95% CI 19.3, 20.0%), respectively. After adjustment for age, gender, race, insurance, and diagnostic category, HIV infection was associated with 1.50 (95% CI 1.46, 1.54) times higher odds of readmission. Predicted, adjusted readmission rates were higher for PLWH within every insurance category, including Medicaid [12.9% (95% CI 12.8, 13.0%) and 19.1% (95% CI 18.4, 19.7%) for HIV-uninfected persons and PLWH, respectively] and Medicare [13.2% (95% CI 13.1, 13.3%) and 18.0% (95% CI 17.4, 18.7%), respectively], and within every diagnostic category.HIV infection is associated with significantly increased readmission risk independent of demographics, insurance, and diagnostic category. The 19.7% 30-day readmission rate may serve as a preliminary benchmark for assessing quality of care of PLWH. Policy-makers may consider adjusting for HIV infection when calculating a hospital's expected readmission rate.
| S-EPMC4713370 | biostudies-literature
Project description:Systemic lupus erythematosus (SLE) has one of the highest hospital readmission rates among chronic conditions. This study was undertaken to identify patient-level, hospital-level, and geographic predictors of 30-day hospital readmissions associated with SLE.Using hospital discharge databases from 5 geographically dispersed states, we studied all-cause readmission of SLE patients between 2008 and 2009. We evaluated each hospitalization as a possible index event leading up to a readmission, our primary outcome. We accounted for clustering of hospitalizations within patients and within hospitals and adjusted for hospital case mix. Using multilevel mixed-effects logistic regression, we examined factors associated with 30-day readmission and calculated risk-standardized hospital-level and state-level readmission rates.We examined 55,936 hospitalizations among 31,903 patients with SLE. Of these hospitalizations, 9,244 (16.5%) resulted in readmission within 30 days. In adjusted analyses, age was inversely related to risk of readmission. African American and Hispanic patients were more likely to be readmitted than white patients, as were those with Medicare or Medicaid insurance (versus private insurance). Several clinical characteristics of lupus, including nephritis, serositis, and thrombocytopenia, were associated with readmission. Readmission rates varied significantly between hospitals after accounting for patient-level clustering and hospital case mix. We also found geographic variation, with risk-adjusted readmission rates lower in New York and higher in Florida as compared to California.We found that ~1 in 6 hospitalized patients with SLE were readmitted within 30 days of discharge, with higher rates among historically underserved populations. Significant geographic and hospital-level variation in risk-adjusted readmission rates suggests potential for quality improvement.
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Project description:Hypertensive emergency is a clinical entity with potentially serious health implications and high healthcare utilization. There is a lack of nationally representative data on incidence, causes, and predictors of 30-day readmission after hospitalization for hypertensive emergency. We used the 2013 to 2014 Nationwide Readmissions Database to identify index hospitalizations for hypertensive emergency. Primary outcome was all-cause unplanned 30-day readmission. Multivariable hierarchical logistic regression was used to identify independent predictors of readmission. There were 166?531 index hospitalizations for hypertensive emergency representative of 355?627 (SE, 9401) hospitalizations nationwide in 2013 to 2014. Mean age was 66.0 (SE, 0.14) years, and 53.7% were women. The overall incidence of unplanned 30-day readmissions was 17.8%. The most common causes of readmission were heart failure (14.2%), hypertension with complications (10.2%), sepsis (5.9%), acute kidney injury (5.1%), and cerebrovascular accident (5.1%). Noncardiovascular causes accounted for 57.9% of readmissions. We found age <65 years (odds ratio, 1.21; 95% CI, 1.17-1.25; P<0.001), female sex (odds ratio, 1.09; 95% CI, 1.07-1.12; P<0.001), comorbid disease burden, substance use disorders, and socioeconomic risk factors to be significant predictors of readmission. One out of 6 patients hospitalized for hypertensive emergency had an unplanned 30-day readmission. Heart failure, uncontrolled hypertension, and stroke were among the most frequent causes of readmission; however, over half of all readmissions were because of noncardiovascular causes.
| S-EPMC6310036 | biostudies-literature
Project description:BackgroundWith increasing emphasis on readmissions as an important quality metric, there is an interest in regionalization of care to high-volume centers. As a result, care of readmitted cardiac surgery patients may be fragmented if readmission occurs at a nonindex hospital. This study characterizes the frequency, risk factors, and outcomes of nonindex hospital readmission after cardiac surgery.MethodsIn this multicenter, population-based, nationally representative sample, we used weighted 2010-2015 National Readmission Database claims to identify all US adult patients who underwent 2 of the major cardiac surgeries, isolated coronary artery bypass grafting (CABG) or isolated surgical aortic valve replacement (SAVR), during their initial hospitalization. We examined characteristics, predictors, and outcomes after nonindex readmission.ResultsOverall, 1,070,073 procedures were included (844,206 CABG and 225,866 SAVR). Readmission at 30 days was 12.8% for CABG and 14.5% for SAVR. Nonindex readmissions accounted for 23% and 26% at 30 days; these were primarily noncardiac in etiology. The proportion of nonindex readmissions did not change significantly from 2010 to 2015. For CABG and SAVR, in-hospital mortality (adjusted odds ratios of 1.26 and 1.37, respectively) and major complications (odds ratios of 1.17 and 1.25, respectively) were significantly higher during nonindex versus index readmission, even after adjusting for patient risk profile, case mix, and hospital characteristics. Older age, higher income, and increased comorbidity burden were all independent predictors of nonindex readmission.ConclusionsA considerable proportion of patients readmitted after cardiac surgery are readmitted to nonindex hospitals. This fragmentation of care may account for worse outcomes associated with nonindex readmissions in this complex population.
| S-EPMC7382395 | biostudies-literature
Project description:A recent study found that approximately 1 in every 6 patients hospitalized for the 1st episode of syncope had an underlying pulmonary embolism (PE). As current guidelines do not strongly emphasize evaluation for PE in the workup of syncope, we hypothesize that there might be a higher rate of 30-day readmission due to untreated venous thromboembolism (VTE). The objective of this study is to measure the 30-day readmission rate due to VTE and identify predictors of 30-day readmission with VTE among syncope patients. We identified patients admitted with syncope with ICD9 diagnoses code 780.2 in the Nationwide Readmission Database (NRD-2013), Healthcare Cost and Utilization Project (HCUP). The 30-day readmission rate was calculated using methods described by HCUP. Logistic-regression was used to identify predictors of 30-day readmission with VTE. Discharge weights provided by HCUP were used to generate national estimates. In 2013, NRD included 207,339 eligible patients admitted with syncope. The prevalence rates of PE and DVT were 1.1% and 1.4%, respectively. At least one syncope associated condition was present in 60.9% of the patients. Among the patients who were not diagnosed with VTE during index admission for syncope (N = 188,015), 30-day readmission rate with VTE was 0.5% (0.2% with PE and 0.4% with DVT). In conclusion, low prevalence of VTE in patients with syncope and extremely low 30-day readmission rate with VTE argues against missed diagnoses of VTE in index admission for syncope. These results warrant further studies to determine clinical impact of work up for PE in syncope patients without risk factors.
| S-EPMC7153877 | biostudies-literature
Project description:Hospital readmission rates are increasingly used to assess quality. Little is known, however, about potential preventability of readmissions among children. Our objective was to evaluate potential preventability of 30-day readmissions using medical record review and interviews.A cross-sectional study in 305 children (<18 years old) readmitted within 30 days to a freestanding children's hospital between December 2012 and February 2013. Interviews (N = 1459) were conducted with parents/guardians, patients (if ≥13 years old), inpatient clinicians, and primary care providers. Reviewers evaluated medical records, interview summaries, and transcripts, and then rated potential preventability. Multivariate regression analysis was used to identify factors associated with potentially preventable readmission. Adjusted event curves were generated to model days to readmission.Of readmissions, 29.5% were potentially preventable. Potentially preventable readmissions occurred sooner after discharge than non-potentially preventable readmissions (5 vs 9 median days; P < .001). The odds of a readmission being potentially preventable were greatest when the index admission and readmission were causally related (adjusted odds ratio [AOR]: 2.6; 95% confidence interval [CI]: 1.0-6.8) and when hospital (AOR: 16.3; 95% CI: 5.9-44.8) or patient (AOR: 7.1; 95% CI: 2.5-20.5) factors were identified. Interviews provided new information about the readmission in 31.2% of cases.Nearly 30% of 30-day readmissions to a children's hospital may be potentially preventable. Hospital and patient factors are associated with potential preventability and may provide targets for quality improvement efforts. Interviews contribute important information and should be considered when evaluating readmissions.
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Project description:ImportanceThe Medicare Hospital Readmissions Reduction Program (HRRP) has disproportionately penalized hospitals that treat many black patients, which could worsen health outcomes in this population.ObjectiveTo determine whether short-term mortality rates increased among black and white adults 65 years and older after initiation of the HRRP and whether trends differed by race.Design, setting, and participantsIn a cohort study using an interrupted time-series analysis conducted from March 15, 2018, to January 23, 2019, in 3263 eligible acute care hospitals nationally, risk-adjusted mortality rates observed after Medicare started to impose penalties (October 1, 2012, to November 30, 2014) were compared with projections based on pre-HRRP trends (January 1, 2007, to March 31, 2010) among adults 65 years and older with acute myocardial infarction (AMI), heart failure (HF), or pneumonia. Observed-to-projected differences were then compared between racial groups.ExposuresHospital discharge during pre-HRRP and HRRP penalty periods.Main outcomes and measuresThirty-day postdischarge all-cause mortality.ResultsIn the 3263 acute care hospitals included in the analysis, black patients (627?373 index discharges) were more likely than white patients (5?845?130 index discharges) to be younger (mean [SD] age, 77.8 [8.3] vs 80.5 [8.2] years; P?<?.001), women (60.5% vs 53.7%; P?<?.001), dually covered by Medicare and Medicaid (45.7% vs 17.2%; P?<?.001), and treated at a penalized hospital (AMI, 82.8%; HF, 83.8%; and pneumonia, 82.6% vs 69.6%; 73.3%; and 71.7%; all P?<?.001). Pre-HRRP mortality rates for black vs white patients were 7.04% (95% CI, 6.75% to 7.33%) vs 7.47% (95% CI, 7.37% to 7.57%) for AMI, 6.69% (95% CI, 6.56% to 6.82%) vs 8.56% (95% CI, 8.48% to 8.64%) for HF, and 8.08% (95% CI, 7.88% to 8.27%) vs 8.27% (95% CI, 8.19% to 8.35%) for pneumonia. By the HRRP penalty period, observed mortality for AMI decreased more, relative to projections, among black than white patients (difference-in-differences, -1.65 percentage points; 95% CI, -3.19 to -0.10; P?=?.04). For HF, mortality increased relative to projections among white patients but not among black patients; however; mortality trends did not differ by race (difference-in-differences, -0.37 percentage points; 95% CI, -1.08 to 0.34; P?=?.31). For pneumonia, observed mortality was similar to projections in both racial groups, and trends did not differ by race (difference-in-differences, -0.54 percentage points; 95% CI, -1.66 to 0.59; P?=?.35). At both penalized and nonpenalized hospitals, mortality trends were similar or decreased more among black patients than white patients.Conclusions and relevanceIn this study of patients 65 years and older, short-term postdischarge mortality did not appear to increase for black patients under the HRRP, suggesting that certain value-based payment policies can be implemented without harming black populations. However, mortality seemed to increase for white patients with HF and this situation warrants investigation.
| S-EPMC6484660 | biostudies-literature
Project description:Hospital readmission risk prediction remains a motivated area of investigation and operations in light of the hospital readmissions reduction program through CMS. Multiple models of risk have been reported with variable discriminatory performances, and it remains unclear how design factors affect performance.To study the effects of varying three factors of model development in the prediction of risk based on health record data: (1) reason for readmission (primary readmission diagnosis); (2) available data and data types (e.g. visit history, laboratory results, etc); (3) cohort selection.Regularized regression (LASSO) to generate predictions of readmissions risk using prevalence sampling. Support Vector Machine (SVM) used for comparison in cohort selection testing. Calibration by model refitting to outcome prevalence.Predicting readmission risk across multiple reasons for readmission resulted in ROC areas ranging from 0.92 for readmission for congestive heart failure to 0.71 for syncope and 0.68 for all-cause readmission. Visit history and laboratory tests contributed the most predictive value; contributions varied by readmission diagnosis. Cohort definition affected performance for both parametric and nonparametric algorithms. Compared to all patients, limiting the cohort to patients whose index admission and readmission diagnoses matched resulted in a decrease in average ROC from 0.78 to 0.55 (difference in ROC 0.23, p value 0.01). Calibration plots demonstrate good calibration with low mean squared error.Targeting reason for readmission in risk prediction impacted discriminatory performance. In general, laboratory data and visit history data contributed the most to prediction; data source contributions varied by reason for readmission. Cohort selection had a large impact on model performance, and these results demonstrate the difficulty of comparing results across different studies of predictive risk modeling.
| S-EPMC4261028 | biostudies-literature
Project description:Postdischarge care fragmentation, readmission to a hospital other than the one performing the surgery, has not been described in head and neck cancer patients. We sought to determine the frequency, risk factors, and outcomes for head and neck cancer patients experiencing postdischarge care fragmentation.Retrospective cohort study.We analyzed patients in the 2008 to 2010 California State Inpatient Database with a 30-day unplanned readmission following head and neck cancer surgery. The frequency of postdischarge care fragmentation, patient- and hospital-level risk factors for care fragmentation, readmission diagnosis, and readmission outcomes were determined.Of 561 patients with a 30-day unplanned readmission, 210 (37.4%) were readmitted to a hospital other than the one performing the surgery. Surgical hospitalization length of stay ?15 days (odds ratio [OR]: 1.87, 95% confidence interval [CI]: 1.13-3.10) and discharge to a care facility (OR: 2.85, 95% CI: 1.77-4.58) were associated with care fragmentation. Overall, 39.8% of unplanned 30-day readmissions (223/561) were treatment complications, and 30.9% of treatment complication readmissions (69/223) occurred at a nonindex hospital. Patients with postdischarge care fragmentation had a 2.1-fold increased risk of in-hospital mortality within 30 days of readmission compared to patients readmitted to the index hospital (95% CI: 1.04-4.26).Postdischarge care fragmentation following head an neck cancer surgery is common, as 37% of readmitted patients and 31% of patients readmitted with a treatment complication are readmitted to a hospital other than the surgical hospital. Head and neck cancer patients experiencing care fragmentation are at increased risk of in-hospital mortality within 30 days of readmission.4. Laryngoscope, 127:868-874, 2017.
| S-EPMC5493141 | biostudies-literature
Project description:Background Thirty-day readmission has become a significant health care metric reflecting the quality of care and on the cost of service delivery. There is little data on the impact of complications following skull base surgery (SBS) on emergency readmission. Identifying modifiable risk factors for readmission may improve care and reduce cost. Design The study was designed as a single-center retrospective cohort study. Methods Records for a consecutive series of 165 patients who underwent open or endoscopic SBS by a single surgeon reviewed. Patients with pituitary adenoma were excluded. The diagnosis, procedure, complications, length of stay (LOS), body mass index (BMI), and smoking status were recorded. Readmission to the neurosurgical department or regional hospitals was either noted prospectively or the patient contacted. Cause and length of readmission was documented. Results Of the 165 cases, 14 (8.5%) were readmitted within 30 days. Causes for readmission included cerebrospinal fluid (CSF) leak in 5/14 or 35.7% (overall rate for readmission for this complication in the series is 3.1%), infection in 4/14 (28.6%), hyponatraemia in 2/14 (14.3%), vascular: sinus thrombosis in 1/14 (7.1%), seizures in 1/14 (7.1%), and epistaxis in 1/14 (7.1%). Initial and readmission LOS was 6 and 14 days, respectively. BMI was higher in those readmitted within 30 days (33.2 kg/m 2 ) versus no readmission (27.1 kg/m 2 ). In addition, of those readmitted within 30 days, 35.7% were smokers compared with 20.8% in those not readmitted. Conclusion In this series, smoking and raised BMI may be indicators for within 30-day readmission and complications in this population, raising the question of risk factor modification prior to elective intervention.
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