Dataset Information

Temporal Trends in Racial Differences in 30-Day Readmission and Mortality Rates After Acute Myocardial Infarction Among Medicare Beneficiaries.

ABSTRACT:

Importance

The association of the Hospital Readmission Reduction Program (HRRP) with reductions in racial disparities in 30-day outcomes for myocardial infarction (MI), is unknown, including whether this varies by HRRP hospital penalty status.

Objective

To assess temporal trends in 30-day readmission and mortality rates among black and nonblack patients discharged after hospitalization for acute MI at low-performing and high-performing hospitals, as defined by readmission penalty status after HRRP implementation.

Design, setting, and participants

This observational cohort analysis used data from the multicenter National Cardiovascular Data Registry Chest Pain-MI Registry centers that were subject to the first cycle of HRRP, between January 1, 2008, and November 30, 2016. All patients hospitalized with MI who were included in National Cardiovascular Data Registry Chest Pain-MI Registry were included in the analysis. Data were analyzed from April 2018 to September 2019.

Exposures

Hospital performance category and race (black compared with nonblack patients). Centers were classified as high performing or low performing based on the excess readmission ratio (predicted to expected 30-day risk adjusted readmission rate) for MI during the first HRRP cycle (in October 2012).

Main outcomes and measures

Thirty-day all-cause readmission and mortality rates.

Results

Among 753 hospitals that treated 155?397 patients with acute MI (of whom 11?280 [7.3%] were black), 399 hospitals (53.0%) were high performing. Thirty-day readmission rates declined over time in both black and nonblack patients (annualized 30-day readmission rate: 17.9% vs 20.8%). Black (compared with nonblack) race was associated with higher unadjusted odds of 30-day readmission in both low-performing and high-performing centers (odds ratios: before HRRP: low-performing hospitals, 1.14 [95% CI, 1.03-1.26]; P?=?.01; high-performing hospitals, 1.17 [95% CI, 1.04-1.32]; P?=?.01; after HRRP: low-performing hospitals, 1.23 [95% CI, 1.13-1.34]; P?Conclusions and relevanceIn this analysis, 30-day readmission rates among patients with MI declined over time for both black and nonblack patients. Differences in race-specific 30-day readmission rates persisted but appeared to be attributable to patient-level factors. The 30-day mortality rates have declined for nonblack patients and remained stable among black patients. Implementation of the HRRP was not associated with improvement or worsening of racial disparities in readmission and mortality rates.

SUBMITTER: Pandey A

PROVIDER: S-EPMC6990949 | biostudies-literature | 2020 Feb

REPOSITORIES: biostudies-literature

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Publications

Temporal Trends in Racial Differences in 30-Day Readmission and Mortality Rates After Acute Myocardial Infarction Among Medicare Beneficiaries.

Pandey Ambarish A Keshvani Neil N Khera Rohan R Lu Di D Vaduganathan Muthiah M Joynt Maddox Karen E KE Das Sandeep R SR Kumbhani Dharam J DJ Goyal Abhinav A Girotra Saket S Chan Paul P Fonarow Gregg C GC Matsouaka Roland R Wang Tracy Y TY de Lemos James A JA

JAMA cardiology 20200201 2

<h4>Importance</h4>The association of the Hospital Readmission Reduction Program (HRRP) with reductions in racial disparities in 30-day outcomes for myocardial infarction (MI), is unknown, including whether this varies by HRRP hospital penalty status.<h4>Objective</h4>To assess temporal trends in 30-day readmission and mortality rates among black and nonblack patients discharged after hospitalization for acute MI at low-performing and high-performing hospitals, as defined by readmission penalty ...[more]

PMID: 31913411

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Project description:ObjectiveTo determine whether black patients have higher odds of readmission than white patients after major surgery, and to ascertain whether these disparities are related to where black patients receive care.BackgroundRacial disparities are known to exist for many aspects of surgical care. However, it is unknown if disparities exist in readmissions after a surgical procedure, an area which is becoming a prime focus for clinical leaders and policymakers.MethodsUsing national Medicare data from 2007 to 2010, we examined 30-day readmissions for patients undergoing coronary artery bypass grafting, pulmonary lobectomy, endovascular abdominal aortic aneurysm repair, open abdominal aortic aneurysm repair, colectomy, and hip replacement. The main outcome measure was risk-adjusted odds of all-cause 30-day readmission. We used multivariate logistic regression to determine if black patients had higher readmission rates than white patients, and if so, whether this effect was mediated by the hospitals at which patients received care, or by poverty.ResultsBlack patients had higher readmission rates than white patients (14.8% vs 12.8%, odds ratio [OR] 1.19; 95% confidence interval [CI], 1.16-1.22; P < 0.001). Patients undergoing major surgery at minority-serving hospitals also had higher readmission rates (14.3% vs 12.8%, OR 1.14, 95% CI 1.09-1.19; P < 0.001). In multivariate analyses, black patients at minority-serving hospitals had the highest overall odds of readmissions (OR 1.34). White patients at minority-serving hospitals (OR 1.15) and black patients at non-minority-serving hospitals (OR 1.20) also had higher odds of readmission than the reference group of white patients at non-minority-serving hospitals. Racial disparities were mediated in part by poverty.ConclusionsAmong Medicare beneficiaries, black patients were more likely to be readmitted after hospitalization for surgical procedures. Since racial disparities in readmission rates are mediated both by patients' race and the hospital at which care is delivered, efforts at reducing disparities should focus not only on race-based measures but also on improving outcomes of care at minority-serving hospitals.

Project description:BACKGROUND:Recent policy efforts have focused on improving the value of acute myocardial infarction (AMI) care. Medicare payment programs, for example, increasingly evaluate hospital performance based on spending, as determined by payments made to institutions and providers, and outcome measures for a longitudinal episode of AMI care. Little is known about the relationship between total 30-day payments-both in the inpatient and immediate postdischarge timeframe-and outcomes after an admission for AMI. METHODS AND RESULTS:Using Medicare claims data, we identified Medicare fee-for-service beneficiaries ?65 years of age who were hospitalized at an acute-care hospital for AMI between July 1, 2011, and June 30, 2014, and examined the association between hospital-level 30-day payments for an episode of AMI care and patient 30-day mortality using mixed regression models with a logit link function and random hospital intercepts. Our cohort included 642 105 index hospitalizations for AMI at 2319 acute-care hospitals. Overall mean 30-day episode payments per beneficiary were $22 128 (SD, $1750). The observed 30-day mortality rate was 12.9%. Higher 30-day payments were associated with lower 30-day mortality after adjustment for patient characteristics and comorbidities (adjusted odds ratio for additional $1000 payments, 0.986; 95% confidence interval, 0.979-0.992; P<0.001). Additional adjustment for potential mediating factors, including hospital characteristics, coronary revascularization rates, and discharge disposition, did not significantly attenuate the relationship (adjusted odds ratio for additional $1000 payments, 0.987; 95% confidence interval, 0.980-0.994; P<0.001). CONCLUSIONS:Higher hospital-level 30-day payments-both inpatient and in multiple settings after discharge-for AMI care were associated with lower 30-day mortality among beneficiaries. This may have implications for payment programs that incent reduction in payments without considering value.

Project description:Understanding whether and why there are racial disparities in readmissions has implications for efforts to reduce readmissions.To determine whether black patients have higher odds of readmission than white patients and whether these disparities are related to where black patients receive care.Using national Medicare data, we examined 30-day readmissions after hospitalization for acute myocardial infarction (MI), congestive heart failure (CHF), and pneumonia. We categorized hospitals in the top decile of proportion of black patients as minority-serving. We determined the odds of readmission for black patients compared with white patients at minority-serving vs non-minority-serving hospitals.Medicare Provider Analysis Review files of more than 3.1 million Medicare fee-for-service recipients who were discharged from US hospitals in 2006-2008.Risk-adjusted odds of 30-day readmission.Overall, black patients had higher readmission rates than white patients (24.8% vs 22.6%, odds ratio [OR], 1.13; 95% confidence interval [CI], 1.11-1.14; P < .001); patients from minority-serving hospitals had higher readmission rates than those from non-minority-serving hospitals (25.5% vs 22.0%, OR, 1.23; 95% CI, 1.20-1.27; P < .001). Among patients with acute MI and using white patients from non-minority-serving hospitals as the reference group (readmission rate 20.9%), black patients from minority-serving hospitals had the highest readmission rate (26.4%; OR, 1.35; 95% CI, 1.28-1.42), while white patients from minority-serving hospitals had a 24.6% readmission rate (OR, 1.23; 95% CI, 1.18-1.29) and black patients from non-minority-serving hospitals had a 23.3% readmission rate (OR, 1.20; 95% CI, 1.16-1.23; P < .001 for each); patterns were similar for CHF and pneumonia. The results were unchanged after adjusting for hospital characteristics including markers of caring for poor patients.Among elderly Medicare recipients, black patients were more likely to be readmitted after hospitalization for 3 common conditions, a gap that was related to both race and to the site where care was received.

Project description:BackgroundLowering hospital readmission rates has become a primary target for the Centers for Medicare & Medicaid Services, but studies of the relationship between adherence to the recommended hospital care processes and readmission rates have provided inconsistent and inconclusive results.ObjectiveTo examine the association between hospital performance on Medicare's Hospital Compare process quality measures and 30-day readmission rates for patients with acute myocardial infarction (AMI), heart failure and pneumonia, and for those undergoing major surgery.Design, setting and participantsWe assessed hospital performance on process measures using the 2007 Hospital Inpatient Quality Reporting Program. The process measures for each condition were aggregated in two separate measures: Overall Measure (OM) and Appropriate Care Measure (ACM) scores. Readmission rates were calculated using Medicare claims.Main outcome measureRisk-standardized 30-day all-cause readmission rate was calculated as the ratio of predicted to expected rate standardized by the overall mean readmission rate. We calculated predicted readmission rate using hierarchical generalized linear models and adjusting for patient-level factors.ResultsAmong patients aged ≥ 66 years, the median OM score ranged from 79.4 % for abdominal surgery to 95.7 % for AMI, and the median ACM scores ranged from 45.8 % for abdominal surgery to 87.9 % for AMI. We observed a statistically significant, but weak, correlation between performance scores and readmission rates for pneumonia (correlation coefficient R = 0.07), AMI (R = 0.10), and orthopedic surgery (R = 0.06). The difference in the mean readmission rate between hospitals in the 1st and 4th quartiles of process measure performance was statistically significant only for AMI (0.25 percentage points) and pneumonia (0.31 percentage points). Performance on process measures explained less than 1 % of hospital-level variation in readmission rates.ConclusionsHospitals with greater adherence to recommended care processes did not achieve meaningfully better 30-day hospital readmission rates compared to those with lower levels of performance.

Project description:ImportanceMedicare Advantage health plans covered 37% of beneficiaries in 2018, and coverage increased to 48% in 2022. Whether Medicare Advantage plans provide similar care for patients presenting with specific clinical conditions is unknown.ObjectiveTo compare 30-day mortality and treatment for Medicare Advantage and traditional Medicare patients presenting with acute myocardial infarction (MI) from 2009 to 2018.Design, setting, and participantsRetrospective cohort study that included 557 309 participants with ST-segment elevation [acute] MI (STEMI) and 1 670 193 with non-ST-segment elevation [acute] MI (NSTEMI) presenting to US hospitals from 2009-2018 (date of final follow up, December 31, 2019).ExposuresEnrollment in Medicare Advantage vs traditional Medicare.Main outcomes and measuresThe primary outcome was adjusted 30-day mortality. Secondary outcomes included age- and sex-adjusted rates of procedure use (catheterization, revascularization), postdischarge medication prescriptions and adherence, and measures of health system performance (intensive care unit [ICU] admission and 30-day readmissions).ResultsThe study included a total of 2 227 502 participants, and the mean age in 2018 ranged from 76.9 years (Medicare Advantage STEMI) to 79.3 years (traditional Medicare NSTEMI), with similar proportions of female patients in Medicare Advantage and traditional Medicare (41.4% vs 41.9% for STEMI in 2018). Enrollment in Medicare Advantage vs traditional Medicare was associated with significantly lower adjusted 30-day mortality rates in 2009 (19.1% vs 20.6% for STEMI; difference, -1.5 percentage points [95% CI, -2.2 to -0.7] and 12.0% vs 12.5% for NSTEMI; difference, -0.5 percentage points [95% CI, -0.9% to -0.1%]). By 2018, mortality had declined in all groups, and there were no longer statically significant differences between Medicare Advantage (17.7%) and traditional Medicare (17.8%) for STEMI (difference, 0.0 percentage points [95% CI, -0.7 to 0.6]) or between Medicare Advantage (10.9%) and traditional Medicare (11.1%) for NSTEMI (difference, -0.2 percentage points [95% CI, -0.4 to 0.1]). By 2018, there was no statistically significant difference in standardized 90-day revascularization rates between Medicare Advantage and traditional Medicare. Rates of guideline-recommended medication prescriptions were significantly higher in Medicare Advantage (91.7%) vs traditional Medicare patients (89.0%) who received a statin prescription (difference, 2.7 percentage points [95% CI, 1.2 to 4.2] for 2018 STEMI). Medicare Advantage patients were significantly less likely to be admitted to an ICU than traditional Medicare patients (for 2018 STEMI, 50.3% vs 51.2%; difference, -0.9 percentage points [95% CI, -1.8 to 0.0]) and significantly more likely to be discharged to home rather than to a postacute facility (for 2018 STEMI, 71.5% vs 70.2%; difference, 1.3 percentage points [95% CI, 0.5 to 2.1]). Adjusted 30-day readmission rates were consistently lower in Medicare Advantage than in traditional Medicare (for 2009 STEMI, 13.8% vs 15.2%; difference, -1.3 percentage points [95% CI, -2.0 to -0.6]; and for 2018 STEMI, 11.2% vs 11.9%; difference, 0.6 percentage points [95% CI, -1.5 to 0.0]).Conclusions and relevanceAmong Medicare beneficiaries with acute MI, enrollment in Medicare Advantage, compared with traditional Medicare, was significantly associated with modestly lower rates of 30-day mortality in 2009, and the difference was no longer statistically significant by 2018. These findings, considered with other outcomes, may provide insight into differences in treatment and outcomes by Medicare insurance type.

Dataset Information

Temporal Trends in Racial Differences in 30-Day Readmission and Mortality Rates After Acute Myocardial Infarction Among Medicare Beneficiaries.

Importance

Objective

Design, setting, and participants

Exposures

Main outcomes and measures

Results

Publications

Temporal Trends in Racial Differences in 30-Day Readmission and Mortality Rates After Acute Myocardial Infarction Among Medicare Beneficiaries.

Similar Datasets

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