Evaluation of 30-Day Hospital Readmission and Mortality Rates Using Regression-Discontinuity Framework.
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ABSTRACT: Background
The Hospital Readmissions Reduction Program (HRRP) has been associated with reduced 30-day readmissions for acute myocardial infarction (AMI) and heart failure (HF).Objectives
The purpose of this study was to test whether this 30-day readmission reduction is a manifestation of practices that defer or avoid hospitalizations beyond the 30-day period.Methods
At all U.S. hospitals under HRRP, the authors calculated daily readmission rates for elderly Medicare fee-for-service beneficiaries through day-60 post-discharge following a hospitalization for AMI and HF-the 2 target cardiovascular conditions-as well as pneumonia in July 2008 to June 2016. The authors applied a robust bias-corrected nonparametric regression approach to evaluate for discontinuities in rates around day 30.Results
The authors identified 3,256 eligible hospitals, with median readmission rates in the days 1 to 30 and 31 to 60 post-discharge of 19.6% (interquartile range [IQR]: 16.7% to 22.9%) and 7.8% (IQR: 6.5% to 9.4%) for AMI, 23.0% (IQR: 20.6% to 25.3%) and 11.4% (IQR: 10.2% to 12.6%) for HF, and 17.5% (IQR: 15.4% to 19.8%) and 8.3% (IQR: 7.3% to 9.3%) for pneumonia, respectively. Daily readmission rates decreased across most of the 60 post-discharge days, with no discontinuities in the local polynomial regression for readmission at the 30-day mark, with a >95% power to detect 0.1% difference for each outcome across post-discharge day 30. Similarly, there was no discontinuity in mortality at 30 days post-discharge, or for either outcome at hospitals that incurred readmission penalties.Conclusions
There was no evidence that clinicians adopted strategies that specifically deferred admissions or affected mortality in the 30-day period after discharge. The findings are consistent with the institution of strategies that generally affected readmission risk after discharge.
SUBMITTER: Khera R
PROVIDER: S-EPMC8669780 | biostudies-literature |
REPOSITORIES: biostudies-literature
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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.
| S-EPMC3579957 | biostudies-literature
Project description:ObjectiveTo investigate risk-adjusted, 30-day postdischarge heart failure mortality and readmission rates stratified by hospital teaching intensity.Data sources and study settingA total of 709 221 Medicare fee-for-service beneficiaries discharged from 3135 US hospitals between 1/1/2013 and 11/30/2014 with a principal diagnosis of heart failure.Study designHospitals were classified as Council of Teaching Hospitals and Health Systems (COTH) major teaching hospitals, non-COTH teaching hospitals, and nonteaching hospitals. Hospital teaching status was linked with MedPAR patient data and FY2016 Hospital Readmission Reduction Program penalties. Index hospitalization survival probabilities were estimated with hierarchical logistic regression and used to stratify index hospitalization survivors into severity deciles. Decile-specific models were estimated for 30-day postdischarge readmission and mortality. Thirty-day postdischarge outcomes were estimated by teaching intensity and penalty categories.Principal findingsAveraged across deciles, adjusted 30-day COTH hospital readmission rates were, on a relative scale ([COTH minus nonteaching] ÷ nonteaching), 1.63 percent higher (95% CI: 0.89 percent, 2.25 percent) than at nonteaching hospitals, but their average adjusted 30-day postdischarge mortality rates were 11.55 percent lower (95% CI: -13.78 percent, -9.37 percent). Penalized COTH hospitals had the highest readmission rates of all categories (23.99 percent [95% CI: 23.50 percent, 24.49 percent]) but the lowest 30-day postdischarge mortality (8.30 percent [95% CI: 7.99 percent, 8.57 percent] vs 9.84 percent [95% CI: 9.69 percent, 9.99 percent] for nonpenalized, nonteaching hospitals).ConclusionsHeart failure readmission penalties disproportionately impact major teaching hospitals and inadequately credit their better postdischarge survival.
| S-EPMC7080393 | biostudies-literature
Project description:ImportanceThirty-day readmission rates have been suggested as a marker for quality of care. By investigating the factors associated with readmissions in all otolaryngology subspecialties we provide data relevant for the development of risk stratification systems to improve outcomes.ObjectiveTo establish the association of surgical and hospital volume and patient characteristics with 30-day readmission rates to guide the development of otolaryngology-specific risk stratification models.Design, setting, and participantsA retrospective cohort study including adult patients who underwent inpatient otolaryngology surgery in New York State between 1995 and 2015 was conducted using the Statewide Planning and Research Cooperative System (SPARCS). Regression techniques were used to describe relationships of patient-level factors, hospital, and surgeon volume to 30-day readmission rates in New York State.Main outcomes and measuresThe main outcome measures were patient-, surgeon-, and hospital-level risk factors for readmission. Secondary outcome measures were rate of readmissions by subspecialty procedure and by diagnosis on readmission.ResultsWe identified 254 257 cases of otolaryngology surgery (147 065 women [58%], mean [SD] age 50 [17] years). The 30-day readmission rate was 6%. In a multivariable model, odds ratios (ORs) identified Medicaid insurance (OR, 1.46; 99% CI, 1.36-1.57), Medicare insurance (OR, 1.32; 99% CI, 1.24-1.42), bottom quartile income (OR, 1.08; 99% CI, 1.01-1.15), patient comorbidities measured by the Charlson Comorbidity Index (CCI) (CCI >1; OR, 2.31; 99% CI, 2.16-2.47), length of stay (LOS) (LOS >10 days; OR, 2.29; 99% CI, 2.00-2.45), rhinology (OR, 1.37; 99% CI, 1.24-1.51), laryngology (OR, 1.98; 99% CI, 1.62-2.43), and head and neck cancer (OR, 1.27; 99% CI, 1.17-1.37) procedures as readmission predictors. High-volume surgeons were protective of 30-day readmission (OR, 0.67; 99% CI, 0.635-0.708) relative to low volume. Hospital volume was not significantly associated to readmissions. The most common causes of readmission included wound- (2682 patients, 18%), respiratory- (1776 patients, 12%), cardiovascular- (1210 patients, 8%), and volume- (1089 patients, 7%) related disorders.Conclusions and relevanceThis study evaluated the combined effects of patient-, surgeon-, and hospital-level factors on 30-day readmission after otolaryngology surgery. Socioeconomic factors, patient comorbidities, surgeon volumes, and procedure were significantly associated with 30-day readmission. Though the cause of 30-day readmission is multifactorial, a large portion is driven by socioeconomic factors. Addressing these disparities at the system level is necessary to address the described readmission disparities. The development of risk-stratification models based on patient-, procedure-, and surgeon-level factors may help facilitate resource distribution.
| S-EPMC6481432 | biostudies-literature
Project description:PurposeHospital readmissions in the first weeks following surgery are common, expensive, and associated with increased mortality among colorectal cancer patients. This study is designed to assess the 30-day hospital readmission after colorectal cancer surgery and evaluate the risk factors that affect hospital readmission.MethodsThe study uses data from the Ministry of National Guard-Health Affairs Cancer Registry. All colorectal cancer patients who underwent colorectal cancer surgery between January 1, 2016, and November 31, 2021, were investigated. Factors examined were age, gender, marital status, Body Mass Index, Charlson Comorbidity Index, chemotherapy, radiotherapy, tumor stage, grade, site, surgical approach, length of stay, and discharge location. Kaplan-Meier curves were constructed to assess survival rates between readmitted and non-readmitted patients, and logistic regressions were performed to assess predictors of readmission.ResultsA total of 356 patients underwent tumor resection and 49 patients were readmitted within 30-day of index discharge. The most common reasons for hospital readmissions were gastrointestinal (22.45%), urinary tract infection (16.33%), and surgical site infection (12.24%). In the multivariable analysis, females were 89% more likely to be readmitted compared to males (odds ratio 1.89, 95% confidence intervals 1.00-3.58). Patients with distant metastatic tumors have higher odds of readmission (odds ratio 4.52, 95% confidence intervals 1.39-14.71) compared to patients with localized disease.ConclusionsColorectal cancer readmission is more common in patients with metastatic disease. Strategies to reduce readmission include planned transition to outpatient care, especially among patients with a high risk of readmission.
| S-EPMC9563783 | biostudies-literature
Project description:BackgroundSeveral care transition interventions propose that post-discharge phone calls can reduce adverse events and decrease costly return visits to the hospital. However, given the multi-faceted nature of most care transitions interventions, the true relationship between post-discharge phone calls and readmissions in a real world setting is uncertain.ObjectiveTo determine the effect of receiving a post-discharge telephone call on all-cause 30-day readmission in a general medicine population.DesignRetrospective observational study.ParticipantsPatients discharged home from the Medicine Service at a tertiary care academic medical center between November 2010 and May 2012.InterventionPatients received two telephone call attempts by a nurse within 72 h of discharge. Nurses followed a standard script to address issues associated with readmission.Main outcome and measuresBilling data captured readmissions. We used logistic regression-adjusted patient and clinical covariates as well as a propensity score representing likelihood of being called to determine the association between call receipt and risk for readmission.Key resultsThere were 5,507 eligible patients. In unadjusted analyses, patients who received a call and completed the intervention were significantly less likely to be readmitted compared to those who did not [155 (5.8 %) vs 123 (8.6 %), p < 0.01]. In multivariable models adjusting for socio-demographic and clinical covariates alone, completing a post-discharge telephone call intervention was associated with lower odds for readmission (AOR 0.71; 95 % CI: 0.55-0.91). However, when models adjusted for the likelihood of receiving the phone call using the propensity score, no association between call receipt and readmission was observed (AOR 0.91; 95%CI: 0.69-1.20).ConclusionsEffectiveness of post-discharge phone call programs may be more related to whether patients are able to answer a phone call than to the care delivered by the phone call. Programs would benefit from improving their ability to perform phone outreach while simultaneously improving on the care delivered during the calls.
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Project description:ObjectiveDelirium is associated with poor outcomes among critically ill patients. However, it is not well characterized among patients with ischemic or hemorrhagic stroke (IS and HS). We provide the population-level frequency of in-hospital delirium and assess its association with in-hospital outcomes and with 30-day readmission among IS and HS patients.MethodsWe analyzed Nationwide in-hospital and readmission data for years 2010-2015 and identified stroke patients using ICD-9 codes. Delirium was identified using validated algorithms. Outcomes were in-hospital mortality, length of stay, unfavorable discharge disposition, and 30-day readmission. We used survey design logistic regression methods to provide national estimates of proportions and 95% confidence intervals (CI) for delirium, and odds ratios (OR) for association between delirium and poor outcomes.ResultsWe identified 3,107,437 stroke discharges of whom 7.45% were coded to have delirium. This proportion significantly increased between 2010 (6.3%) and 2015 (8.7%) (aOR, 95% CI: 1.04, 1.03-1.05). Delirium proportion was higher among HS patients (ICH: 10.0%, SAH: 9.8%) as compared to IS patients (7.0%). Delirious stroke patients had higher in-hospital mortality (12.3% vs. 7.8%), longer in-hospital stay (11.6 days vs. 7.3 days) and a significantly greater adjusted risk of 30-day-readmission (16.7%) as compared to those without delirium (12.2%) (aRR, 95% CI: 1.13, 1.11-1.15). Upon readmission, patients with delirium at initial admission continued to have a longer length of stay (7.7 days vs. 6.6 days) and a higher in-hospital mortality (9.3% vs. 6.4%).ConclusionDelirium identified through claims data in stroke patients is independently associated with poor in-hospital outcomes both at index admission and readmission. Identification and management of delirium among stroke patients provides an opportunity to improve outcomes.
| S-EPMC6855446 | biostudies-literature
Project description:Background and Purpose- Kidney dysfunction is common among patients hospitalized for ischemic stroke. Understanding the association of kidney disease with poststroke outcomes is important to properly adjust for case mix in outcome studies, payment models and risk-standardized hospital readmission rates. Methods- In this cohort study of fee-for-service Medicare patients admitted with ischemic stroke to 1579 Get With The Guidelines-Stroke participating hospitals between 2009 and 2014, adjusted multivariable Cox proportional hazards models were used to determine the independent associations of estimated glomerular filtration rate (eGFR) and dialysis status with 30-day and 1-year postdischarge mortality and rehospitalizations. Results- Of 204?652 patients discharged alive (median age [25th-75th percentile] 80 years [73.0-86.0], 57.6% women, 79.8% white), 48.8% had an eGFR ?60, 26.5% an eGFR 45 to 59, 16.3% an eGFR 30 to 44, 5.1% an eGFR 15 to 29, 0.6% an eGFR <15 without dialysis, and 2.8% were receiving dialysis. Compared with eGFR ?60, and after adjusting for relevant variables, eGFR <45 was associated with increased 30-day mortality with the risk highest among those with eGFR <15 without dialysis (hazard ratio [HR], 2.09; 95% CI, 1.66-2.63). An eGFR <60 was associated with increased 1-year poststroke mortality that was highest among patients on dialysis (HR, 2.65; 95% CI, 2.49-2.81). Dialysis was also associated with the highest 30-day and 1-year rehospitalization rates (HR, 2.10; 95% CI, 1.95-2.26 and HR, 2.55; 95% CI, 2.44-2.66, respectively) and 30-day and 1-year composite of mortality and rehospitalization (HR, 2.04; 95% CI, 1.90-2.18 and HR, 2.46; 95% CI, 2.36-2.56, respectively). Conclusions- Within the first year after index hospitalization for ischemic stroke, eGFR and dialysis status on admission are associated with poststroke mortality and hospital readmissions. Kidney function should be included in risk-stratification models for poststroke outcomes.
| S-EPMC6338440 | biostudies-literature
Project description:BackgroundReducing hospital readmissions, including preventable healthcare-associated infections, is a national priority. The proportion of readmissions due to infections is not well-understood. Better understanding of hospital risk factors for readmissions and infection-related readmissions may help optimize interventions to prevent readmissions.MethodsRetrospective cohort study of California acute care hospitals and their patient populations discharged between 2009 and 2011. Demographics, comorbidities, and socioeconomic status were entered into a hierarchical generalized linear mixed model predicting all-cause and infection-related readmissions. Crude verses adjusted hospital rankings were compared using Cohen's kappa.ResultsWe assessed 30-day readmission rates from 323 hospitals, accounting for 213 879 194 post-discharge person-days of follow-up. Infection-related readmissions represented 28% of all readmissions and were associated with discharging a high proportion of patients to skilled nursing facilities. Hospitals serving populations with high proportions of males, comorbidities, prolonged length of stay, and populations living in a federal poverty area, had higher all-cause and infection-related readmission rates. Academic hospitals had higher all-cause and infection-related readmission rates (odds ratio 1.24 and 1.15, respectively). When comparing adjusted vs crude hospital rankings for infection-related readmission rates, adjustment revealed 31% of hospitals changed performance category for infection-related readmissions.ConclusionsInfection-related readmissions accounted for nearly 30% of all-cause readmissions. High hospital infection-related readmissions were associated with serving a high proportion of patients with comorbidities, long lengths of stay, discharge to skilled nursing facility, and those living in federal poverty areas. Preventability of these infections needs to be assessed.
| S-EPMC4583583 | biostudies-literature
Project description:ObjectiveTo assess the reliability of risk-standardized readmission rates (RSRRs) for medical conditions and surgical procedures used in the Hospital Readmission Reduction Program (HRRP).Data sourcesState Inpatient Databases for six states from 2011 to 2013 were used to identify patient cohorts for the six conditions used in the HRRP, which was augmented with hospital characteristic and HRRP penalty data.Study designHierarchical logistic regression models estimated hospital-level RSRRs for each condition, the reliability of each RSRR, and the extent to which socioeconomic and hospital factors further explain RSRR variation. We used publicly available data to estimate payments for excess readmissions in hospitals with reliable and unreliable RSRRs.Principal findingsOnly RSRRs for surgical procedures exceeded the reliability benchmark for most hospitals, whereas RSRRs for medical conditions were typically below the benchmark. Additional adjustment for socioeconomic and hospital factors modestly explained variation in RSRRs. Approximately 25 percent of payments for excess readmissions were tied to unreliable RSRRs.ConclusionsMany of the RSRRs employed by the HRRP are unreliable, and one quarter of payments for excess readmissions are associated with unreliable RSRRs. Unreliable measures blur the connection between hospital performance and incentives, and threaten the success of the HRRP.
| S-EPMC5134200 | biostudies-literature
Project description:Risk-standardized 30-day mortality and hospital readmission rates for pneumonia are increasingly being tied to hospital reimbursement to incentivize the delivery of high-quality care. Such measures may be susceptible to gaming by recoding patients with pneumonia to a primary diagnosis of sepsis or respiratory failure. We sought to determine the degree to which hospitals can game mortality or readmission measures and change their rankings by recoding patients with pneumonia.Simulated experimental study of 2,906 U.S. acute care hospitals with at least 25 admissions for pneumonia using 2009 Medicare data.Elderly (age ? 65 yr) Medicare fee-for-service beneficiaries hospitalized with pneumonia. Patients eligible for recoding to sepsis or respiratory failure were those with a principal International Classification of Diseases, 9th Edition, Clinical Modification, discharge code for pneumonia and secondary codes for respiratory failure or acute organ dysfunction.None.We measured the number of hospitals that improved their pneumonia mortality or readmission rates after recoding eligible patients. When a sample of 100 hospitals with pneumonia mortality rates above the 50th percentile recoded all eligible patients to sepsis or respiratory failure, 90 hospitals (95% CI, 84-95) improved their mortality rate (mean improvement, 1.09%; 95% CI, 0.94-1.28%) and 41 hospitals dropped below the 50th percentile (95% CI, 33-52). When a sample of 100 hospitals with pneumonia readmission rates above the 50th percentile recoded all eligible patients, 66 hospitals (95% CI, 54-75) improved their readmission rate (mean improvement, 0.34%; 95% CI, 0.19-0.45%) and 15 hospitals (95% CI, 9-22) dropped below the 50th percentile.Hospitals can improve apparent pneumonia mortality and readmission rates by recoding pneumonia patients. Centers for Medicare and Medicaid Services should consider changes to their methods used to calculate hospital-level pneumonia outcome measures to make them less susceptible to gaming.
| S-EPMC4617210 | biostudies-literature