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Can Vertical Integration Reduce Hospital Readmissions? A Difference-in-Differences Approach.

ABSTRACT: Vertical integration is expected to improve communication and coordination between inpatient care and care after discharge. Despite being used across health systems worldwide, evidence about its impact on readmissions is sparse and contradictory.To assess the impact of vertical integration on hospital readmissions.Using difference-in-differences we compared readmissions before and after vertical integration in 6 Portuguese hospitals for years 2004-2013. A control group with 6 similar hospitals not integrated was utilized. Considered outcome was 30-day unplanned readmission. We used logistic regression at the admission level and accounted for patients' risk factors using claims data. Analyses for each hospital and selected conditions were also run.Our results suggest that readmissions decreased overall after vertical integration [odds ratio (OR)=0.900; 95% confidence interval (CI), 0.812-0.997]. Hospital analysis indicated that there was no impact for 2 hospitals (OR=0.960; 95% CI, 0.848-1.087 and OR=0.944; 95% CI, 0.857-1.038), and a positive effect in 4 hospitals (greatest effect: OR=0.811; 95% CI, 0.736-0.894). A positive evolution was observed for a limited number of conditions, with better results for diabetes with complications (OR=0.689; 95% CI, 0.525-0.904), but no impact regarding congestive heart failure (OR=1.067; 95% CI, 0.827-1.377).Merging acute and primary care providers was associated with reduced readmissions, even though improvements were not found for all institutions or condition-specific groups. There are still challenges to be addressed regarding the success of vertical integration in reducing 30-day hospital readmissions.

SUBMITTER: Lopes S

PROVIDER: S-EPMC5398905 | biostudies-other | 2017 May

REPOSITORIES: biostudies-other

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Can Vertical Integration Reduce Hospital Readmissions? A Difference-in-Differences Approach.

Lopes Sílvia S Fernandes Óscar B ÓB Marques Ana Patrícia AP Moita Bruno B Sarmento João J Santana Rui R

Medical care 20170501 5

<h4>Background</h4>Vertical integration is expected to improve communication and coordination between inpatient care and care after discharge. Despite being used across health systems worldwide, evidence about its impact on readmissions is sparse and contradictory.<h4>Objective</h4>To assess the impact of vertical integration on hospital readmissions.<h4>Research design, subjects, and measures</h4>Using difference-in-differences we compared readmissions before and after vertical integration in 6 ...[more]

PMID: 28403012

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Project description:ObjectiveTo assess the efficacy of medication review as an isolated intervention and with several co-interventions for preventing hospital readmissions in older adults.MethodsOvid MEDLINE, Embase, The Cochrane Central Register of Controlled Trials and CINAHL were searched for randomized controlled trials evaluating the effectiveness of medication review interventions with or without co-interventions to prevent hospital readmissions in hospitalized or recently discharged adults aged ≥65, until September 13, 2019. Included outcomes were "at least one all-cause hospital readmission within 30 days and at any time after discharge from the index admission."ResultsTwenty-five studies met the inclusion criteria. Of these, 11 studies (7,318 participants) contributed to the network meta-analysis (NMA) on all-cause hospital readmission within 30 days. Medication review in combination with (a) medication reconciliation and patient education (risk ratio (RR) 0.45; 95% confidence interval (CI) 0.26-0.80) and (b) medication reconciliation, patient education, professional education and transitional care (RR 0.64; 95% CI 0.49-0.84) were associated with a lower risk of all-cause hospital readmission compared to usual care. Medication review in isolation did not significantly influence hospital readmissions (RR 1.06; 95% CI 0.45-2.51). The NMA on all-cause hospital readmission at any time included 24 studies (11,677 participants). Medication review combined with medication reconciliation, patient education, professional education and transitional care resulted in a reduction of hospital readmissions (RR 0.82; 95% CI 0.74-0.91) compared to usual care. The quality of the studies included in this systematic review raised some concerns, mainly regarding allocation concealment, blinding and contamination.ConclusionMedication review in combination with medication reconciliation, patient education, professional education and transitional care, was associated with a lower risk of hospital readmissions compared to usual care. An effect of medication review without co-interventions was not demonstrated. Trials of higher quality are needed in this field.

Project description:ImportanceDifferences in readmission rates among racial and ethnic minorities have been reported, but data among people with diabetes are lacking despite the high burden of diabetes and its complications in these populations.ObjectivesTo examine racial/ethnic differences in all-cause readmission among US adults with diabetes and categorize patient- and system-level factors associated with these differences.Design, setting, and participantsThis retrospective cohort study includes 272?758 adult patients with diabetes, discharged alive from the hospital between January 1, 2009, and December 31, 2014, and stratified by race/ethnicity. An administrative claims data set of commercially insured and Medicare Advantage beneficiaries across the United States was used. Data analysis took place between October 2016 and February 2019.Main outcomes and measuresUnplanned all-cause readmission within 30 days of discharge and individual-, clinical-, economic-, index hospitalization-, and hospital-level risk factors for readmission.ResultsA total of 467?324 index hospitalizations among 272?758 adults with diabetes (mean [SD] age, 67.7 [12.7]; 143?498 [52.6%] women) were examined. The rates of 30-day all-cause readmission were 10.2% (33?683 of 329?264) among white individuals, 12.2% (11?014 of 89?989) among black individuals, 10.9% (4151 of 38?137) among Hispanic individuals, and 9.9% (980 of 9934) among Asian individuals (P?<?.001). After adjustment for all factors, only black patients had a higher risk of readmission compared with white patients (odds ratio, 1.05; 95% CI, 1.02-1.08). This increased readmission risk among black patients was sequentially attenuated, but not entirely explained, by other demographic factors, comorbidities, income, reason for index hospitalization, or place of hospitalization. Compared with white patients, both black and Hispanic patients had the highest observed-to-expected (OE) readmission rate ratio when their income was low (annual household income <$40?000 among black patients: OE ratio, 1.11; 95% CI, 1.09-1.14; among Hispanic patients: OE ratio, 1.11; 95% CI, 1.07-1.16) and when they were hospitalized in nonprofit hospitals (black patients: OE ratio, 1.10; 95% CI, 1.08-1.12; among Hispanic patients: OE ratio, 1.08; 95% CI, 1.05-1.12), academic hospitals (black patients: OE ratio, 1.16; 95% CI, 1.13-1.20; Hispanic patients: OE ratio, 1.12; 95% CI, 1.06-1.19), or large hospitals (ie, with ?400 beds; black patients: OE ratio, 1.11; 95% CI, 1.09-1.14; Hispanic patients: OE ratio, 1.09; 95% CI, 1.04-1.14).Conclusions and relevanceIn this study, black patients with diabetes had a significantly higher risk of readmission than members of other racial/ethnic groups. This increased risk was most pronounced among lower-income patients hospitalized in nonprofit, academic, or large hospitals. These findings reinforce the importance of identifying and addressing the many reasons for persistent racial/ethnic differences in health care quality and outcomes.

Project description:Importance:Previous research suggests the important role of timely primary care follow-up in reducing hospital readmissions, although effectiveness varies by program design and patients' readmission risk level. Objective:To evaluate the outcomes of the 7-Day Pledge program to reduce readmissions by increasing access to timely primary care appointments after hospitalization. Design, Setting, and Participants:Retrospective cohort study of hospital readmissions among Medicaid patients 18 years or older hospitalized from January 1, 2014, to April 30, 2016, in Camden, New Jersey. To assess each patient's hospital use before and after hospital discharge, all-payer claims data from 4 health care systems were linked to insurers' lists of patients assigned to Camden-based primary care practices. A total of 1531 records were categorized by timing of a primary care appointment after discharge. Discharges followed by a primary care appointment within 7 days (treatment group) were matched by propensity scores to those with less timely or no primary care follow-up (nontreatment pool). Interventions:Targeted patient enrollment during hospital admission, primary care practice engagement, patient incentives to overcome barriers to keeping an appointment, and reimbursements to practices for prioritizing patients recently discharged from the hospital. Main Outcomes and Measures:The primary outcome was the number of hospital discharges followed by a readmission within 30 days. The secondary outcome was the number of hospital discharges followed by a readmission within 90 days. Results:There were 2580 hospitalizations of patients 18 years and older included on the patient lists from January 1, 2014, to April 30, 2016. Of these, 1531 records categorized by timing of a primary care appointment after discharge were studied. The treatment group consisted of 450 discharged patients (mean [SD] age, 48.7 [14.7] years; 289 [64.2%] female; 203 [45.1%] black, non-Hispanic). The nontreatment pool consisted of 1081 discharged patients (mean [SD] age, 48.1 [14.9] years; 599 [55.4%] female; 526 [48.7%] black, non-Hispanic). Among this cohort, the number of discharges followed by any readmission was lower for patients with a primary care visit within 7 days of hospital discharge than for their matched referents at 30 days (57 of 450 [12.7%] vs 78.8 of 450 [17.5%]; P?=?.03) and 90 days (126 of 450 [28.0%] vs 174 of 450 [38.7%]; P?=?.002) after discharge. Conclusions and Relevance:Facilitated receipt of primary care follow-up within 7 days of hospital discharge was associated with fewer Medicaid readmissions. The findings illuminate the importance of reducing barriers that patients and providers face during care transitions.

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Can Vertical Integration Reduce Hospital Readmissions? A Difference-in-Differences Approach.

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Can Vertical Integration Reduce Hospital Readmissions? A Difference-in-Differences Approach.

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