Hospital readmission performance and patterns of readmission: retrospective cohort study of Medicare admissions

Abstract

Objectives To determine whether high performing hospitals with low 30 day risk standardized readmission rates have a lower proportion of readmissions from specific diagnoses and time periods after admission or instead have a similar distribution of readmission diagnoses and timing to lower performing institutions.Design Retrospective cohort study.Setting Medicare beneficiaries in the United States.Participants Patients aged 65 and older who were readmitted within 30 days after hospital admission for heart failure, acute myocardial infarction, or pneumonia in 2007-09. Main outcome measuresReadmission diagnoses were classified with a modified version of the Centers for Medicare and Medicaid Services' condition categories, and readmission timing was classified by day (0-30) after hospital discharge. Hospital 30 day risk standardized readmission rates over the three years of study were calculated with public reporting methods of the US federal government, and hospitals were categorized with bootstrap analysis as having high, average, or low readmission performance for each index condition. High and low performing hospitals had ≥95% probability of having an interval estimate respectively less than or greater than the national 30 day readmission rate over the three year period of study. All remaining hospitals were considered average performers.Results For readmissions in the 30 days after the index admission, there were 320 003 after 1 291 211 admissions for heart failure (4041 hospitals), 102 536 after 517 827 admissions for acute myocardial infarction (2378 hospitals), and 208 438 after 1 135 932 admissions for pneumonia (4283 hospitals). The distribution of readmissions by diagnosis was similar across categories of hospital performance for all three conditions. High performing hospitals had fewer readmissions for all common diagnoses. Median time to readmission was similar by hospital performance for heart failure and acute myocardial infarction, though was 1.4 days longer among high versus low performing hospitals for pneumonia (P<0.001). Findings were unchanged after adjustment for other hospital characteristics potentially associated with readmission patterns.Conclusions High performing hospitals have proportionately fewer 30 day readmissions without differences in readmission diagnoses and timing, suggesting the possible benefit of strategies that lower risk of readmission globally rather than for specific diagnoses or time periods after hospital stay.

Can valid and practical risk-prediction or casemix adjustment models, including adjustment for comorbidity, be generated from English hospital administrative data (Hospital Episode Statistics)? A national observational study

“…For example, when do the 'excess' deaths or readmissions occur at hospitals with high rates compared with those with low rates? Some recent evidence for HF patients suggests that the timing of readmissions within the standard 30-day follow-up period does not vary in Medicare patients, 92 but this is not well established with other populations, patient groups or outcomes.…”

The identification of post-acute patients at risk for hospital readmission: Clinical implications of the LACE index

“…A national study conducted by Dharmarajan et al [14] found that readmission diagnoses and timing after admission for heart failure, acute myocardial infarction, or pneumonia do not differ by hospital 30 day risk standardized readmission rates. [14] Both acute myocardial infarction and heart failure are comorbidities included on the LACE index.…”

“…[14] Both acute myocardial infarction and heart failure are comorbidities included on the LACE index. [9] The re-…”

“…[14] This may suggest that broad clinical strategies and timely nursing interventions may be more helpful in reducing hospital readmission rather than examining medical diagnoses for specified time periods after admission to the hospital.…”

Understanding Hospitalization in Patients with Heart Failure

“…[16][17][18][19] The relevance of the "rehospitalization" topic in the last decade involves two important points: first, the perception that reducing these rates would be a window of opportunity to decrease the waste of resources in the health system and, second, that the hospitalization causes additional damage to the heart and other organs. Hospitals in the United States with high rates of rehospitalization have started to be penalized, which led to a search for evidence-based strategies capable of improving the performance of these instituitions.…”