Thirty-Day Postdischarge Mortality Among Black and White Patients 65 Years and Older in the Medicare Hospital Readmissions Reduction Program

Huckfeldt, Peter J.; Escarce, José J.; Sood, Neeraj; Yang, Zhiyou; Popescu, Ioana; Nuckols, Teryl K.

doi:10.1001/jamanetworkopen.2019.0634

Cited by 23 publications

(22 citation statements)

References 36 publications

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“…Other studies using national Medicare data have focused on temporal trends in subgroups of hospitals and patients and are, therefore, not directly comparable to the above studies focusing on overall trends 3031. Finally, an analysis using 100 000 hospital admissions among Medicare beneficiaries in a quality improvement registry drawn from 500 US hospitals, which captured an inconceivably low two admissions for heart failure on average per hospital per month, did not replicate the secular trends in heart failure readmissions or mortality nationally 2232.…”

Section: Discussionmentioning

confidence: 89%

Post-discharge acute care and outcomes following readmission reduction initiatives: national retrospective cohort study of Medicare beneficiaries in the United States

Khera

Wang

Bernheim

et al. 2020

BMJ

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Objectives To determine whether patients discharged after hospital admissions for conditions covered by national readmission programs who received care in emergency departments or observation units but were not readmitted within 30 days had an increased risk of death and to evaluate temporal trends in post-discharge acute care utilization in inpatient units, emergency departments, and observation units for these patients. Design Retrospective cohort study. Setting Medicare claims data for 2008-16 in the United States. Participants Patients aged 65 or older admitted to hospital with heart failure, acute myocardial infarction, or pneumonia—conditions included in the US Hospital Readmissions Reduction Program. Main outcome measures Post-discharge 30 day mortality according to patients’ 30 day acute care utilization; acute care utilization in inpatient and observation units and the emergency department during the 30 day and 31-90 day post-discharge period. Results 3 772 924 hospital admissions for heart failure, 1 570 113 for acute myocardial infarction, and 3 131 162 for pneumonia occurred. The overall post-discharge 30 day mortality was 8.7% for heart failure, 7.3% for acute myocardial infarction, and 8.4% for pneumonia. Risk adjusted mortality increased annually by 0.05% (95% confidence interval 0.02% to 0.08%) for heart failure, decreased by 0.06% (−0.09% to −0.04%) for acute myocardial infarction, and did not significantly change for pneumonia. Specifically, mortality increased for patients with heart failure who did not utilize any post-discharge acute care, increasing at a rate of 0.08% (0.05% to 0.12%) per year, exceeding the overall absolute annual increase in post-discharge mortality in heart failure, without an increase in mortality in observation units or the emergency department. Concurrent with a reduction in 30 day readmission rates, stays for observation and visits to the emergency department increased across all three conditions during and beyond the 30 day post-discharge period. Overall 30 day post-acute care utilization did not change significantly. Conclusions The only condition with increasing mortality through the study period was heart failure; the increase preceded the policy and was not present among patients who received emergency department or observation unit care without admission to hospital. During this period, the overall acute care utilization in the 30 days after discharge significantly decreased for heart failure and pneumonia, but not for acute myocardial infarction.

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Section: Discussionmentioning

confidence: 89%

Post-discharge acute care and outcomes following readmission reduction initiatives: national retrospective cohort study of Medicare beneficiaries in the United States

Khera

Wang

Bernheim

et al. 2020

BMJ

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“…However, several independent analyses have found that the implementation of the HRRP was associated with an increase in post-discharge mortality at 30 days among patients admitted for heart failure and pneumonia compared with pre-HRRP trends (pre-2010), and that this increase was concentrated entirely among patients not readmitted after discharge. 6 17 18 19 Whether intensified efforts to manage returning patients in emergency departments and observation units explain increases in mortality observed in the years that preceded our study period is an important area for further research, given that this potential mechanism could explain increased mortality under the HRRP. 20 21 22 23 24 …”

Section: Discussionmentioning

confidence: 98%

Hospital revisits within 30 days after discharge for medical conditions targeted by the Hospital Readmissions Reduction Program in the United States: national retrospective analysis

Wadhera

Maddox

Kazi

et al. 2019

BMJ

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ObjectiveTo determine any changes in total hospital revisits within 30 days of discharge after a hospital stay for medical conditions targeted by the Hospital Readmissions Reduction Program (HRRP).DesignRetrospective cohort study.SettingHospital stays among Medicare patients for heart failure, acute myocardial infarction, or pneumonia between 1 January 2012 and 1 October 2015.ParticipantsMedicare fee-for-service patients aged 65 or over.Main outcomesTotal hospital revisits within 30 days of discharge after hospital stays for medical conditions targeted by the HRRP, and by type of revisit: treat-and-discharge visit to an emergency department, observation stay (not leading to inpatient readmission), and inpatient readmission. Patient subgroups (age, sex, race) were also evaluated for each type of revisit.ResultsOur study cohort included 3 038 740 total index hospital stays from January 2012 to September 2015: 1 357 620 for heart failure, 634 795 for acute myocardial infarction, and 1 046 325 for pneumonia. Counting all revisits after discharge, the total number of hospital revisits per 100 patient discharges for target conditions increased across the study period (monthly increase 0.023 visits per 100 patient discharges (95% confidence interval 0.010 to 0.035)). This change was due to monthly increases in treat-and-discharge visits to an emergency department (0.023 (0.015 to 0.032) and observation stays (0.022 (0.020 to 0.025)), which were only partly offset by declines in readmissions (−0.023 (−0.035 to −0.012)). Increases in observation stay use were more pronounced among non-white patients than white patients. No significant change was seen in mortality within 30 days of discharge for target conditions (−0.0034 (−0.012 to 0.0054)).ConclusionsIn the United States, total hospital revisits within 30 days of discharge for conditions targeted by the HRRP increased across the study period. This increase was due to a rise in post-discharge emergency department visits and observation stays, which exceeded the decline in readmissions. Although reductions in readmissions have been attributed to improvements in discharge planning and care transitions, our findings suggest that these declines could instead be because hospitals and clinicians have intensified efforts to treat patients who return to a hospital within 30 days of discharge in emergency departments and as observation stays.

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“…Earlier work has explored the potential for unintended harms to patients resulting from the HRRP, with mixed findings, reflecting different study designs and model specifications. [38][39][40][41][42] A 2018 study by Wadhera et al 39 observed an increase in 30-day mortality, which was likely driven by patients not readmitted within 30 days of discharge. Our study found that the HRRP was associated with a 1.2% decrease in the likelihood of readmission when recently discharged patients presented to the ED with conditions for which admission is potentially nondiscretionary, particularly CHF.…”

Section: Discussionmentioning

confidence: 99%

Assessment of Hospital Readmissions From the Emergency Department After Implementation of Medicare’s Hospital Readmissions Reduction Program

et al. 2020

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IMPORTANCE The Medicare Hospital Readmissions Reduction Program (HRRP) is associated with reduced readmission rates, but it is unknown how this decrease occurred. OBJECTIVE To examine whether the HRRP was associated with changes in the probability of readmission at emergency department (ED) visits after hospital discharge (ED revisits) overall and depending on whether admission is typically indicated for the patient's condition at the ED revisit.

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Thirty-Day Postdischarge Mortality Among Black and White Patients 65 Years and Older in the Medicare Hospital Readmissions Reduction Program

Cited by 23 publications

References 36 publications

Post-discharge acute care and outcomes following readmission reduction initiatives: national retrospective cohort study of Medicare beneficiaries in the United States

Post-discharge acute care and outcomes following readmission reduction initiatives: national retrospective cohort study of Medicare beneficiaries in the United States

Hospital revisits within 30 days after discharge for medical conditions targeted by the Hospital Readmissions Reduction Program in the United States: national retrospective analysis

Assessment of Hospital Readmissions From the Emergency Department After Implementation of Medicare’s Hospital Readmissions Reduction Program

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