Readmissions To New York Hospitals Fell For Three Target Conditions From 2008 To 2012, Consistent With Medicare Goals

The cost of readmissions in hospitals: the case of the Spanish public hospitals

BACKGROUND

In this paper, we propose a novel model that allows us to understand the effect of hospital readmissions on technology and costs. To do this, we consider that hospitals may experience heterogeneous discharges: on the one hand, discharges corresponding to patients who have completed their healing process in hospital and, on the other hand, discharges resulting from patients who have been discharged too early and are therefore required to be readmitted to hospital. In the first case, discharges involve more resources; in the second case, the patient returns implying an additional use of resources. In tandem, two new issues arise which need to be addressed: a) Does a trade-off exist between the decision to discharge at the finalisation of fully completed treatment or the decision to discharge taken at an earlier stage; b) Readmissions may prove endogenous and if so, their econometric treatment must be considered in order to obtain unbiased results. Our study contributes to the literature by proposing a novel model which estimates the marginal cost of readmissions, thus allowing us to understand the effect of readmission on technology and hospital costs.

METHODS

To resolve the foregoing concerns, this paper proposes a theoretical and empirical model based on the dual theory, which combines cost and input-oriented distance functions to obtain the marginal cost of readmissions. Our empirical application uses a panel of Spanish public hospitals observed over the period 2002-2016.

RESULTS

Results indicate that the treatment required by a patient who is readmitted proves more expensive than keeping the patient under observation for a few extra days in order to achieve a definitive discharge. Moreover, this additional cost follows an increasing temporal trend, especially in times of expansion when the availability of resources is greater.

CONCLUSIONS

Given that the results indicate that readmissions imply an additional cost for the hospital system, they must be contained. In fact, readmission rates are a significant component of current hospital sector activity improvement strategies. Therefore, knowing the cost which readmission implies is relevant for the design of policies that seek to penalize those hospitals with high readmission rates.

Medicare's Hospital Readmission Reduction Program reduced fall-related health care use: An unexpected benefit?

OBJECTIVE

To assess whether Medicare's Hospital Readmissions Reduction Program (HRRP) was associated with a reduction in severe fall-related injuries (FRIs).

DATA SOURCES AND STUDY SETTING

Secondary data from Medicare were used.

STUDY DESIGN

Using an event study design, among older (≥65) Medicare fee-for-service beneficiaries, we assessed changes in 30- and 90-day FRI readmissions before and after HRRP's announcement (April 2010) and implementation (October 2012) for conditions targeted by the HRRP (acute myocardial infarction [AMI], congestive heart failure [CHF], and pneumonia) versus "non-targeted" (gastrointestinal) conditions. We tested for modification by hospitals with "high-risk" before HRRP and accounted for potential upcoding. We also explored changes in 30-day FRI readmissions involving emergency department (ED) or outpatient care, care processes (length of stay, discharge destination, and primary care visit), and patient selection (age and comorbidities).

DATA COLLECTION

Not applicable.

PRINCIPAL FINDINGS

We identified 1.5 million (522,596 pre-HRRP, 514,844 announcement, and 474,029 implementation period) index discharges. After its announcement, HRRP was associated with 12%-20% reductions in 30- and 90-day FRI readmissions for patients with CHF (-0.42 percentage points [ppt], p = 0.02; -1.53 ppt, p < 0.001) and AMI (-0.35, p = 0.047; -0.97, p = 0.001). Two years after implementation, HRRP was associated with reductions in 90-day FRI readmission for AMI (-1.27 ppt, p = 0.01) and CHF (-0.98 ppt, p = 0.02) patients. Results were similar for hospitals at higher versus lower baseline risk of FRI readmission. After HRRP's announcement, decreases were observed in home health (AMI: -2.43 ppt, p < 0.001; CHF: -8.83 ppt, p < 0.001; pneumonia: -1.97 ppt, p < 0.001) and skilled nursing facility referrals (AMI: -5.95 ppt, p < 0.001; CHF: -3.19 ppt, p < 0.001; pneumonia: -10.27 ppt, p < 0.001).

CONCLUSIONS

HRRP was associated with reductions in FRIs, primarily for HF and pneumonia patients. These decreases may reflect improvements in transitional care including changes in post-acute referral patterns that benefit patients at risk for falls.

Did the Hospital Readmissions Reduction Program Reduce Readmissions? An Assessment of Prior Evidence and New Estimates

In this article, we provide a comprehensive, empirical assessment of the hypothesis that the Hospital Readmissions Reduction Program (HRRP) affected hospital readmissions. In doing so, we provide evidence as to the validity of prior empirical approaches used to evaluate the HRRP and we present results from a previously unused approach to study this research question-a regression-kink design. Results of our analysis document that the empirical approaches used in most prior research assessing the efficacy of the HRRP often lack internal validity. Therefore, results from these studies may not be informative about the causal consequences of the HRRP. Results from our regression-kink analysis, which we validate, suggest that the HRRP had little effect on hospital readmissions. This finding contrasts with the results of most prior studies, which report that the HRRP significantly reduced readmissions. Our finding is consistent with conceptual considerations related to the assumptions underlying HRRP penalty: in particular, the difficulty of identifying preventable readmissions, the highly imperfect risk adjustment that affects the penalty determination, and the absence of proven tools to reduce readmissions.

Characteristics and Outcomes of Pediatric Nonindex Readmission: Evidence From Florida Hospitals

OBJECTIVES

Increasing pediatric care regionalization may inadvertently fragment care if children are readmitted to a different (nonindex) hospital rather than the discharge (index) hospital. Therefore, this study aimed to assess trends in pediatric nonindex readmission rates, examine the risk factors, and determine if this destination difference affects readmission outcomes.

METHODS

In this retrospective cohort study, we use the Healthcare Cost and Utilization Project State Inpatient Database to include pediatric (0 to 18 years) admissions from 2010 to 2017 across Florida hospitals. Risk factors of nonindex readmissions were identified by using logistic regression analyses. The differences in outcomes between index versus nonindex readmissions were compared for in-hospital mortality, morbidity, hospital cost, length of stay, against medical advice discharges, and subsequent hospital visits by using generalized linear regression models.

RESULTS

Among 41 107 total identified readmissions, 5585 (13.6%) were readmitted to nonindex hospitals. Adjusted nonindex readmission rate increased from 13.3% in 2010% to 15.4% in 2017. Patients in the nonindex readmissions group were more likely to be adolescents, live in poor neighborhoods, have higher comorbidity scores, travel longer distances, and be discharged at the postacute facility. After risk adjusting, no difference in in-hospital mortality was found, but morbidity was 13% higher, and following unplanned emergency department visits were 28% higher among patients with nonindex readmissions. Length of stay, hospital costs, and against medical advice discharges were also significantly higher for nonindex readmissions.

CONCLUSIONS

A substantial proportion of children experienced nonindex readmissions and relatively poorer health outcomes compared with index readmission. Targeted strategies for improving continuity of care are necessary to improve readmission outcomes.

The Effect of Medicare Shared Savings Program on Readmissions and Variations by Race/Ethnicity and Payer Status (December 9, 2020)

OBJECTIVE

Accountable care organizations in the Medicare Shared Savings Program (MSSP) in the United States attempt to reduce cost and improve quality for their patients by improving care coordination across care settings. We examined the impact of hospital participation in the MSSP on 30-day readmissions for several groups of Medicare inpatients, and by race/ethnicity and payer status.

MAIN DATA SOURCE

A 2010-2016 Medicare Provider Analysis and Review files.

RESEARCH DESIGN

With propensity score matched sample of MSSP and non-MSSP-participating hospitals, patient-level linear probability models with difference-in-differences approach were used to compare the changes in readmission rates for Medicare fee-for-service patients initially admitted for ischemic stroke, hip fracture, or total joint arthroplasty in MSSP-participating hospitals with non-MSSP-participating hospitals as well as to compare the changes in disparities in readmission rates over time.

PRINCIPAL FINDINGS

Hospital participation in MSSP was associated with further reduced readmission rate by 1.1 percentage points (95% confidence interval: -0.02 to 0.00, P<0.05) and 1.5 percentage points (95% confidence interval: -0.03 to 0.00, P=0.08) for ischemic stroke and hip fracture cohorts, respectively, compared with non-MSSP-participating hospitals, after the third year of hospital participation in the MSSP. There was no evidence that MSSP had an impact on racial/ethnic disparities, but increased disparity by payer status (dual vs. Medicare-only) was observed. These findings together suggest that MSSP accountable care organizations may take at least 3 years to achieve reduced readmissions and may increase disparities by payer status.

Association of a multiple-step action with cervical lymph node yield of oral cancer patients in an Asian country

Background

High quality lymph node (LN) yield could increase survival, however strategies to improve LN yield have been seldom reported. This study aimed to assess the multiple-step action to promote quality of neck dissection in oral cancer.

Methods

A total of 400 patients with oral cancer who underwent primary tumor resection and neck dissection, including elective and radical neck dissection, were recruited after propensity score matching by clinical T and N categories between January 2009 and September 2018. Patients were treated by two independent departments in our institute. A multiple-step action was initiated in October 2015 in one department, and another department was as a control group. The impact of multiple-step action on LN yield and regional recurrence were analyzed using multivariate analysis and difference-in-differences (DID) linear regression analysis.

Results

The mean patient age was 55.2 + 11.1 years, and 92% were male. A total of 180 (45%) patients had T3-4 disease, and 129 (32%) patients had N2-3 disease. The multivariate linear regression and DID analyses revealed that multiple-step action had a positive effect on LN yield. A net improvement of LN yield with a coefficient of 13.78 (p < 0.001) after launching multiple-step action (since October 2015) was observed. A borderline protective effect of multiple-step action for cN0 patients with a reduced regional recurrence rate of 11.6% (p = 0.072) through DID analysis was noted.

Conclusions

Multiple-step action was associated with increased LN yield and decreased regional recurrence in patients with oral cancer. The observed activity may promote surgeons to improve the quality of neck dissections, is feasible, and could be applied to a widespread patient population.

Readmission Rates for Chronic Obstructive Pulmonary Disease Under the Hospital Readmissions Reduction Program: an Interrupted Time Series Analysis

BACKGROUND

Hospital readmission rates decreased for myocardial infarction (AMI), heart failure (CHF), and pneumonia with implementation of the first phase of the Hospital Readmissions Reduction Program (HRRP). It is not established whether readmissions fell for chronic obstructive pulmonary disease (COPD), an HRRP condition added in 2014.

OBJECTIVE

We sought to determine whether HRRP penalties influenced COPD readmissions among Medicare, Medicaid, or privately insured patients.

DESIGN

We analyzed a retrospective cohort, evaluating readmissions across implementation periods for HRRP penalties ("pre-HRRP" January 2010-April 2011, "implementation" May 2011-September 2012, "partial penalty" October 2012-September 2014, and "full penalty" October 2014-December 2016).

PATIENTS

We assessed discharged patients ≥ 40 years old with COPD versus those with HRRP Phase 1 conditions (AMI, CHF, and pneumonia) or non-HRRP residual diagnoses in the Nationwide Readmissions Database.

INTERVENTIONS

HRRP was announced and implemented during this period, forming a natural experiment.

MEASUREMENTS

We calculated differences-in-differences (DID) for 30-day COPD versus HRRP Phase 1 and non-HRRP readmissions.

KEY RESULTS

COPD discharges for 1.2 million Medicare enrollees were compared with 22 million non-HRRP and 3.4 million HRRP Phase 1 discharges. COPD readmissions decreased from 19 to 17% over the study. This reduction was significantly greater than non-HRRP conditions (DID - 0.41%), but not HRRP Phase 1 (DID + 0.02%). A parallel trend was observed in the privately insured, with significant reduction compared with non-HRRP (DID - 0.83%), but not HRRP Phase 1 conditions (DID - 0.45%). Non-significant reductions occurred in Medicaid (DID - 0.52% vs. non-HRRP and - 0.21% vs. Phase 1 conditions).

CONCLUSIONS

In Medicare, HRRP implementation was associated with reductions in COPD readmissions compared with non-HRRP controls but not versus other HRRP conditions. Parallel findings were observed in commercial insurance, but not in Medicaid. Condition-specific penalties may not reduce readmissions further than existing HRRP trends.

Patient Coded Severity and Payment Penalties Under the Hospital Readmissions Reduction Program: A Machine Learning Approach

OBJECTIVE

The objective of this study was to examine variation in hospital responses to the Centers for Medicare and Medicaid's expansion of allowable secondary diagnoses in January 2011 and its association with financial penalties under the Hospital Readmission Reduction Program (HRRP).

DATA SOURCES/STUDY SETTING

Medicare administrative claims for discharges between July 2008 and June 2011 (N=3102 hospitals).

RESEARCH DESIGN

We examined hospital variation in response to the expansion of secondary diagnoses by describing changes in comorbidity coding before and after the policy change. We used random forest machine learning regression to examine hospital characteristics associated with coded severity. We then used a 2-part model to assess whether variation in coded severity was associated with readmission penalties.

RESULTS

Changes in severity coding varied considerably across hospitals. Random forest models indicated that greater baseline levels of condition categories, case-mix index, and hospital size were associated with larger changes in condition categories. Hospital coding of an additional condition category was associated with a nonsignificant 3.8 percentage point increase in the probability for penalties under the HRRP (SE=2.2) and a nonsignificant 0.016 percentage point increase in penalty amount (SE=0.016).

CONCLUSION

Changes in patient coded severity did not affect readmission penalties.

Patient Readmission Rates For All Insurance Types After Implementation Of The Hospital Readmissions Reduction Program

Since the implementation of the Hospital Readmissions Reduction Program (HRRP), readmissions have declined for Medicare patients with conditions targeted by the policy (acute myocardial infarction, heart failure, and pneumonia). To understand whether HRRP implementation was associated with a readmission decline for patients across all insurance types (Medicare, Medicaid, and private), we conducted a difference-in-differences analysis using information from the Nationwide Readmissions Database. We compared how quarterly readmissions for target conditions changed before (2010-12) and after (2012-14) HRRP implementation, using nontarget conditions as the control. Our results demonstrate that readmissions declined at a significantly faster rate after HRRP implementation not just for Medicare patients but also for those with Medicaid, both in the aggregate and for individual target conditions. However, composite Medicaid readmission rates remained higher than those for Medicare. Throughout the study period privately insured patients had the lowest aggregate readmission rates, which declined at a similar rate compared to nontarget conditions. The HRRP was associated with nationwide readmission reductions beyond the Medicare patients originally targeted by the policy. Further research is needed to understand the specific mechanisms by which hospitals have achieved reductions in readmissions.

Medicare Shared Savings Program and readmission rate among patients with ischemic stroke

OBJECTIVE

Hospitals participating in the Medicare Shared Savings Program (MSSP) share with the Centers for Medicare and Medicaid Services (CMS) the savings generated by reduced cost of care. Our aim was to determine whether MSSP is associated with changes in readmissions and mortality for Medicare patients hospitalized with ischemic stroke, and whether MSSP has a different impact on safety net hospitals (SNHs) compared to non-SNHs.

METHODS

This study was based on the CMS Hospital Compare data for risk-standardized 30-day readmission and mortality rates for Medicare patients hospitalized with ischemic strokes between 2010 and 2017. With a propensity score-matched sample, hospital-level difference-in-difference analysis was used to determine whether MSSP was associated with changes in hospital readmission and mortality as well as to examine the impact of MSSP on SNHs compared to non-SNHs.

RESULTS

MSSP-participating hospitals had slightly greater reductions in readmission rates compared to matched nonparticipating hospitals (difference, 0.25 percentage points; 95% confidence interval [CI], -0.42 to -0.08). Mortality rates decreased among all hospitals, but mortality reduction was not significantly different between MSSP-participating hospitals and matched hospitals (difference, 0.06 percentage points; 95% CI, -0.28 to 0.17). Prior to MSSP, readmission rates in SNHs were higher compared to non-SNHs, but MSSP did not have significantly different impact on hospital readmission and mortality rates for SNHs and non-SNHs.

CONCLUSION

MSSP led to slightly fewer readmissions without increases in mortality for Medicare patients hospitalized with ischemic stroke. Similar reductions in readmission rates were observed in SNHs and non-SNHs participating in MSSP, indicating persistent gaps between SNHs and non-SNHs.

The Hospital Readmissions Reduction Program's Impact on Readmissions From Skilled Nursing Facilities

EXECUTIVE SUMMARY

Hospital readmissions have long served as an indicator of patient recovery and the effectiveness of care. The present study examines the Hospital Readmissions Reduction Program's (HRRP's) impact on hospital readmissions from skilled nursing facilities (SNFs) and the characteristics of SNFs that were predictive of lower readmission rates. Adjusted 30-day readmission rates among 14,666 SNFs in the United States from 2011 through 2015 were examined using linear regression with generalized estimating equations to determine the relationship of the HRRP mandate to readmission rates from SNFs. Findings indicate a significant downward trend in adjusted 30-day readmission rates over time, decreasing 1.4% from 2011 to 2015. Furthermore, lower readmission rates were associated with SNF characteristics including location in a hospital facility, rural designation, higher registered nurse-to-nurse ratios, and not-for-profit status. We found a substantial decrease in SNF-related readmissions associated with HRRP, which may limit the impact of the Protecting Access to Medicare Act. Policy-makers may consider these systemic and structural differences before drafting future legislation targeting hospital readmission from SNFs. In addition, acute care facility operators who do not have an SNF may consider adding one to their facility and/or consider partnering with SNFs to ensure that high-quality programs in these SNFs are in place to reduce 30-day readmissions to the acute care facilities.

A qualitative study of old patients' experiences of the quality of the health services in hospital and 30 days after hospitalization

Background

The number of people aged 80 years and above is projected to triple over the next 30 years. People in this age group normally have at least two chronic conditions. The impact of multimorbidity is often significantly greater than expected from the sum of the effects of each condition. The World Health Organization has indicated that healthcare systems must prepare for a change in the focus of clinical care for older people. The World Health Organization (WHO) defines healthcare quality as care that is effective, efficient, integrated, patient centered, equitable and safe. The degree to which healthcare quality can be defined as acceptable is determined by services’ ability to meet the needs of users and adapt to patients’ expectations and perceptions.

Method

We took a phenomenological perspective to explore older patients’ subjective experiences and conducted semistructured individual interviews. Eighteen patients (aged from 82 to 100 years) were interviewed twice after discharge from hospital. The interview transcriptions were analyzed thematically.

Results

The patients found their meetings with the health service to be complex and demanding. They reported attempting to restore a sense of security and meaning in everyday life, balancing their own needs against external requirements. Five overarching themes emerged from the interviews: hospital stay and the person behind the diagnosis, poor communication and coordination, life after discharge, relationship with their next of kin, and organizational and systemic determinants.

Conclusion

According to the WHO, to deliver quality healthcare, services must include all six of the dimensions listed above. Our findings show that they do not. Healthcare focused on measurable values and biomedical inquiries. Few opportunities for participation, scant information and suboptimal care coordination left the patients with a feeling of being in limbo, where they struggled to find balance in their everyday life. Further work must be done to ensure that integrated services are provided without a financial burden, centered on the needs and rights of older people.

The Association Between Structural, Performance, and Community Factors and the Likelihood of Receiving a Penalty Under the Hospital Readmissions Reduction Program (Fiscal Year 2013-2019)

Purpose: Little is known about the role of structural, performance, and community factors that impact the likelihood of receiving a penalty under the Hospital Readmission Reduction Program. This study examined the association between structural, performance, and community factors and the likelihood of receiving a penalty as well as investigated the likelihood of hospitals serving vulnerable populations of receiving a penalty.

Methods: Centers for Medicare and Medicaid Services and United States Census Bureau data were used in this analysis. Ordered logistic regressions in a cross-sectional analysis were employed to estimate the probability of receiving a high or low penalty in the fiscal year 2013 through 2019.

Results: On average, medium-sized, major teaching, and safety-net hospitals had the highest proportion of hospitals with a high penalty. After controlling for performance and community factors, structural factor variables such as safety-net status, rural status, and teaching status either were no longer significant or the likelihood magnitude changed. However, after controlling for performance and community factors, the statistical significance of hospital size variables and geographic location persisted across the years. Length of stay and occupancy rate variables were also statistically significant across the 7 years under review.

Conclusion: Taken together, structural, performance, and community factors are important in explaining variation in the likelihood of receiving a penalty. There is no evidence that safety-net, rural, and public hospitals are more likely to receive a penalty. The results also suggest that there is room for providers to reduce avoidable readmissions and policymakers to mitigate unintended consequences.

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

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.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used hospital and ED discharge data from California, Florida, and New York from January 1, 2010, to December 31, 2014. A difference-in-differences analysis examined change in readmission probability at ED revisits for recently discharged patients; ED revisits with clinical presentations for which admission is typically indicated vs those for which admission is more variable (ie, discretionary) were examined separately. Inclusion criteria were Medicare patients 65 years and older who revisited an ED within 30 days of inpatient discharge. Data were analyzed from December 18, 2018, to September 11, 2019.

EXPOSURES

Before and after HRRP implementation among patients initially hospitalized for targeted vs nontargeted conditions.

MAIN OUTCOMES AND MEASURES

Thirty-day unplanned hospital readmissions at the ED revisit.

RESULTS

A total of 9 914 068 index hospitalizations were identified in California, Florida, and New York from 2010 to 2014. Of 2 052 096 discharges in 2010, 1 168 126 (56.9%) discharges were women and 566 957 discharges (27.6%) were among patients older than 85 years. Among 1 421 407 patients with an unplanned readmission within 30 days of discharge, 1 266 107 patients (89.1%) were admitted through the ED. A total of 1 906 498 ED revisits were identified. After adjusting for patient demographic and clinical characteristics from the index hospitalization, HRRP implementation was associated with fewer readmissions from the ED, with a difference-in-difference estimate of -0.9 (95% CI, -1.4 to -0.4) percentage points (P < .001), or a 1.4% relative decrease from the 65.8% pre-HRRP readmission rates. Implementation of the HRRP was associated with fewer readmissions at the ED revisit involving clinical presentations for which admission is typically indicated (difference-in-differences estimate, -1.1 [95% CI, -1.6 to -0.6] percentage points; P < .001), or a 1.2% relative decrease from the 93.6% pre-HRRP rate. These results appear to be associated with patients presenting at the ED revisit with congestive heart failure (difference-in-difference estimate, -1.2 [95% CI, -2.0 to -0.4] percentage points; P = .003).

CONCLUSIONS AND RELEVANCE

These findings suggest that implementation of the HRRP was associated with a lower likelihood of readmission for recently discharged patients presenting to the ED, specifically for congestive heart failure. This highlights the critical role of the ED in readmission reduction under the HRRP and suggests that patient outcomes after HRRP implementation should be further studied.

Informal caregivers' views on the quality of healthcare services provided to older patients aged 80 or more in the hospital and 30 days after discharge

Background

In the European Union (EU), informal caregivers provide 60% of all care. Informal caregiving ranges from assistance with daily activities and provision of direct care to helping care recipients to navigate within complex healthcare and social services systems. While recent caregiver surveys document the impact of informal caregivers, systematic reviews show that they have unmet needs.

Because of the political desire to reduce the length of hospital stays, older patients are discharged from the hospital ‘quicker and sicker’ than before. The transition between different levels of the healthcare system and the period after hospital discharge is critical for elderly patients.

Caregivers’ perspectives on the quality of older patients’ care journeys between levels of the healthcare system may provide valuable information for healthcare providers and policymakers. This study aims to explore older patient’s informal caregivers’ views on healthcare quality in the hospital and in the first 30 days after hospitalisation.

Method

We conducted semi-structured individual interviews with 12 participants to explore and describe informal caregivers’ subjective experiences of providing care to older relatives. The interviews were then transcribed and analysed thematically.

Results

The analysis yielded the overarching theme ‘Informal caregivers – a health service alliance – quality contributor’, which was divided into four main themes: ‘Fast in, fast out’, ‘Scant information’, ‘Disclaimer of responsibility’ and ‘A struggle to secure professional care’. The healthcare system seemed to pay little attention to ensuring mutual understandings between those involved in discharge, treatment and coordination. The participants experienced that the healthcare providers’ main focus was on the patients’ diseases, although the health services are supposed to view patients holistically.

Conclusion

Based on the information given by informal caregivers, health services must take into account each person’s needs and preferences. To deliver quality healthcare, better coordination between inter-professional care teams and the persons they serve is necessary. Health professionals must strengthen the involvement of caregivers in transitions between care and healthcare. Future work should evaluate targeted strategies for formal caregivers to cooperate, support and empower family members as informal caregivers.

Impact of the Medicare hospital readmissions reduction program on vulnerable populations

BACKGROUND

The Hospital Readmissions Reduction Program (HRRP) was established by the 2010 Patient Protection and Affordable Care Act (ACA) in an effort to reduce excess hospital readmissions, lower health care costs, and improve patient safety and outcomes. Although studies have examined the policy's overall impacts and differences by hospital types, research is limited on its effects for different types of vulnerable populations. The aim of this study was to analyze the impact of the HRRP on readmissions for three targeted conditions (acute myocardial infarction, heart failure, and pneumonia) among four types of vulnerable populations, including low-income patients, patients served by hospitals that serve a high percentage of low-income or Medicaid patients, and high-risk patients at the highest quartile of the Elixhauser comorbidity index score.

METHODS

Data on patient and hospital information came from the Nationwide Readmission Database (NRD), which contained all discharges from community hospitals in 27 states during 2010-2014. Using difference-in-difference (DD) models, linear probability regressions were conducted for the entire sample and sub-samples of patients and hospitals in order to isolate the effect of the HRRP on vulnerable populations. Multiple combinations of treatment and control groups and triple difference (DDD) methods were used for testing the robustness of the results. All models controlled for the patient and hospital characteristics.

RESULTS

There have been statistically significant reductions in readmission rates overall as well as for vulnerable populations, especially for acute myocardial infarction patients in hospitals serving the largest percentage of low-income patients and high-risk patients. There is also evidence of spillover effects for non-targeted conditions among Medicare patients compared to privately insured patients.

CONCLUSIONS

The HRRP appears to have created the right incentives for reducing readmissions not only overall but also for vulnerable populations, accruing societal benefits in addition to previously found reductions in costs. As the reduction in the rate of readmissions is not consistent across patient and hospital groups, there could be benefits to adjusting the policy according to the socioeconomic status of a hospital's patients and neighborhood.

Inaugural Readmission Penalties for Total Hip and Total Knee Arthroplasty Procedures Under the Hospital Readmissions Reduction Program

IMPORTANCE

The Hospital Readmissions Reduction Program (HRRP) is a Centers for Medicare and Medicaid Services policy that levies hospital reimbursement penalties based on excess readmissions of patients with 4 medical conditions and 3 surgical procedures. A greater understanding of factors associated with the 3 surgical reimbursement penalties is needed for clinicians in surgical practice.

OBJECTIVE

To investigate the first year of HRRP readmission penalties applied to 2 surgical procedures-elective total hip arthroplasty (THA) and total knee arthroplasty (TKA)-in the context of hospital and patient characteristics.

DESIGN, SETTING, AND PARTICIPANTS

Fiscal year 2015 HRRP penalization data from Hospital Compare were linked with the American Hospital Association Annual Survey and with the Healthcare Cost and Utilization Project State Inpatient Database for hospitals in the state of Florida. By using a case-control framework, those hospitals were separated based on HRRP penalty severity, as measured with the HRRP THA and TKA excess readmission ratio, and compared according to orthopedic volume as well as hospital-level and patient-level characteristics. The first year of HRRP readmission penalties applied to surgery in Florida Medicare subsection (d) hospitals was examined, identifying 60 663 Medicare patients who underwent elective THA or TKA in 143 Florida hospitals. The data analysis was conducted from February 2016 to January 2017.

EXPOSURES

Annual hospital THA and TKA volume, other hospital-level characteristics, and patient factors used in HRRP risk adjustment.

MAIN OUTCOMES AND MEASURES

The HRRP penalties with HRRP excess readmission ratios were measured, and their association with annual THA and TKA volume, a common measure of surgical quality, was evaluated. The HRRP penalties for surgical care according to hospital and readmitted patient characteristics were then examined.

RESULTS

Among 143 Florida hospitals, 2991 of 60 663 Medicare patients (4.9%) who underwent THA or TKA were readmitted within 30 days. Annual hospital arthroplasty volume seemed to follow an inverse association with both unadjusted readmission rates (r = -0.16, P = .06) and HRRP risk-adjusted readmission penalties (r = -0.12, P = .14), but these associations were not statistically significant. Other hospital characteristics and readmitted patient characteristics were similar across HRRP orthopedic penalty severity.

CONCLUSIONS AND RELEVANCE

This study's findings suggest that higher-volume hospitals had less severe, but not significantly different, rates of readmission and HRRP penalties, without systematic differences across readmitted patients.

Comparison of Machine Learning Algorithms for the Prediction of Preventable Hospital Readmissions

A diverse universe of statistical models in the literature aim to help hospitals understand the risk factors of their preventable readmissions. However, these models are usually not necessarily applicable in other contexts, fail to achieve good discriminatory power, or cannot be compared with other models. We built and compared predictive models based on machine learning algorithms for 30-day preventable hospital readmissions of Medicare patients. This work used the same inclusion/exclusion criteria for diseases used by the Centers for Medicare and Medicaid Services. In addition, risk stratification techniques were implemented to study covariate behavior on each risk strata. The new models resulted in improved performance measured by the area under the receiver operating characteristic curve. Finally, factors such as higher length of stay, disease severity index, being discharged to a hospital, and primary language other than English were associated with increased risk to be readmitted within 30 days. In the future, better predictive models for 30-day preventable hospital readmissions can point to the development of systems that identify patients at high risk and lead to the implementation of interventions (e.g., discharge planning and follow-up) to those patients, providing consistent improvement in the quality and efficiency of the healthcare system.

Cirrhosis as a Comorbidity in Conditions Subject to the Hospital Readmissions Reduction Program

INTRODUCTION

Although the Hospital Readmissions Reduction Program (HRRP) has decreased readmissions in targeted conditions, outcomes in high-risk subgroups are unknown. This study analyzed the impact of cirrhosis as a comorbidity on readmissions in conditions subjected to the HRRP.

METHODS

Using a longitudinal analysis of the New York, Florida, and Washington State inpatient databases from 2009 to 2013, adult Medicare beneficiaries with a diagnosis-related group of targeted conditions by the HRRP-pneumonia, congestive heart failure (CHF), and myocardial infarction (MI)-were included. Exclusion criteria included inability to assess for readmission, previous liver transplant, or having a readmission not subject to penalty under the HRRP. A sensitivity analysis used the International Classification of Diseases, 9th Revision, Clinical Modification codes to identify pneumonia, CHF, and MI hospitalizations. The primary outcome was 30-day readmission, with secondary outcomes including 90-day readmission, trends, and cirrhosis-specific risk factors for readmission.

RESULTS

Of the 797,432 patients included, 8,964 (1.1%) had cirrhosis. Patients with cirrhosis had significantly higher 30-day readmissions overall (29.3% vs 23.8%, P < 0.001) and specifically for pneumonia and CHF, but not for MI. Thirty-day readmission rates significantly decreased in patients without cirrhosis (annual percent change -1.8%, P < 0.001), but not in patients with cirrhosis (P = 0.39). Similar findings were present for 90-day readmissions. A sensitivity analysis confirmed these findings. On multivariable analysis, cirrhosis was associated with significantly higher 30-day readmissions (odds ratio 1.13, P < 0.001).

DISCUSSION

When cirrhosis is comorbid in patients with conditions subjected to the HRRP, readmissions are higher and have not improved. Focused efforts are needed to improve outcomes in cirrhosis and other high-risk comorbidities within the HRRP cohort.

Peering Behind the Veil: Trends in Types of Contracts Between Private Health Plans and Hospitals

Contracting between private health plans and hospitals has been described as "chaos behind a veil of secrecy." We develop a novel algorithm that classifies inpatient claims as one of three contract types-discounted charges, fixed rates, or per diems-and apply it to the 2009-2014 Colorado All Payer Claims Database. Of $1.1 billion in classifiable private health plan payments for inpatient care in Colorado, we find that 42.1% were fixed rates, 41.1% were discounted charges, and 16.0% were per diems. We find wide variation in contract types among private health plans and hospital types, and a pronounced shift over the study period in private plans' contract types, away from discounted charges, and toward fixed rates. To test our algorithm's validity, we apply it to Colorado Medicare and Medicaid claims-both of which are known primarily to pay using fixed rates-and find, reassuringly, that 86.3% of Medicare payments (98.6% when we exclude Medicare claims with special payment rules) and 79.7% of Medicaid payments are classified as fixed rates.

The Supply of Hospital Care to Minority and Low-Income Communities and the Hospital Readmission Reduction Program

To determine if the Centers for Medicare and Medicaid Services Hospital Readmission Reduction Program reduced hospital discharges for penalized conditions in minority and low-income communities, we used hospital discharge data for 2006 and 2013 from Arizona, California, Colorado, Florida, New Jersey, New York, North Carolina, and Wisconsin and readmission data from the Medicare Hospital Compare website. Negative binomial regression was used for 6,564 zip codes for each year to estimate the association between the expected penalty for an excess readmission in the hospital service area and the number of hospital discharges for penalized conditions (acute myocardial infarction, congestive heart failure, and pneumonia) for zip codes. The results showed that the expected penalty for excess readmissions had a negative association with the number of discharges for acute myocardial infarction, congestive heart failure, and pneumonia. The negative association increased with the percentage of minority residents but not with the poverty rate.

One-year costs of medical admissions with and without a 30-day readmission and enhanced risk adjustment

BACKGROUND

To overcome the limitations of administrative data in adequately adjusting for differences in patients' risk of readmissions, recent studies have added supplemental data from patient surveys and other sources (e.g., electronic health records). However, judging the adequacy of enhanced risk adjustment for use in assessment of 30-day readmission as a hospital quality indicator is not straightforward. In this paper, we evaluate the adequacy of risk adjustment by comparing the one-year costs of those readmitted within 30 days to those not after excluding the costs of the readmission.

METHODS

In this two-step study, we first used comprehensive administrative and survey data on a nationally representative Medicare cohort of hospitalized patients to compare patients with a medical admission who experienced a 30-day readmission to patients without a readmission in terms of their overall Medicare payments during 12 months following the index discharge. We then examined the extent to which a series of enhanced risk adjustment models incorporating code-based comorbidities, self-reported health status and prior healthcare utilization, reduced the payment differences between the admitted and not readmitted groups.

RESULTS

Our analytic cohort consisted 4684 index medical hospitalization of which 842 met the 30-day readmission criteria. Those readmitted were more likely to be older, White, sicker and with higher healthcare utilization in the previous year. The unadjusted subsequent one-year Medicare spending among those readmitted ($56,856) was 60% higher than that among the non-readmitted ($35,465). Even with enhanced risk adjustment, and across a variety of sensitivity analyses, one-year Medicare spending remained substantially higher (46.6%, p < 0.01) among readmitted patients.

CONCLUSIONS

Enhanced risk adjustment models combining health status indicators from administrative and survey data with previous healthcare utilization are unable to substantially reduce the cost differences between those medical admission patients readmitted within 30 days and those not. The unmeasured patient severity that these cost differences most likely reflect raises the question of the fairness of programs that place large penalties on hospitals with higher than expected readmission rates.

Trends in Pediatric Hospitalizations and Readmissions: 2010-2016

BACKGROUND

Health reform and policy initiatives over the last 2 decades have led to significant changes in pediatric clinical practice. However, little is known about recent trends in pediatric hospitalizations and readmissions at a national level.

METHODS

Data from the 2010-2016 Healthcare Cost and Utilization Project Nationwide Readmissions Database and National Inpatient Sample were analyzed to characterize patient-level and hospital-level trends in annual pediatric (ages 1-17 years) admissions and 30-day readmissions. Poisson regression was used to evaluate trends in pediatric readmissions over time.

RESULTS

From 2010 to 2016, the total number of index admissions decreased by 21.3%, but the percentage of admissions for children with complex chronic conditions increased by 5.7%. Unadjusted pediatric 30-day readmission rates increased over time from 6.26% in 2010 to 7.02% in 2016 with a corresponding increase in numbers of admissions for patients with complex chronic conditions. When stratified by complex or chronic conditions, readmission rates declined or remained stable across patient subgroups. Mean risk-adjusted hospital readmission rates increased over time overall (6.46% in 2010 to 7.14% in 2016) and in most hospital subgroups but decreased over time in metropolitan teaching hospitals.

CONCLUSIONS

Pediatric admissions declined from 2010 to 2016 as 30-day readmission rates increased. The increase in readmission rates was associated with greater numbers of admissions for children with chronic conditions. Hospitals serving pediatric patients need to account for the rising complexity of pediatric admissions and develop strategies for reducing readmissions in this high-risk population.

Aiming to Improve Readmissions Through InteGrated Hospital Transitions (AIRTIGHT): a Pragmatic Randomized Controlled Trial

BACKGROUND

Despite years of intense focus, inpatient and observation readmission rates remain high and largely unchanged. Hospitals have little, robust evidence to guide the selection of interventions effective at reducing 30-day readmissions in real-world settings.

OBJECTIVE

To evaluate if implementation of recent recommendations for hospital transition programs is effective at reducing 30-day readmissions in a population discharged to home and at high-risk for readmission.

DESIGN

A non-blinded, pragmatic randomized controlled trial ( Clinicaltrials.gov : NCT02763202) conducted at two hospitals in Charlotte, North Carolina.

PATIENTS

A total of 1876 adult patients, under the care of a hospitalist, and at high risk for readmissions.

INTERVENTION

Random allocation to a Transition Services (TS) program (n = 935) that bridges inpatient, outpatient, and home settings, providing patients virtual and in-person access to a dedicated multidisciplinary team for 30-days, or usual care (n = 941).

MAIN MEASURE

Thirty-day, unplanned, inpatient, or observation readmission rate.

KEY RESULTS

The 30-day readmission rate was 15.2% in the TS group and 16.3% in the usual care group (RR 0.93; 95% [CI, 0.76 to 1.15]; P = 0.52). There were no significant differences in readmissions at 60 and 90 days or in 30-day Emergency Department visit rates. Patients, who were referred to TS and readmitted, had less Intensive Care Unit admissions 15.5% vs. 26.8% (RR 0.74; 95% [CI, 0.59 to 0.93]; P = 0.02).

CONCLUSIONS

An intervention inclusive of contemporary recommendations does not reduce a high-risk population's 30-day readmission rate. The high crossover to usual care (74.8%) reflects the challenge of non-participation that is ubiquitous in the real-world implementation of population health interventions.

TRIAL REGISTRY

ClinicalTrials.gov ; registration ID number: NCT02763202, URL: https://clinicaltrials.gov/ct2/show/NCT02763202.

Racial/Ethnic Disparities in Readmissions in US Hospitals: The Role of Insurance Coverage

We examine differences in rates of 30-day readmissions across patients by race/ethnicity and the extent to which these differences were moderated by insurance coverage. We use hospital discharge data of patients in the 18 years and above age group for 5 US states, California, Florida, Missouri, New York, and Tennessee for 2009, the latest year prior to the start of Centers for Medicare & Medicaid Services’ Hospital Compare program of public reporting of hospital performance on 30-day readmissions. We use logistic regression models by state to estimate the association between insurance status, race, and the likelihood of a readmission within 30 days of an index hospital admission for any cause. Overall in 5 states, non-Hispanic blacks had a slightly higher risk of 30-day readmissions relative to non-Hispanic whites, although this pattern varied by state and insurance coverage. We found higher readmission risk for non-Hispanic blacks, compared with non-Hispanic whites, among those covered by Medicare and private insurance, but lower risk among uninsured and similar risk among Medicaid. Hispanics had lower risk of readmissions relative to non-Hispanic whites, and this pattern was common across subgroups with private, Medicaid, and no insurance coverage. Uninsurance was associated with lower risk of readmissions among minorities but higher risk of readmissions among non-Hispanic whites relative to private insurance. The study found that risk of readmissions by racial ethnic groups varies by insurance status, with lower readmission rates among minorities who were uninsured compared with those with private insurance or Medicare, suggesting that lower readmission rates may not always be construed as a good outcome, because it could result from a lack of insurance coverage and poor access to care, particularly among the minorities.

Thirty-day rehospitalizations among elderly patients with acute myocardial infarction: Impact of postdischarge ambulatory care

Rehospitalization after acute myocardial infarction (AMI) is common in elderly patients. It increases morbimortality and health care expenditures. The association between ambulatory care after discharge for AMI and rehospitalization has never been studied in France. We analyzed the impact of ambulatory care on rehospitalization of elderly patients (≥65 years) within 30 days after hospital discharge.We conducted a nationwide population-based study of elderly patients hospitalized with a main diagnosis of AMI in France between 2011 and 2013. We excluded patients hospitalized for AMI in the previous year and those who died during the index hospitalization or within 30 days after discharge. The primary outcome was the first all-cause 30-day rehospitalization in an acute care hospital. Individual and neighborhood-level variables were compared among rehospitalized and nonrehospitalized patients. Determinants of 30-day rehospitalization were identified using logistic regression models.Among the 624 eligible patients, 137 (22.0%) were rehospitalized within 30 days after discharge. In multivariate analyses, chronic kidney failure (odds ratio [OR] 1.88; 95% confidence interval [CI], 1.01-3.53) was an independent predictor of 30-day rehospitalization. We found no association among deprivation and spatial accessibility measures and 30-day rehospitalization. The purchase of lipid-lowering drugs prescription within 7 days after discharge was associated with a reduced risk of 30-day rehospitalization (OR 0.53; 95% CI, 0.36-0.79).This study highlights the role of coordination among hospital and primary care physicians in post-AMI discharge and follow-up among elderly patients. Specifically, targeted interventions to reduce 30-day rehospitalizations should focus on patients with comorbidities and use of prescription drugs after hospital discharge.

Multiple Chronic Conditions and Disparities in 30-Day Hospital Readmissions Among Nonelderly Adults

This study examines the patterns of 30-day hospital readmissions by race/ethnicity and multiple chronic conditions (MCC) burden among nonelderly adult patients. We used hospital discharge data of patients in the 18- to 64-year age group in 5 US states, California, Florida, Missouri, New York, and Tennessee, for 2009 from the Healthcare Cost and Utilization Project State Inpatient Database (HCUP-SID) of the Agency for Healthcare Research and Quality, linked to contextual and provider data from the Health Resources and Services Administration. A multilevel logistic regression model was used for data pooled over 5 states, adjusting for patient, hospital, and community characteristics. Controlling for other covariates, the study found that a higher MCC burden was associated with a higher all-cause 30-day readmission risk. We found considerable heterogeneity in levels of readmission risk among racial/ethnic subgroups stratified by chronic conditions. Among patients with a lowest MCC burden, African Americans had the highest risk of readmission, but with a higher MCC burden, the risk of readmission increased most for Hispanics.

The Impact of the Hospital Readmissions Reduction Program across Insurance Types in California

OBJECTIVE

Examine 30-day readmission rates for indicator conditions before and after adoption of the Hospital Readmissions Reduction Program (HRRP).

DATA

California hospital discharge data, 2005 to 2014.

STUDY DESIGN

Estimated difference between pre-HRRP trends and post-HRRP rates of hospital readmissions after hospitalization for indicator conditions targeted by the HRRP (heart attack, heart failure, and pneumonia) by payer among insured adults.

PRINCIPAL FINDINGS

Post-HRRP, reductions occurred for the three conditions among Fee-for-Service (FFS) Medicare. Readmissions decreased for heart attack and heart failure in Medicare Managed Care (MC). No reductions were observed in the younger commercially insured.

CONCLUSIONS

Post-HRRP, greater than expected reductions occurred in rehospitalizations for patients with Medicare FFS and Medicare MC. HRRP incentives may be influencing system-wide changes influencing care outside of traditional Medicare.

Most Hospitals Received Annual Penalties For Excess Readmissions, But Some Fared Better Than Others

The Hospital Readmissions Reduction Program (HRRP) initiated by the Affordable Care Act levies financial penalties against hospitals with excess thirty-day Medicare readmissions. We sought to understand the penalty burden over the program's first five years, focusing on characteristics of hospitals that received penalties during all five years, how penalties changed over time, and the relationship between baseline and subsequent performance. More than half of participating hospitals were penalized by the Centers for Medicare and Medicaid Services in all five years of the program. From fiscal years 2013 to 2017, the growth in average penalties was modest, doubling from 0.29 percent to 0.60 percent, despite increasing opportunities for penalization. The penalty burden was greater in hospitals that were urban, major teaching, large, or for-profit and that treated larger shares of Medicare or socioeconomically disadvantaged patients. Surprisingly, hospitals treating greater proportions of medically complex Medicare patients had a lower cumulative penalty burden compared to those treating fewer proportions of these patients. Lastly, we found that hospitals with high baseline penalties in the first year continued to receive significantly higher penalties in subsequent years. For many hospitals, the HRRP leads to persistent penalization and limited capacity to reduce penalty burden. Alternative structures might avoid persistent penalization, while still motivating reductions in hospital readmissions.

Should Emergency Department Attendances be Used With or Instead of Readmission Rates as a Performance Metric?: Comparison of Statistical Properties Using National Data

BACKGROUND

Hospital readmissions are common and are viewed as unfavorable. They are commonly used as a measure of quality of care and, in the United States and England, are associated with financial penalties. Readmissions are not the only possible return-to-acute-care metric; patients may also attend emergency departments (EDs).

OBJECTIVE

To assess hospital-level return-to-acute-care metrics using statistical criteria.

RESEARCH DESIGN

Patient readmissions and/or ED attendances were aggregated to produce risk-standardized hospital rates. Return-to-acute-care rates at 7, 30, 90, and 365 days were assessed using key statistical properties: (i) variability between hospitals; (ii) the relative contribution of patient and nonpatient factors to variation; and (iii) the statistical power to detect performance differences.

SUBJECTS

We had pseudonymized administrative data on all inpatient hospital admissions and ED attendances in National Health Service hospitals in England between April 2009 and March 2011. Patients with an inpatient stay for chronic obstructive pulmonary disorder or heart failure were eligible for inclusion.

MEASURES

ED attendances and readmissions for patients discharged from an inpatient stay for chronic obstructive pulmonary disorder or heart failure.

RESULTS

Interhospital variation was greatest for ED attendance; in addition, readmission was more strongly determined by patient characteristics than was ED attendance or both combined. Because of smaller numbers, the statistical power to detect differences in rates at 7 days for any indicator was limited.

CONCLUSIONS

Despite the current emphasis on readmissions, we found that ED attendance within 30 days has more desirable statistical properties and therefore the potential to be a useful metric when comparing hospitals.

Reducing excess hospital readmissions: Does destination matter?

Reducing excess hospital readmissions has become a high policy priority to lower health care spending and improve quality. The Affordable Care Act (ACA) penalizes hospitals with higher-than-expected readmission rates. This study tracks patient-level admissions and readmissions to Florida hospitals from 2006 to 2014 to examine whether the ACA has reduced readmission effectively. We compare not only the change in readmissions in targeted conditions to that in non-targeted conditions, but also changes in sites of readmission over time and differences in outcomes based on destination of readmission. We find that the drop in readmissions is largely owing to the decline in readmissions to the original hospital where they received operations or treatments (i.e., the index hospital). Patients readmitted into a different hospital experienced longer hospital stays. The results suggest that the reduction in readmission is likely achieved via both quality improvement and strategic admission behavior.

Hospital Readmissions Reduction Program: Intended and Unintended Effects

This study examines whether the Hospital Readmissions Reduction Program (HRRP), which penalizes hospitals with excess readmissions for certain conditions, has reduced hospital readmissions and led to unintended consequences. Our analyses of Florida hospital administrative data between 2008 and 2014 find that the HRRP resulted in a reduction in the likelihood of readmissions by 1% to 2% for traditional Medicare (TM) beneficiaries with heart failure, pneumonia, or chronic obstructive pulmonary disease. Readmission rates for Medicare Advantage (MA) beneficiaries and privately insured patients with heart attack and heart failure decreased even more than TM patients with the same target condition (e.g., for heart attack, the likelihood for TM beneficiaries to be remitted is 2.2% higher than MA beneficiaries and 2.3% higher than privately insured patients). We do not find any evidence of cost-shifting, delayed readmission, or selection on discharge disposition or patient income. However, the HRRP reduced the likelihood of Hispanic patients with target conditions being admitted by 2% to 4%.

Effect of a Hospital-wide Measure on the Readmissions Reduction Program

BACKGROUND

The Hospital Readmissions Reduction Program penalizes hospitals that have high 30-day readmission rates across specific conditions. There is support for changing to a hospital-wide readmission measure to broaden hospital eligibility and provide incentives for improvement across more conditions.

METHODS

We used Medicare claims from 2011 through 2013 to evaluate the number of hospitals that were eligible for penalties, in that they met a volume threshold of 25 admissions over a 3-year period for a specific condition or 25 admissions over a 1-year period for the cohorts included in the hospital-wide measure. We estimated the expected effects that changing from the condition-specific readmission measures to a hospital-wide measure would have on average penalties for safety-net hospitals (i.e., hospitals that treat a large proportion of low-income patients) and other hospitals.

RESULTS

Our sample included 6,807,899 admissions for the hospital-wide measure and 4,392,658 admissions for the condition-specific measures. Of 3443 hospitals, 688 were considered to be safety-net hospitals. Changing to the hospital-wide measure would result in 76 more hospitals being eligible to receive penalties. The hospital-wide measure would increase penalties (mean [±SE] Medicare payment reductions across all hospitals) from 0.42±0.01% to 0.89±0.01% of Medicare base diagnosis-related-group payments. It would also increase the disparity in penalties between safety-net hospitals and other hospitals from -0.03±0.02 to 0.41±0.06 percentage points.

CONCLUSIONS

A transition to a hospital-wide readmission measure would only modestly increase the number of hospitals eligible for penalties and would substantially increase the penalties for safety-net hospitals.

Patterns of Readmissions for Three Common Conditions Among Younger US Adults

BACKGROUND

Thirty-day readmissions among elderly Medicare patients are an important hospital quality measure. Although plans for using 30-day readmission measures are under consideration for younger patients, little is known about readmission in younger patients or the relationship between readmissions in younger and elderly patients at the same hospital.

METHODS

By using the 2014 Nationwide Readmissions Database, we examined readmission patterns in younger patients (18-64 years) using hierarchical models to evaluate associations between hospital 30-day, risk-standardized readmission rates in elderly Medicare patients and readmission risk in younger patients with acute myocardial infarction, heart failure, or pneumonia.

RESULTS

There were 87,818, 98,315, and 103,251 admissions in younger patients for acute myocardial infarction, heart failure, and pneumonia, respectively, with overall 30-day unplanned readmission rates of 8.5%, 21.4%, and 13.7%, respectively. Readmission risk in younger patients was significantly associated with hospital 30-day risk-standardized readmission rates for elderly Medicare patients for all 3 conditions. A decrease in an average hospital's 30-day, risk-standardized readmission rates from the 75th percentile to the 25th percentile was associated with reduction in younger patients' risk of readmission from 8.8% to 8.0% (difference: 0.7%; 95% confidence interval, 0.5-0.9) for acute myocardial infarction; 21.8% to 20.0% (difference: 1.8%; 95% confidence interval, 1.4-2.2) for heart failure; and 13.9% to 13.1% (difference: 0.8%; 95% confidence interval, 0.5-1.0) for pneumonia.

CONCLUSIONS

Among younger patients, readmission risk was moderately associated with hospital 30-day, risk-standardized readmission rates in elderly Medicare beneficiaries. Efforts to reduce readmissions among older patients may have important areas of overlap with younger patients, although further research may be necessary to identify specific mechanisms to tailor initiatives to younger patients.

Reductions in Readmission Rates Are Associated With Modest Improvements in Patient-reported Health Gains Following Hip and Knee Replacement in England

Supplemental Digital Content is available in the text.

Background:

Although many hospital readmission reduction initiatives have been introduced globally, health care systems ultimately aim to improve patients’ health and well-being. We examined whether the hospitals that report greater success in reducing readmissions also see greater improvements in patient-reported outcomes.

Research Design:

We examined hospital groups (Trusts) that provided hip replacement or knee replacement surgery in England between April 2010 and February 2013. For each Trust, we calculated risk-adjusted 30-day readmission rates from administrative datasets. We also obtained changes in patient-reported health between presurgical assessment and 6-month follow-up, using general health EuroQuol five dimensions questionaire (EQ-5D) and EuroQuol visual analogue scales (EQ-VAS) and procedure-specific (Oxford Hip and Knee Scores) measures. Panel models were used to assess whether changes over time in risk-adjusted readmission rates were associated with changes over time in risk-adjusted health gains.

Results:

Each percentage point reduction in the risk-adjusted readmission rate for hip replacement was associated with an additional health gain of 0.004 for EQ-5D [95% confidence interval (CI), 0.002–0.006], 0.39 for EQ-VAS (95% CI, 0.26–0.52), and 0.32 for Oxford Hip Score (95% CI, 0.15–0.27). Corresponding figures for knee replacement were 0.003 for EQ-5D (95% CI, 0.001–0.004), 0.21 for EQ-VAS (95% CI, 0.12–0.30), and 0.14 in the Oxford Knee Score (95% CI, 0.09–0.20).

Conclusions:

Reductions in readmission rates were associated with modest improvements in patients’ sense of their health and well-being at the hospital group level. In particular, fears that efforts to reduce readmission rates have had unintended consequences for patients appear to be unfounded.

Does It Pay to Penalize Hospitals for Excess Readmissions? Intended and Unintended Consequences of Medicare's Hospital Readmissions Reductions Program

To incentivize hospitals to provide better quality care at a lower cost, the Affordable Care Act of 2010 included the Hospital Readmissions Reduction Program (HRRP), which reduces payments to hospitals with excess 30-day readmissions for Medicare patients treated for certain conditions. We use triple difference estimation to identify the HRRP's effects in Virginia hospitals; this method estimates the difference in changes in readmission over time between patients targeted by the policy and a comparison group of patients and then compares those difference-in-differences estimates in patients treated at hospitals with readmission rates above the national average (i.e., those at risk for penalties) and patients treated at hospitals with readmission rates below or equal to the national average (those not at risk). We find that the HRRP significantly reduced readmission for Medicare patients treated for acute myocardial infarction (AMI). We find no evidence that hospitals delay readmissions, treat patients with greater intensity, or alter discharge status in response to the HRRP, nor do we find changes in the age, race/ethnicity, health status, and socioeconomic status of patients admitted for AMI. Future research on the specific mechanisms behind reduced AMI readmissions should focus on actions by healthcare providers once the patient has left the hospital. Copyright © 2016 John Wiley & Sons, Ltd.

Association Between Hospitals' Engagement in Value-Based Reforms and Readmission Reduction in the Hospital Readmission Reduction Program

IMPORTANCE

Medicare is experimenting with numerous concurrent reforms aimed at improving quality and value for hospitals. It is unclear if these myriad reforms are mutually reinforcing or in conflict with each other.

OBJECTIVE

To evaluate whether hospital participation in voluntary value-based reforms was associated with greater improvement under Medicare's Hospital Readmission Reduction Program (HRRP).

DESIGN, SETTING, AND PARTICIPANTS

Retrospective, longitudinal study using publicly available national data from Hospital Compare on hospital readmissions for 2837 hospitals from 2008 to 2015. We assessed hospital participation in 3 voluntary value-based reforms: Meaningful Use of Electronic Health Records; the Bundled Payment for Care Initiative episode-based payment program (BPCI); and Medicare's Pioneer and Shared Savings accountable care organization (ACO) programs. We used an interrupted time series design to test whether hospitals' time-varying participation in these value-based reforms was associated with greater improvement in Medicare's HRRP.

MAIN OUTCOMES AND MEASURES

Thirty-day risk standardized readmission rates for acute myocardial infarction (AMI), heart failure, and pneumonia.

RESULTS

Among the 2837 hospitals in this study, participation in value-based reforms varied considerably over the study period. In 2010, no hospitals were participating in the meaningful use, ACO, or BPCI programs. By 2015, only 56 hospitals were not participating in at least 1 of these programs. Among hospitals that did not participate in any voluntary reforms, the association between the HRRP and 30-day readmission was -0.76 percentage points for AMI (95% CI, -0.93 to -0.60), -1.30 percentage points for heart failure (95% CI, -1.47 to -1.13), and -0.82 percentage points for pneumonia (95% CI, -0.97 to -0.67). Participation in the meaningful use program alone was associated with an additional change in 30-day readmissions of -0.78 percentage points for AMI (95% CI, -0.89 to -0.67), -0.97 percentage points for heart failure (95% CI, -1.08 to -0.86), and -0.56 percentage points for pneumonia (95% CI, -0.65 to -0.47). Participation in ACO programs alone was associated with an additional change in 30-day readmissions of -0.94 percentage points for AMI (95% CI, -1.29 to -0.59), -0.83 percentage points for heart failure (95% CI, -1.26 to -0.41), and -0.59 percentage points for pneumonia (95% CI, -1.00 to -0.18). Participation in multiple reforms led to greater improvement: participation in all 3 programs was associated with an additional change in 30-day readmissions of -1.27 percentage points for AMI (95% CI, -1.58 to -0.97), -1.64 percentage points for heart failure (95% CI, -2.02 to -1.26), and -1.05 percentage points for pneumonia (95% CI, -1.32 to -0.78).

CONCLUSIONS AND RELEVANCE

Hospital participation in voluntary value-based reforms was associated with greater reductions in readmissions. Our findings lend support for Medicare's multipronged strategy to improve hospital quality and value.

Further Evidence on the System-Wide Effects of the Hospital Readmissions Reduction Program

OBJECTIVE

To investigate the potential spillover effects of the Hospital Readmissions Reduction Program (HRRP) on readmissions for nontargeted conditions and patient populations. We examine HRRP effects on nontargeted conditions separately and on non-Medicare populations in Florida and California.

DATA SOURCES

From 2007-2013, 100 percent Medicare inpatient claims data, 2007-2013 State Inpatient Database (SID) for Florida, and 2007-2011 SID for California.

STUDY DESIGN

We conducted an interrupted time series analysis to estimate the change in 30-day all-cause unplanned readmission trends after the start of HRRP using logistic regression.

PRINCIPAL FINDINGS

Hospitals with the largest reductions in targeted Medicare readmissions experienced higher reductions in nontargeted Medicare readmissions. Among nontargeted conditions, reductions were higher for neurology and surgery conditions than for the cardiovascular and cardiorespiratory conditions, which are clinically similar to the targeted conditions. For non-Medicare patients, readmission trends for targeted conditions in Florida and California did not change after HRRP.

CONCLUSIONS

Our findings are consistent with positive spillover benefits associated with HRRP. The extent of these benefits, however, varies across condition and patient groups. The observed patterns suggest a complex response, including a role of nonfinancial factors, in driving lower readmissions.

Hospital Characteristics Associated With Risk-standardized Readmission Rates

BACKGROUND

Safety-net and teaching hospitals are somewhat more likely to be penalized for excess readmissions, but the association of other hospital characteristics with readmission rates is uncertain and may have relevance for hospital-centered interventions.

OBJECTIVE

To examine the independent association of 8 hospital characteristics with hospital-wide 30-day risk-standardized readmission rate (RSRR).

DESIGN

This is a retrospective cross-sectional multivariable analysis.

SUBJECTS

US hospitals.

MEASURES

Centers for Medicare and Medicaid Services specification of hospital-wide RSRR from July 1, 2013 through June 30, 2014 with race and Medicaid dual-eligibility added.

RESULTS

We included 6,789,839 admissions to 4474 hospitals of Medicare fee-for-service beneficiaries aged over 64 years. In multivariable analyses, there was regional variation: hospitals in the mid-Atlantic region had the highest RSRRs [0.98 percentage points higher than hospitals in the Mountain region; 95% confidence interval (CI), 0.84-1.12]. For-profit hospitals had an average RSRR 0.38 percentage points (95% CI, 0.24-0.53) higher than public hospitals. Both urban and rural hospitals had higher RSRRs than those in medium metropolitan areas. Hospitals without advanced cardiac surgery capability had an average RSRR 0.27 percentage points (95% CI, 0.18-0.36) higher than those with. The ratio of registered nurses per hospital bed was not associated with RSRR. Variability in RSRRs among hospitals of similar type was much larger than aggregate differences between types of hospitals.

CONCLUSIONS

Overall, larger, urban, academic facilities had modestly higher RSRRs than smaller, suburban, community hospitals, although there was a wide range of performance. The strong regional effect suggests that local practice patterns are an important influence. Disproportionately high readmission rates at for-profit hospitals may highlight the role of financial incentives favoring utilization.

Impact of Provider Incentives on Quality and Value of Health Care

The use of financial incentives to improve quality in health care has become widespread. Yet evidence on the effectiveness of incentives suggests that they have generally had limited impact on the value of care and have not led to better patient outcomes. Lessons from social psychology and behavioral economics indicate that incentive programs in health care have not been effectively designed to achieve their intended impact. In the United States, Medicare's Hospital Readmission Reduction Program and Hospital Value-Based Purchasing Program, created under the Affordable Care Act (ACA), provide evidence on how variations in the design of incentive programs correspond with differences in effect. As financial incentives continue to be used as a tool to increase the value and quality of health care, improving the design of programs will be crucial to ensure their success.

Does Medicare Advantage Reduce Racial Disparity in 30-Day Rehospitalization for Medicare Beneficiaries?

This study determined potential racial and ethnic disparities in risk for all-cause 30-day readmission among traditional Medicare (TM) and Medicare Advantage (MA) beneficiaries initially hospitalized for acute myocardial infarction, congestive heart failure, or pneumonia. Our analyses of New York State hospital administrative data between 2009 and 2012 found that overall 30-day readmission rate declined from 22.0% in 2009 to 20.7% in 2012 for TM beneficiaries, and from 20.2% in 2009 to 17.9% in 2012 for MA beneficiaries. However, persistent racial disparities were found in propensity-score–based analyses among TM beneficiaries (e.g., in 2012, adjusted odds ratio [OR] = 1.11, 95% confidence interval [CI] = 1.01-1.23, p = .029), though not among MA beneficiaries (in 2012, adjusted OR = 1.05, 95% CI = 0.92-1.19, p = .476). We did not find evidence of persistent ethnic disparity for TM (in 2012, adjusted OR = 1.08, 95% CI = 0.93-1.25, p = .303) or MA (in 2012, adjusted OR = 0.99, 95% CI = 0.88-1.11, p = .837) beneficiaries. We conclude that enrollment in MA seemed to be associated with significantly reduced readmission rate and potentially reduced racial disparity.

Physician EHR Adoption and Potentially Preventable Hospital Admissions among Medicare Beneficiaries: Panel Data Evidence, 2010-2013

OBJECTIVE

To test for correlation between the growth in adoption of ambulatory electronic health records (EHRs) in the United States during 2010-2013 and hospital admissions and readmissions for elderly Medicare beneficiaries with at least one of four common ambulatory care-sensitive conditions (ACSCs).

DATA SOURCES

SK&A Information Services Survey of Physicians, American Hospital Association General Survey and Information Technology Supplement; and the Centers for Medicare & Medicaid Services Chronic Conditions Data Warehouse Geographic Variation Database for 2010 through 2013.

STUDY DESIGN

Fixed effects model estimated the relationship between hospital referral region (HRR) level measures of physician EHR adoption and ACSC admissions and readmissions. Analyzed rates of admissions and 30-day readmissions per beneficiary at the HRR level (restricting the denominator to beneficiaries in our sample), adjusted for differences across HRRs in Medicare beneficiary age, gender, and race. Calculated physician EHR adoption rates as the percentage of physicians in each HRR who report using EHR in ambulatory care settings.

PRINCIPAL FINDINGS

Each percentage point increase in market-level EHR adoption by physicians is correlated with a statistically significant decline of 1.06 ACSC admissions per 10,000 beneficiaries over the study period, controlling for the overall time trend as well as market fixed effects and characteristics that changed over time. This finding implies 26,689 fewer ACSC admissions in our study population during 2010 to 2013 that were related to physician ambulatory EHR adoption. This represents 3.2 percent fewer ACSC admissions relative to the total number of such admissions in our study population in 2010. We found no evidence of a correlation between EHR use, by either physicians or hospitals, and hospital readmissions at either the market level or hospital level.

CONCLUSIONS

This study extends knowledge about EHRs' relationship with quality of care and utilization. The results suggest a significant association between EHR use in ambulatory care settings and ACSC admissions that is consistent with policy goals to improve the quality of ambulatory care for patients with chronic conditions. The null findings for readmissions support the need for improved interoperability between ambulatory care EHRs and hospital EHRs to realize improvements in readmissions.

Hospital Readmissions Reduction Program: Safety-Net Hospitals Show Improvement, Modifications To Penalty Formula Still Needed

Many observers are calling for modification of Medicare's Hospital Readmissions Reduction Program (HRRP) to relieve an unfair burden on safety-net hospitals, which serve low-income populations and consequently have relatively high readmission rates. To broaden the perspective on this issue, we addressed the fundamental question of whether the HRRP has been an effective tool for reducing thirty-day readmissions in safety-net hospitals. In the first three years of the program, these hospitals reduced readmissions for heart attack by 2.86 percentage points, heart failure by 2.78 percentage points, and pneumonia by 1.77 percentage points, and they also reduced the disparity between their readmission rates and those of other hospitals. While the fairness issue remains unresolved, it appears that safety-net hospitals have been able to respond to HRRP incentives.

Rethinking Thirty-Day Hospital Readmissions: Shorter Intervals Might Be Better Indicators Of Quality Of Care

Public reporting and payment programs in the United States have embraced thirty-day readmissions as an indicator of between-hospital variation in the quality of care, despite limited evidence supporting this interval. We examined risk-standardized thirty-day risk of unplanned inpatient readmission at the hospital level for Medicare patients ages sixty-five and older in four states and for three conditions: acute myocardial infarction, heart failure, and pneumonia. The hospital-level quality signal captured in readmission risk was highest on the first day after discharge and declined rapidly until it reached a nadir at seven days, as indicated by a decreasing intracluster correlation coefficient. Similar patterns were seen across states and diagnoses. The rapid decay in the quality signal suggests that most readmissions after the seventh day postdischarge were explained by community- and household-level factors beyond hospitals' control. Shorter intervals of seven or fewer days might improve the accuracy and equity of readmissions as a measure of hospital quality for public accountability.

Effect of a Home-Based Palliative Care Program on Healthcare Use and Costs

Objectives

To evaluate the nonclinical outcomes of a proactive palliative care program funded and operated by a health system for Medicare Advantage plan beneficiaries.

Design

Observational, retrospective study using propensity‐based matching.

Setting

A health system in southern California.

Participants

Individuals who received the intervention between 2007 and 2014 (n = 368) were matched with 1,075 comparison individuals within each of four disease groups: cancer, chronic obstructive pulmonary disease, heart failure, and dementia. All were known to be dead at the time of the retrospective study, were Medicare Advantage beneficiaries, and had 2 years of usage data before death. Median age at death for each disease group was older than 80.

Intervention

Home‐ and clinic‐based palliative care (PC) services provided by a multidisciplinary team.

Measurements

Outcomes included hospital costs, other healthcare costs, readmission rates, hospital admissions and bed days, intensive care unit use in final 30 days of life, and death within 30 days of an admission.

Results

Intervention participants in all four disease groups had less hospital use and lower hospital costs nonintervention participants, which drove lower overall healthcare costs. In the final 6 months of life, healthcare costs for the intervention groups stayed largely the same from month to month, whereas costs for comparison participants increased dramatically.

Conclusion

In the context of an alternative payment model in which the provider was “at risk” of bearing the costs of care, a proactive PC program helped to avoid the escalation in hospital use and costs commonly seen in the final months of life.