Timely estimation of National Admission, readmission, and observation-stay rates in medicare patients with acute myocardial infarction, heart failure, or pneumonia using near real-time claims data

Shu-Xia Li,Jennifer Schwartz,Sonam D Lama,Zhenqiu Lin,Harlan M Krumholz,Steven Spivack,Jeph Herrin,Susannah M Bernheim,Hao Mei,Lisa G Suter,Yongfei Wang

doi:10.1186/s12913-020-05611-w

Abstract

BackgroundTo estimate, prior to finalization of claims, the national monthly numbers of admissions and rates of 30-day readmissions and post-discharge observation-stays for Medicare fee-for-service beneficiaries hospitalized with acute myocardial infarction (AMI), heart failure (HF), or pneumonia.MethodsThe centers for Medicare & Medicaid Services (CMS) Integrated Data Repository, including the Medicare beneficiary enrollment database, was accessed in June 2015, February 2017, and February 2018. We evaluated patterns of delay in Medicare claims accrual, and used incomplete, non-final claims data to develop and validate models for real-time estimation of admissions, readmissions, and observation stays.ResultsThese real-time reporting models accurately estimate, within 2 months from admission, the monthly numbers of admissions, 30-day readmission and observation-stay rates for patients with AMI, HF, or pneumonia.ConclusionsThis work will allow CMS to track the impact of policy decisions in real time and enable hospitals to better monitor their performance nationally.

Highlights

To estimate, prior to finalization of claims, the national monthly numbers of admissions and rates of 30-day readmissions and post-discharge observation-stays for Medicare fee-for-service beneficiaries hospitalized with acute myocardial infarction (AMI), heart failure (HF), or pneumonia
We focused on AMI, HF, and pneumonia because they were the first three conditions targeted by Centers for Medicare and Medicaid Services (CMS)’s Hospital Readmission Reduction Program (HRRP)
Consistent with our prior work on observation stays and the definition used for surveillance assessment in the CMS Medicare Hospital Quality Chartbook (2014) [12], we identified observation-stay claims using the Healthcare Common Procedure Coding System (HCPC S) code G0378, found in the outpatient claim line data file

Summary

Introduction

Prior to finalization of claims, the national monthly numbers of admissions and rates of 30-day readmissions and post-discharge observation-stays for Medicare fee-for-service beneficiaries hospitalized with acute myocardial infarction (AMI), heart failure (HF), or pneumonia. Medicare provides health care coverage for over 60 million Americans [1]; over 95% of those are over the age of 65 [2]. The information available in Medicare claims, offers a detailed and comprehensive view of patterns of health and healthcare for older Americans. Claims data are frequently used by researchers and government to examine trends in disease, healthcare utilization, and quality [3, 4]. These claims could provide critical early insight on changing disease patterns or allow for monitoring of short term changes in care patterns, including responses to policy changes. To track critical information from hospital claims, it can take up to a year for the accrual of all the final claims for a particular period [6]

Methods

Results

Conclusion