30-day Risk-adjusted Readmission Rates Research Articles

Interventional analytics in skilled nursing facilities associated with reduced readmissions.

To assess differences in longitudinal profiles for 30-day risk-adjusted readmission rates in skilled nursing facilities (SNFs) associated with Penn Medicine's Lancaster General Hospital (LGH) that implemented an interventional analytics (IA) platform vs other LGH facilities lacking IA vs other SNFs in Pennsylvania vs facilities in all other states. Retrospective longitudinal analysis of CMS readmissions data from 2017 through 2022, and cross-sectional analysis using CMS quality metrics data. CMS SNF quality performance data were aggregated and compared with risk-adjusted readmissions by facility and time period. Each SNF was assigned to a cohort based on location, referral relationship with LGH, and whether it had implemented IA. Multivariable mixed effects modeling was used to compare readmissions by cohort, whereas quality measures from the fourth quarter of 2022 were compared descriptively. LGH profiles differed significantly from both state and national profiles, with LGH facilities leveraging IA demonstrating an even greater divergence. In the most recent 12 months ending in the fourth quarter of 2022, LGH SNFs with IA had estimated readmission rates that were 15.24, 12.30, and 13.06 percentage points lower than the LGH SNFs without IA, Pennsylvania, and national cohorts, respectively (all pairwise P < .0001). SNFs with IA also demonstrated superior CMS claims-based quality metric outcomes for the 12 months ending in the fourth quarter of 2022. SNFs implementing the studied IA platform demonstrated statistically and clinically significant superior risk-adjusted readmission rate profiles compared with peers nationally, statewide, and within the same SNF referral network (P < .0001). A more detailed study on the use of IA in this setting is warranted.

Annual Variation in 30-Day Risk-Adjusted Readmission Rates in U.S. Children's Hospitals.

Reducing pediatric readmissions has become a national priority; however, the use of readmission rates as a quality metric remains controversial. The goal of this study was to examine short-term stability and long-term changes in hospital readmission rates. Data from the Pediatric Health Information System were used to compare annual 30-day risk-adjusted readmission rates (RARRs) in 47 US children's hospitals from 2016 to 2017 (short-term) and 2016 to 2019 (long-term). Pearson correlation coefficients and weighted Cohen's Kappa statistics were used to measure correlation and agreement across years for hospital-level RARRs and performance quartiles. Median (IQR) 30-day RARRs remained stable from 7.7% (7.0-8.3) in 2016 to 7.6% (7.0-8.1) in 2019. Individual hospital RARRs in 2016 were strongly correlated with the same hospital's 2017 rate (R2=0.89 [95% confidence interval (CI) 0.80-0.94]) and moderately correlated with those in 2019 (R2=0.49 [95%CI 0.23-0.68]). Short-term RARRs (2016 vs 2017) were more highly correlated for medical conditions than surgical conditions, but correlations between long-term medical and surgical RARRs (2016 vs 2019) were similar. Agreement between RARRs was higher when comparing short-term changes (0.73 [95%CI 0.59-0.86]) than long-term changes (0.45 [95%CI 0.27-0.63]). From 2016 to 2019, RARRs increased by ≥1% in 7 (15%) hospitals and decreased by ≥1% in 6 (13%) hospitals. Only 7 (15%) hospitals experienced reductions in RARRs over the short and long-term. Hospital-level performance on RARRs remained stable with high agreement over the short-term suggesting stability of readmission measures. There was little evidence of sustained improvement in hospital-level performance over multiple years.

Looking Outwards and Inwards to Improve Patient Care Quality and Clinical Outcomes in U.S. Hospitals

Keeping a typical U.S. hospital in mind, we draw support from quality management and lean systems theory to empirically test a framework that links variables looking outwards (supplier relationship management), and inwards (internal lean orientation) to patient care quality and two important hospital clinical outcomes—mortality rate and readmission rate. This integrated framework can help U.S. hospitals identify and solve issues—both internal and external, some of which lie outside their current boundaries, with their supply chain partners. Contrary to our expectations, we do not find support for a link between patient care quality and readmission rate; and instead, internal lean orientation is positively associated with the mortality rate for a hospital. We offer plausible explanations and conclude with broader implications of our research for both health care research and practice. KEYWORDS: Supplier relationship management; internal lean orientation; patient care quality; 30-day risk-adjusted mortality rate (RAMR); 30-day risk-adjusted readmission rate (RARR); hospital clinical outcomes

Factors Associated With Disparities in Hospital Readmission Rates Among US Adults Dually Eligible for Medicare and Medicaid

Low-income older adults who are dually eligible (DE) for Medicare and Medicaid often experience worse outcomes following hospitalization. Among other federal policies aimed at improving health for DE patients, Medicare has recently begun reporting disparities in within-hospital readmissions. The degree to which disparities for DE patients are owing to differences in community-level factors or, conversely, are amenable to hospital quality improvement, remains heavily debated. To examine the extent to which within-hospital disparities in 30-day readmission rates for DE patients are ameliorated by state- and community-level factors. In this retrospective cohort study, Centers for Medicare & Medicaid Services (CMS) Disparity Methods were used to calculate within-hospital disparities in 30-day risk-adjusted readmission rates for DE vs non-DE patients in US hospitals participating in Medicare. All analyses were performed in February and March 2019. The study included Medicare patients (aged ≥65 years) hospitalized for acute myocardial infarction (AMI), heart failure (HF), or pneumonia in 2014 to 2017. Within-hospital disparities, as measured by the rate difference (RD) in 30-day readmission between DE vs non-DE patients following admission for AMI, HF, or pneumonia; variance across hospitals; and correlation of hospital RDs with and without adjustment for state Medicaid eligibility policies and community-level factors. The final sample included 475 444 patients admitted for AMI, 898 395 for HF, and 1 214 282 for pneumonia, of whom 13.2%, 17.4%, and 23.0% were DE patients, respectively. Dually eligible patients had higher 30-day readmission rates relative to non-DE patients (RD >0) in 99.0% (AMI), 99.4% (HF), and 97.5% (pneumonia) of US hospitals. Across hospitals, the mean (IQR) RD between DE vs non-DE was 1.00% (0.87%-1.10%) for AMI, 0.82% (0.73%-0.96%) for HF, and 0.53% (0.37%-0.71%) for pneumonia. The mean (IQR) RD after adjustment for community-level factors was 0.87% (0.73%-0.97%) for AMI, 0.67% (0.57%-0.80%) for HF, and 0.42% (0.29%-0.57%) for pneumonia. Relative hospital rankings of corresponding within-hospital disparities before and after community-level adjustment were highly correlated (Pearson coefficient, 0.98). In this cohort study, within-hospital disparities in 30-day readmission for DE patients were modestly associated with differences in state Medicaid policies and community-level factors. This suggests that remaining variation in these disparities should be the focus of hospital efforts to improve the quality of care transitions at discharge for DE patients in efforts to advance equity.

Reducing Length of Stay is not Associated with Increased Readmission Rates Following Lower Extremity Arterial Bypass

Objective: &#x0D; Traditional fee-for-service reimbursement models for medical services have been increasingly replaced with the merit-based and efficiency-driven pay-for-performance initiatives. Financial incentives to decrease expenditures have added pressure on hospitals and providers to reduce length of stay (LOS). Concern has been raised that this strategy may unwittingly increase readmission rates. We sought to better understand potential trade-offs between these two outcome measures for hospitals performing lower extremity arterial bypass (LEAB). &#x0D; Methods: &#x0D; We performed a retrospective observational cohort study of 479,366 Medicare beneficiaries undergoing LEAB in 1,708 hospitals from 2005-2009. Using LOS quintiles and a multiple logistic regression model, we generated risk-adjusted readmission rates (RARR) accounting for age, gender, pre-existing comorbidities, non-elective admission status, post-operative complications, and discharge destination. We then compared RARRs across LOS quintiles. Finally, we evaluated the association between hospital LOS on readmissions performance after adjusting for hospital volume, location, teaching status, bed size, and non-home discharges. &#x0D; Results: &#x0D; The mean hospital 30-day RARR was 14.5% (SD 3.5%) and the median LOS 4 days (range 3-6 days). Hospitals with the shortest median LOS (2.3 days) had slightly lower readmission rates compared to those with the highest median LOS (9.2 days) (13.3% vs 15.8%, p &lt;0.001). The Spearman correlation coefficient was 0.15 (p &lt; 0.001), indicating a very weak correlation between LOS and RARR. &#x0D; Conclusion and Potential Implications: &#x0D; At the hospital-level, there appears to be little tradeoff between LOS and RARR, implying these outcomes measure different domains of hospital quality and can be used as indicators of care quality and the likelihood for post-discharge adverse events. As it is possible for hospitals to perform well on both measures, pay-for-performance initiatives may consider incentivizing reducing LOS and readmissions.

Temporal Trends in Racial Differences in 30-Day Readmission and Mortality Rates After Acute Myocardial Infarction Among Medicare Beneficiaries

The association of the Hospital Readmission Reduction Program (HRRP) with reductions in racial disparities in 30-day outcomes for myocardial infarction (MI), is unknown, including whether this varies by HRRP hospital penalty status. To assess temporal trends in 30-day readmission and mortality rates among black and nonblack patients discharged after hospitalization for acute MI at low-performing and high-performing hospitals, as defined by readmission penalty status after HRRP implementation. This observational cohort analysis used data from the multicenter National Cardiovascular Data Registry Chest Pain-MI Registry centers that were subject to the first cycle of HRRP, between January 1, 2008, and November 30, 2016. All patients hospitalized with MI who were included in National Cardiovascular Data Registry Chest Pain-MI Registry were included in the analysis. Data were analyzed from April 2018 to September 2019. Hospital performance category and race (black compared with nonblack patients). Centers were classified as high performing or low performing based on the excess readmission ratio (predicted to expected 30-day risk adjusted readmission rate) for MI during the first HRRP cycle (in October 2012). Thirty-day all-cause readmission and mortality rates. Among 753 hospitals that treated 155 397 patients with acute MI (of whom 11 280 [7.3%] were black), 399 hospitals (53.0%) were high performing. Thirty-day readmission rates declined over time in both black and nonblack patients (annualized 30-day readmission rate: 17.9% vs 20.8%). Black (compared with nonblack) race was associated with higher unadjusted odds of 30-day readmission in both low-performing and high-performing centers (odds ratios: before HRRP: low-performing hospitals, 1.14 [95% CI, 1.03-1.26]; P = .01; high-performing hospitals, 1.17 [95% CI, 1.04-1.32]; P = .01; after HRRP: low-performing hospitals, 1.23 [95% CI, 1.13-1.34]; P < .001; high-performing hospitals, 1.25 [95% CI, 1.12-1.39]; P < .001). However, these racial differences were not significant after adjustment for patient characteristics. The 30-day mortality rates declined significantly over time in nonblack patients, with stable (nonsignificant) temporal trends among black patients. Adjusted associations between race and 30-day mortality showed that 30-day mortality rates were significantly lower among black (compared with nonblack) patients in the low-performing hospitals (odds ratios: pre-HRRP, 0.79 [95% CI, 0.63-0.97]; P = .03; post-HRRP, 0.80 [95% CI, 0.68-0.95]; P = .01) but not in high-performing hospitals. Finally, the association between race and 30-day outcomes did not vary after the HRRP period began in either high-performing or low-performing hospitals. In this analysis, 30-day readmission rates among patients with MI declined over time for both black and nonblack patients. Differences in race-specific 30-day readmission rates persisted but appeared to be attributable to patient-level factors. The 30-day mortality rates have declined for nonblack patients and remained stable among black patients. Implementation of the HRRP was not associated with improvement or worsening of racial disparities in readmission and mortality rates.

Association Between Hospital Participation in Medicare Shared Savings Program Accountable Care Organizations and Readmission Following Major Surgery.

To evaluate the effect of Medicare Shared Savings Program accountable care organizations (ACOs) on hospital readmission after common surgical procedures. Hospital readmissions following surgery lead to worse patient outcomes and wasteful spending. ACOs, and their associated hospitals, have strong incentives to reduce readmissions from 2 distinct Centers for Medicare and Medicaid Services policies. We performed a retrospective cohort study using a 20% national Medicare sample to identify beneficiaries undergoing 1 of 7 common surgical procedures-abdominal aortic aneurysm repair, colectomy, cystectomy, prostatectomy, lung resection, total knee arthroplasty, and total hip arthroplasty-between 2010 and 2014. The primary outcome was 30-day risk-adjusted readmission rate. We performed difference-in-differences analyses using multilevel logistic regression models to quantify the effect of hospital ACO affiliation on readmissions following these procedures. Patients underwent a procedure at one of 2974 hospitals, of which 389 were ACO affiliated. The 30-day risk-adjusted readmission rate decreased from 8.4% (95% CI, 8.1-8.7%) to 7.0% (95% CI, 6.7-7.3%) for ACO affiliated hospitals (P < 0.001) and from 7.9% (95% CI, 7.8-8.0%) to 7.1% (95% CI, 6.9-7.2%) for non-ACO hospitals (P < 0.001). The difference-in-differences of the 2 trends demonstrated an additional 0.52% (95% CI, 0.97-0.078%) absolute reduction in readmissions at ACO hospitals (P = 0.021), which would translate to 4410 hospitalizations avoided. Readmissions following common procedures decreased significantly from 2010 to 2014. Hospital affiliation with Shared Savings ACOs was associated with significant additional reductions in readmissions. This emphasis on readmission reduction is 1 mechanism through which ACOs improve value in a surgical population.

Reduction in Hospitals' Readmission Rates: Role of Hospital-Based Skilled Nursing Facilities.

Hospital readmission within 30 days of discharge is an important quality measure given that it represents a potentially preventable adverse outcome. Approximately, 20% of Medicare beneficiaries are readmitted within 30 days of discharge. Many strategies such as the hospital readmission reduction program have been proposed and implemented to reduce readmission rates. Prior research has shown that coordination of care could play a significant role in lowering readmissions. Although having a hospital-based skilled nursing facility (HBSNF) in a hospital could help in improving care for patients needing short-term skilled nursing or rehabilitation services, little is known about HBSNFs’ association with hospitals’ readmission rates. This study seeks to examine the association between HBSNFs and hospitals’ readmission rates. Data sources included 2007-2012 American Hospital Association Annual Survey, Area Health Resources Files, the Centers for Medicare and Medicaid Services (CMS) Medicare cost reports, and CMS Hospital Compare. The dependent variables were 30-day risk-adjusted readmission rates for acute myocardial infarction (AMI), congestive heart failure, and pneumonia. The independent variable was the presence of HBSNF in a hospital (1 = yes, 0 = no). Control variables included organizational and market factors that could affect hospitals’ readmission rates. Data were analyzed using generalized estimating equation (GEE) models with state and year fixed effects and standard errors corrected for clustering of hospitals over time. Propensity score weights were used to control for potential selection bias of hospitals having a skilled nursing facility (SNF). GEE models showed that the presence of HBSNFs was associated with lower readmission rates for AMI and pneumonia. Moreover, higher SNFs to hospitals ratio in the county were associated with lower readmission rates. These findings can inform policy makers and hospital administrators in evaluating HBSNFs as a potential strategy to lower hospitals’ readmission rates.

Unintended Consequences of Hospital Regulation: The Case of the Hospital Readmissions Reduction Program

This paper examines the impact of the Hospital Readmissions Reduction Program (HRRP) on hospitals' admission decisions. HRRP provides incentives for hospitals to reduce readmissions by imposing penalties to hospitals that exhibited higher than average 30-day risk-adjusted readmission rates. Indeed, after HRRP was introduced in 2012, readmission rates have fallen by 1.2% on average across monitored conditions. In this paper, we show that part of this reduction may be due to hospitals admitting more patients for observation as opposed to inpatient admission. Under this classification, patients receive hospital-level care but do not count towards admissions for HRRP purposes. To show that this is the case, we combine four hospital-level datasets. We exploit variation in hospitals' financial exposure to HRRP due to: i) readmission performance relative to national average; and ii) financial constraints. We find that hospitals exposed to HRRP penalties increased observation bed usage by 16.9% more compared to non-penalized hospitals, and by as much as 40.6% if they were also financially constrained. A back-of-the-envelope calculation suggests that if just 10% of the change in observation admissions was done to avoid readmissions, the observed reduction in readmissions following HRRP would be 21% smaller than reported. Furthermore, if hospitals are indeed using observation admissions to avoid readmissions then one would expect that post-HRRP readmissions of patients originally discharged from the same hospital would have decreased at a higher rate compared to readmissions to hospitals other than the discharging hospital. Using a detailed patient-level dataset, we confirm that this is indeed the case.

Patients\u2019 perceptions of interactions with hospital staff are associated with hospital readmissions: a national survey of 4535 hospitals

BackgroundReducing 30-day hospital readmissions has become a focus of the current national payment policies. Medicare requires that hospitals collect and report patients’ experience with their care as a condition of payment. However, the extent to which patients’ experience with hospital care is related to hospital readmission is unknown.MethodsWe established multivariate regression models in which 30-day risk-adjusted readmission rates were the dependent variables and patients’ perceptions of the responsiveness of the hospital staff and communication (as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores) were the independent variables of interest. We selected six different clinical conditions for analyses, including acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), heart failure, hip/knee surgery, pneumonia, and stroke. Data included all acute care hospitals reporting in Hospital Compare in 2014.ResultsThe number of hospitals with reported readmissions ranged from 2234 hospitals for AMI to 3758 hospitals for pneumonia. The average 30-day readmission rates ranged from 5.19% for knee/hip surgery to 22.7% for COPD. Patient experience of hospital-staff responsiveness as “top-box” ranged from 64% to 67% across the six clinical conditions, communication with nurses ranged from 77% to 79% and communication with doctors ranged from 80% to 81% (higher numbers are better). Our finding suggests that hospitals with better staff responsiveness were significantly more likely to have lower 30-day readmissions for all conditions. The effect size depended on the baseline readmission rates, with the largest effect on hospitals in the upper 75th quartile. A ten-percentage-point increase in staff responsiveness led to a 0.03–0.18 percentage point decrease in readmission rates. We found that neither communication with physicians nor communication with nurses was significantly associated with hospital readmissions.ConclusionsOur findings suggest that elements of care related to staff responsiveness during patients’ stay may influence rehospitalization rates. Changes in staff responsiveness may offer an additional tool for hospitals to employ ongoing efforts to achieve reductions in readmissions, an important objective both financially and for patient health outcomes.

Association of the Hospital Readmissions Reduction Program Implementation With Readmission and Mortality Outcomes in Heart Failure

Public reporting of hospitals' 30-day risk-standardized readmission rates following heart failure hospitalization and the financial penalization of hospitals with higher rates have been associated with a reduction in 30-day readmissions but have raised concerns regarding the potential for unintended consequences. To examine the association of the Hospital Readmissions Reduction Program (HRRP) with readmission and mortality outcomes among patients hospitalized with heart failure within a prospective clinical registry that allows for detailed risk adjustment. Interrupted time-series and survival analyses of index heart failure hospitalizations were conducted from January 1, 2006, to December 31, 2014. This study included 115 245 fee-for-service Medicare beneficiaries across 416 US hospital sites participating in the American Heart Association Get With The Guidelines-Heart Failure registry. Data analysis took place from January 1, 2017, to June 8, 2017. Time intervals related to the HRRP were before the HRRP implementation (January 1, 2006, to March 31, 2010), during the HRRP implementation (April 1, 2010, to September 30, 2012), and after the HRRP penalties went into effect (October 1, 2012, to December 31, 2014). Risk-adjusted 30-day and 1-year all-cause readmission and mortality rates. The mean (SD) age of the study population (n = 115 245) was 80.5 (8.4) years, 62 927 (54.6%) were women, and 91 996 (81.3%) were white and 11 037 (9.7%) were black. The 30-day risk-adjusted readmission rate declined from 20.0% before the HRRP implementation to 18.4% in the HRRP penalties phase (hazard ratio (HR) after vs before the HRRP implementation, 0.91; 95% CI, 0.87-0.95; P < .001). In contrast, the 30-day risk-adjusted mortality rate increased from 7.2% before the HRRP implementation to 8.6% in the HRRP penalties phase (HR after vs before the HRRP implementation, 1.18; 95% CI, 1.10-1.27; P < .001). The 1-year risk-adjusted readmission and mortality rates followed a similar pattern as the 30-day outcomes. The 1-year risk-adjusted readmission rate declined from 57.2% to 56.3% (HR, 0.92; 95% CI, 0.89-0.96; P < .001), and the 1-year risk-adjusted mortality rate increased from 31.3% to 36.3% (HR, 1.10; 95% CI, 1.06-1.14; P < .001) after vs before the HRRP implementation. Among fee-for-service Medicare beneficiaries discharged after heart failure hospitalizations, implementation of the HRRP was temporally associated with a reduction in 30-day and 1-year readmissions but an increase in 30-day and 1-year mortality. If confirmed, this finding may require reconsideration of the HRRP in heart failure.

Abstract 136: The Relationship of Changing Hospital Readmission Rates and Mortality Rates After Hospitalization for Heart Failure, Acute Myocardial Infarction, and Pneumonia

Background: It is unknown if financial pressures to reduce hospital readmission rates following passage of the Affordable Care Act (ACA) have had the unintended effect of increasing mortality rates after hospitalization. We therefore examined correlations between paired changes in hospital 30-day readmission rates and 30-day mortality rates among Medicare fee-for-service beneficiaries hospitalized with heart failure (HF), acute myocardial infarction (AMI), or pneumonia from 2008 to 2014. Methods: We used linear regression to calculate monthly changes in hospitals’ 30-day risk-adjusted readmission rates (RARRs) and 30-day risk-adjusted mortality rates (RAMRs) after discharge for HF, AMI, and pneumonia from 2008 to 2014. Adjustment was made for patient age, sex, comorbidities, hospital length of stay, and season. We then examined the correlation of hospitals’ paired monthly changes in 30-day RARRs and monthly changes in 30-day RAMRs after discharge. Results: From 2008 to 2014, we identified 2,962,554, 1,229,939, and 2,544,530 hospitalizations for HF, AMI, and pneumonia at 5,016, 4,772, and 5,057 hospitals, respectively. Hospital 30-day RARRs declined for all three conditions from 2008 to 2014; the monthly change in RARRs was -0.053 (95% CI -0.055, -0.051) for HF, -0.044 (95% CI -0.047, -0.041) for AMI, and -0.033 (95% CI -0.035, -0.031) for pneumonia. In contrast, the monthly change in hospital 30-day RAMRs after discharge varied by admitting condition and was 0.008 (95% CI 0.007, 0.010) for HF, -0.003 (95% CI -0.006, -0.001) for AMI, and 0.001 (95% CI -0.001, 0.003) for pneumonia. The correlation between monthly changes in hospitals’ 30-day RARRs and 30-day RAMRs after discharge was 0.060 for HF (p&lt;0.001), 0.059 for AMI (p=0.003), and 0.106 for pneumonia (p&lt;0.001). Representative data showing the poor correlation in hospitals’ paired monthly changes in 30-day RARRs and 30-day RAMRs for AMI is shown in the Figure. Conclusion: Changes in hospital readmission rates for HF, AMI, and pneumonia were poorly correlated with changes in mortality rates after hospitalization between 2008 and 2014. These findings suggest that financial incentives to improve hospitals’ readmission performance have not increased mortality after hospitalization.

Hospital Readmissions after Surgery: How Important Are Hospital and Specialty Factors?

Hospital readmission rates after surgery can represent an overall hospital effect or a combination of specialty and patient effects. We hypothesized that hospital readmission rates for procedures within specialties were more strongly correlated than rates across specialties within the same hospital. For general, orthopaedic, and vascular specialties at Veterans Affairs hospitals during 2008 to 2014, 30-day risk-adjusted readmission rates were estimated for 6 high-volume procedures and each specialty. Relationships were assessed using the Pearson correlation coefficient. At 84 hospitals, 64,724 orthopaedic, 24,963 general, and 10,399 vascular inpatient procedures were performed; mean readmission rates were 6.3%, 13.6%, and 16.4%, respectively. There was no correlation between specialty-specific adjusted hospital readmission rates: general and orthopaedic (r= 0.21; p= 0.06), general and vascular (r= 0.15; p= 0.19), and vascular and orthopaedic surgery (r= 0.07; p= 0.55). Within specialties, we found modest correlations between knee and hip arthroplasty readmission rates (r= 0.39; p < 0.01) and colectomy and ventral hernia repair (r= 0.24; p= 0.03), but not between lower-extremity bypass and endovascular aortic repair (r= 0.13; p= 0.26). Overall, controlling for patient-level factors, 1.9% of the variation in readmissions was attributable to specialty-level factors; only 0.6% was attributable to hospital-level factors. Hospital readmission rates for orthopaedic, vascular, and general surgery were not correlated between specialties; within each of the 3 specialties, modest correlations were found between 2 procedures within 2 of these specialties. These findings suggest that hospital surgical readmission rates are primarily explained by patient- and procedure-specific factors and less by broader specialty and/or hospital effects.

Trends in 30-Day Readmission Rates for Patients Hospitalized With Heart Failure: Findings From the Get With The Guidelines-Heart Failure Registry.

Reducing hospital readmissions for patients with heart failure is a national priority, and quality improvement campaigns are targeting reductions of ≥20%. However, there are limited data on whether such targets have been met. We analyzed data from the American Heart Association's Get With The Guidelines-Heart Failure registry linked to Medicare claims between 2009 and 2012 to describe trends and relative reduction of rates of 30-day all-cause readmission among patients with heart failure. A total of 21,264 patients with heart failure were included from 70 US sites from January 2009 to October 2012. Overall hospital-level, risk-adjusted, 30-day all-cause readmission rates declined slightly, from 20.0% (SD, 1.3%) in 2009 to 19.0% (SD, 1.2%) in 2012 (P=0.001). Only 1 in 70 (1.4%) hospitals achieved the 20% relative reduction in 30-day risk-adjusted readmission rates. A multivariable linear regression model was used to determine hospital-level factors associated with relative improvements in 30-day risk-adjusted readmissions between 2009 and 2012. Teaching hospitals had higher relative readmission rates as compared with their peers, and hospitals that used postdischarge heart failure disease management programs had lower relative readmission rates. Although there has been slight improvement in 30-day all-cause readmission rates during the past 4 years in patients with heart failure, few hospitals have seen large success.

Abstract 371: Proportion of Readmissions to Non-Index Hospitals is Associated with All-Cause Risk-Adjusted Readmission Rate for Medicare Patients with AMI and CHF

Background: The Affordable Care Act introduced the Hospital Readmissions Reduction Program (HRRP), implementing financial penalties for hospitals with excess risk-standardized readmission rates (RSRRs) for specific diagnoses including congestive heart failure (CHF) and acute myocardial infarction (AMI). Hospitals may have more ability to reduce readmission rates for readmissions at their own hospitals as opposed to other hospitals. We hypothesize that hospitals with higher proportions of patients re-admitted to a different (“non index”) hospital also have higher all-cause 30-day RSRRs. Methods: We used a national sample of Medicare data to identify hospitalizations for CHF and AMI and subsequent all-cause 30-day readmissions using data from 5,291 hospitals for the period 1999 to 2010. For each hospital we calculated the proportion of readmissions at a different (“non-index”) hospital and the all-cause 30-day risk-adjusted readmission rate (RSRR). We then fitted a regression model to estimate the relationship between the proportion of admissions to the non-index hospital and all-cause RSRRs across hospitals. Results: We identified 2,863,696 discharges for AMI and 6,981,895 discharged for CHF for the period 1999 to 2010. On average across hospitals, the percentage of readmissions to non-index hospitals was 28.0% (SD 25.4%) for AMI and 22.7% (SD 17.8%) for CHF. Hospitals with higher RSRRs had higher percentages of their readmissions occurring at a different hospital for both AMI and CHF (p &lt; 0.001 for both conditions). Due to this association, hospitals in the highest decile for 30-day RSRR had 29.1% and 20.7% of readmissions occur at non-index hospitals for AMI and CHF, respectively, while the corresponding proportions for hospitals in the lowest decile were 19.1% and 18.4%. Conclusions: Compared to high performing hospitals, hospitals with the worst 30-day readmission rates for AMI and CHF also have the highest percentage of those readmissions occurring at hospitals other than their own. The relationship was particularly strong for AMI. These results suggest that the proportion of readmissions to other hospitals might be a structural disadvantage associated with higher readmission rates.

The association between skilled nursing facility care quality and 30-day readmission rates after hospitalization for heart failure.

The objective of the study was to assess the association between care quality of skilled nursing facilities (SNFs) and 30-day risk-adjusted readmission rate (RAR) for patients with acute decompensated heart failure (ADHF). A retrospective cohort study was conducted involving 603 discharges from a tertiary care hospital to 17 SNFs after hospitalization for ADHF. SNF quality was assessed based on the CMS 5-star quality rating and a survey of SNF characteristics and processes of care. In all, 20% of cases were readmitted within 30-days; 9.4% were for ADHF. The all-cause RARs for higher- and lower-quality SNFs were 18% (95% confidence interval [CI]=14%-23%) and 22% (95% CI=17%-26%), respectively, and the ADHF RARs were 8.8% (95% CI=6.0%-11.6%) and 10.2% (95% CI=7.0%-12.9%), respectively. There were no significant associations between ADHF RARs and individual processes of care or structural characteristics. Quality ratings of SNF or processes of care did not correlate with RAR.

Circulation: Heart Failure Editors’ Picks

Summary: Medicare’s introduction of public reporting and value-based purchasing centered on 30-day risk-adjusted readmission rates after hospital discharge for heart failure (HF) has helped to heighten interest among state governments and commercial payers in HF readmissions. As all potentially avoidable HF readmissions represent an opportunity to improve healthcare quality and efficiency, understanding the rates and predictors in non-Medicare populations is important. This is particularly true among patients with systolic dysfunction, for whom most HF-specific therapies are targeted. Using claims-based administrative data, we evaluated 1198 Medicaid and 3350 commercially insured unique systolic HF index admissions. All patients were <65 years of age, with a mean age of 55 years. Unadjusted all-cause 30-day readmission rates were 17.4% for Medicaid enrollees and 11.8% for commercially insured patients. After adjustment for differences in case mix, the odds of all-cause readmission were 32% higher among Medicaid than commercially insured patients, and 68% higher when only HF-related readmissions were considered. No significant differences in readmission rates were seen for managed care versus fee-for-service or capitated versus noncapitated plan types. These results suggest that socioeconomically disadvantaged populations, as indicated by Medicaid insurer status, represent a high-risk population potentially warranting specific interventions. Conclusions: Compared with commonly cited Medicare HF readmission rates of 20% to 25%, Medicaid patients with systolic HF had lower 30-day readmission rates, and commercially insured patients had even lower rates. Even after adjustment for case mix, Medicaid patients were more likely to be readmitted than commercially insured patients, suggesting that more attention should be focused on readmissions among socioeconomically disadvantaged populations.1 Summary: Hospital readmissions for heart failure (HF) contribute to increased morbidity and resource burden. However, the predictors of hospitalization and patterns of cardiovascular events during the lifetime of patients with HF have not been elucidated. In this study, the authors examined recurrent hospitalizations, …

Abstract 225B: Nursing Home Care Quality and 30-Day Readmission Rates for patients with Heart Failure

Background: Acute decompensated heart failure (ADHF) is one of the most frequent cause for hospitalization in the United States but little is known about how the quality of care provided by the skilled nursing facilities (SNFs) influences readmission rates. Objectives: 1)To determine the association between care quality reported on Medicare's Nursing Home Compare website and 30-day risk-adjusted readmission rate (RAR) for ADHF. 2) To assess the correlation of processes of care and characteristics of SNFs with 30-day RAR. Methods: Retrospective cohort study at Baystate Medical Center, a 659-bed tertiary care hospital. Subjects: Patients aged ≥18 years discharged to 17 local SNFs after hospitalization for ADHF from November 2008 to October 2011. SNF quality of care was assessed based on the quality rating (health inspection, quality measures and staff rating) obtained from www.medicare.gov/NHCompare (range 1 to 5 stars). Based on the distribution of quality ratings, SNFs with only 1 star were considered lower quality. A telephone survey about SNF characteristics (e.g. physician hours, number of beds, licensed nurse's minutes) and processes of care (e.g. telemonitoring capability, onsite IV lasix, Heart failure (HF) treatment protocol) was completed by each director of nursing. RAR's were calculated using a mixed-effects logistic regression model adjusting for demographics, comorbidities and clinical characteristics of the patients. Results: Of the 605 discharges (491 patients), 121 were readmitted within 30-days, 57 were ADHF related; 64% were female, 86% white and median age was 84 years (interquartile range 13). Nearly all (99%) patients had Medicare or Medicaid. At discharge, 37% had ejection fraction &lt;40% and 60% had at least one high-risk comorbidity (e.g. coronary artery disease, hypertension, atrial fibrillation). Higher quality SNFs (58%) were more likely to be non-profit and had more beds. The 30-day all-cause RAR was 19% (95% CI 14 -23) and 22% (95% CI 17 - 26) and the 30-day ADHF RAR was 9% (95% CI 6 -11.6) and 10% (95% CI 7 - 12.9) for higher and lower quality SNF's respectively. Both all-cause and ADHF RARs declined significantly between 2008- 2011 (P=0.02, χ2 test of trend). Although RAR were slightly lower in higher quality SNFs, these differences were not statistically significant in either adjusted or unadjusted models. Higher SNF staff ratings was marginally correlated with lower readmission rates (Spearmean R = - 0.39, p = 0.05). Self-reported processes of care (e.g. telemonitoring capability, weight graph), as well as SNF care structure (e.g. physician hours) did not correlate with RAR. Conclusions: Overall Quality rating reported on www.medicare.gov/NHCompare, as well as processes of care performed by SNFs were not associated with RARs for patients with Heart failure. Higher staff ratings correlated with lower RAR.

30-day mortality and readmission after hemorrhagic stroke among Medicare beneficiaries in Joint Commission primary stroke center-certified and noncertified hospitals.

Ischemic stroke patients treated at Joint Commission Primary Stroke Center (JC-PSC)-certified hospitals have better outcomes. Data reflecting the impact of JC-PSC status on outcomes after hemorrhagic stroke are limited. We determined whether 30-day mortality and readmission rates after hemorrhagic stroke differed for patients treated at JC-PSC-certified versus noncertified hospitals. The study included all fee-for-service Medicare beneficiaries aged 65 years or older with a primary discharge diagnosis of subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH) in 2006. Covariate-adjusted logistic and Cox proportional hazards regression assessed the effect of care at a JC-PSC-certified hospital on 30-day mortality and readmission. There were 2305 SAH and 8708 ICH discharges from JC-PSC-certified hospitals and 3892 SAH and 22 564 ICH discharges from noncertified hospitals. Unadjusted in-hospital mortality (SAH: 27.5% versus 33.2%, P<0.0001; ICH: 27.9% versus 29.6%, P=0.003) and 30-day mortality (SAH: 35.1% versus 44.0%, P<0.0001; ICH: 39.8% versus 42.4%, P<0.0001) were lower in JC-PSC hospitals, but 30-day readmission rates were similar (SAH: 17.0% versus 17.0%, P=0.97; ICH: 16.0% versus 15.5%, P=0.29). Risk-adjusted 30-day mortality was 34% lower (odds ratio, 0.66; 95% confidence interval, 0.58-0.76) after SAH and 14% lower (odds ratio, 0.86; 95% confidence interval, 0.80-0.92) after ICH for patients discharged from JC-PSC-certified hospitals. There was no difference in 30-day risk-adjusted readmission rates for SAH or ICH based on JC-PSC status. Patients treated at JC-PSC-certified hospitals had lower risk-adjusted mortality rates for both SAH and ICH but similar 30-day readmission rates as compared with noncertified hospitals.