Hospital-Readmission Risk - Isolating Hospital Effects from Patient Effects.

BACKGROUND: To isolate hospital effects on risk-standardized hospital-readmission rates, we examined readmission outcomes among patients who had multiple admissions for a similar diagnosis at more than one hospital within a given year. METHODS: We divided the Centers for Medicare and Medicaid Services hospital-wide readmission measure cohort from July 2014 through June 2015 into two random samples. All the patients in the cohort were Medicare recipients who were at least 65 years of age. We used the first sample to calculate the risk-standardized readmission rate within 30 days for each hospital, and we classified hospitals into performance quartiles, with a lower readmission rate indicating better performance (performance-classification sample). The study sample (identified from the second sample) included patients who had two admissions for similar diagnoses at different hospitals that occurred more than 1 month and less than 1 year apart, and we compared the observed readmission rates among patients who had been admitted to hospitals in different performance quartiles. RESULTS: In the performance-classification sample, the median risk-standardized readmission rate was 15.5% (interquartile range, 15.3 to 15.8). The study sample included 37,508 patients who had two admissions for similar diagnoses at a total of 4272 different hospitals. The observed readmission rate was consistently higher among patients admitted to hospitals in a worse-performing quartile than among those admitted to hospitals in a better-performing quartile, but the only significant difference was observed when the patients were admitted to hospitals in which one was in the best-performing quartile and the other was in the worst-performing quartile (absolute difference in readmission rate, 2.0 percentage points; 95% confidence interval, 0.4 to 3.5; P=0.001). CONCLUSIONS: When the same patients were admitted with similar diagnoses to hospitals in the best-performing quartile as compared with the worst-performing quartile of hospital readmission performance, there was a significant difference in rates of readmission within 30 days. The findings suggest that hospital quality contributes in part to readmission rates independent of factors involving patients. (Funded by Yale-New Haven Hospital Center for Outcomes Research and Evaluation and others.).

Modeling defibrillation benefit for survival among cardiac resynchronization therapy defibrillator recipients.

BACKGROUND: Patients with heart failure having a low expected probability of arrhythmic death may not benefit from implantable cardioverter defibrillators (ICDs). OBJECTIVE: The objective was to validate models to identify cardiac resynchronization therapy (CRT) candidates who may not require CRT devices with ICD functionality. METHODS: Heart failure (HF) patients with CRT-Ds and non-CRT ICDs from the National Cardiovascular Data Registry and others with no device from 3 separate registries and 3 heart failure trials were analyzed using multivariable Cox proportional hazards regression for survival with the Seattle Heart Failure Model (SHFM; estimates overall mortality) and the Seattle Proportional Risk Model (SPRM; estimates proportional risk of arrhythmic death). RESULTS: Among 60,185 patients (age 68.6 ±â€¯11.3 years, 31.9% female) meeting CRT-D criteria, 38,348 had CRT-Ds, 11,389 had non-CRT ICDs, and 10,448 had no device. CRT-D patients had a prominent adjusted survival benefit (HR 0.52, 95% CI 0.50-0.55, P < .0001 versus no device). CRT-D patients with SHFM-predicted 4-year survival ≥81% (median) and a low SPRM-predicted probability of an arrhythmic mode of death ≤42% (median) had an absolute adjusted risk reduction attributable to ICD functionality of just 0.95%/year with the majority of survival benefit (70%) attributable to CRT pacing. In contrast, CRT-D patients with SHFM-predicted survival median had substantially more ICD-attributable benefit (absolute risk reduction of 2.6%/year combined; P < .0001). CONCLUSIONS: The SPRM and SHFM identified a quarter of real-world, primary prevention CRT-D patients with minimal benefit from ICD functionality. Further studies to evaluate CRT pacemakers in these low-risk CRT candidates are indicated.

Admission diagnoses among patients with heart failure: Variation by ACO performance on a measure of risk-standardized acute admission rates.

BACKGROUND: A key quality metric for Accountable Care Organizations (ACOs) is the rate of hospitalization among patients with heart failure (HF). Among this patient population, non-HF-related hospitalizations account for a substantial proportion of admissions. Understanding the types of admissions and the distribution of admission types across ACOs of varying performance may provide important insights for lowering admission rates. METHODS: We examined admission diagnoses among 220 Medicare Shared Savings Program ACOs in 2013. ACOs were stratified into quartiles by their performance on a measure of unplanned risk-standardized acute admission rates (RSAARs) among patients with HF. Using a previously validated algorithm, we categorized admissions by principal discharge diagnosis into: HF, cardiovascular/non-HF, and noncardiovascular. We compared the mean admission rates by admission type as well as the proportion of admission types across RSAAR quartiles (Q1-Q4). RESULTS: Among 220 ACOs caring for 227,356 patients with HF, the median (IQR) RSAARs per 100 person-years ranged from 64.5 (61.7-67.7) in Q1 (best performers) to 94.0 (90.1-99.9) in Q4 (worst performers). The mean admission rates by admission types for ACOs in Q1 compared with Q4 were as follows: HF admissions: 9.8 (2.2) vs 14.6 (2.8) per 100 person years (P < .0001); cardiovascular/non-HF admissions: 11.1 (1.6) vs 15.9 (2.6) per 100 person-years (P < .0001); and noncardiovascular admissions: 42.7 (5.4) vs 69.6 (11.3) per 100 person-years (P < .0001). The proportion of admission due to HF, cardiovascular/non-HF, and noncardiovascular conditions was 15.4%, 17.5%, and 67.1% in Q1 compared with 14.6%, 15.9%, and 69.4% in Q4 (P < .007). CONCLUSIONS: Although ACOs with the best performance on a measure of all-cause admission rates among people with HF tended to have fewer admissions for HF, cardiovascular/non-HF, and noncardiovascular conditions compared with ACOs with the worst performance (highest admission rates), the largest difference in admission rates were for noncardiovascular admission types. Across all ACOs, two-thirds of admissions of patients with HF were for noncardiovascular causes. These findings suggest that comprehensive approaches are needed to reduce the diverse admission types for which HF patients are at risk.

Association of Income Disparities with Patient-Reported Healthcare Experience.

BACKGROUND: Disparities in health outcome exist among patients according to socioeconomic status. However, little is known regarding the differences in healthcare experiences across the various levels of income of patients. In a nationally representative US adult population, we evaluate the differences in healthcare experiences based on patient level of income. OBJECTIVES: To evaluate the differences in patient healthcare experiences based on level of income. PATIENTS AND METHODS: We identified 68,447 individuals (mean age, 48 ± 18 years; 55% female) representing 176.8 million US adults, who had an established healthcare provider in the 2010-2013 Medical Expenditure Panel Survey cohort. This retrospective study examined the differences in all five patient-reported healthcare experience measures (access to care, provider responsiveness, patient-provider communication, shared decision-making, and patient satisfaction) under the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. We examined the relationship between patient income and their healthcare experience. RESULTS: Overall, 32% of the study participants were high-income earners while 23% had very-low income. Lower income was consistently associated with poor patient report on healthcare experience. Compared with those with high income, very-low-income-earning participants had 1.63 times greater odds (OR 1.63, 95% CI 1.45-1.82) of experiencing difficulty accessing care, had 1.34 times higher odds (OR 1.34, 95% CI 1.25-1.45) of experiencing poor communication, had higher odds (OR 1.68, 95% CI 1.46-1.92) of experiencing delays in healthcare delivery, and were more likely to report poor provider satisfaction (OR 1.48, 95% CI 1.37-1.61). CONCLUSION: Lower income-earning patients have poorer healthcare experience in all aspects of access and quality of care. Targeted policies focusing on improving communication, engagement, and satisfaction are needed to enhance patient healthcare experience for this vulnerable population.

Risk Trajectories of Readmission and Death in the First Year after Hospitalization for Chronic Obstructive Pulmonary Disease.

RATIONALE: Characterization of the dynamic nature of posthospital risk in chronic obstructive pulmonary disease (COPD) is needed to provide counseling and plan clinical services. OBJECTIVES: To analyze risk of readmission and death after discharge for COPD among Medicare beneficiaries aged 65 years and older and to determine the association between ventilator support and risk trajectory. METHODS: We computed daily absolute risks of hospital readmission and death for 1 year after discharge for COPD, stratified by ventilator support. We determined the time required for risks to decline by 50% from maximum daily values after discharge and for daily risks to plateau. We compared risks with those found in the general elderly population. MEASUREMENTS AND MAIN RESULTS: Among 2,340,637 hospitalizations, the readmission rate at 1 year was 64.2%, including 63.5%, 66.0%, and 64.1% among those receiving invasive, noninvasive, and no ventilation, respectively. Among 1,283,069 hospitalizations, mortality at 1 year was 26.2%, including 45.7%, 41.8%, and 24.4% among those same respective groups. Daily risk of readmission declined by 50% within 28, 39, and 43 days and plateaued at 46, 54, and 61 days among those receiving invasive, noninvasive, and no ventilation, respectively. Risk of death declined by 50% by 3, 4, and 17 days and plateaued by 21, 18, and 24 days in the same respective groups. Risks of hospitalization and death were significantly higher after discharge for COPD than among the general Medicare population. CONCLUSIONS: Discharge from the hospital is associated with prolonged risks of readmission and death that vary with need for ventilator support. Interventions limited to the first month after discharge may be insufficient to improve longitudinal outcomes.

Sex Differences in 1-Year All-Cause Rehospitalization in Patients After Acute Myocardial Infarction: A Prospective Observational Study.

BACKGROUND: Compared with men, women are at higher risk of rehospitalization in the first month after discharge for acute myocardial infarction (AMI). However, it is unknown whether this risk extends to the full year and varies by age. Explanatory factors potentially mediating the relationship between sex and rehospitalization remain unexplored and are needed to reduce readmissions. The aim of this study was to assess sex differences and factors associated with 1-year rehospitalization rates after AMI. METHODS: We recruited 3536 patients (33% women) ≥18 years of age hospitalized with AMI from 24 US centers into the TRIUMPH study (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status). Data were obtained by medical record abstraction and patient interviews, and a physician panel adjudicated hospitalizations within the first year after AMI. We compared sex differences in rehospitalization using a Cox proportional hazards model, following sequential adjustment for covariates and testing for an age-sex interaction. RESULTS: One-year crude all-cause rehospitalization rates for women were significantly higher than men after AMI (hazard ratio, 1.29 for women; 95% confidence interval, 1.12-1.48). After adjustment for demographics and clinical factors, women had a persistent 26% higher risk of rehospitalization (hazard ratio, 1.26; 95% confidence interval, 1.08-1.47). However, after adjustment for health status and psychosocial factors (hazard ratio, 1.14; 95% confidence interval, 0.96-1.35), the association was attenuated. No significant age-sex interaction was found for 1-year rehospitalization, suggesting that the increased risk applied to both older and younger women. CONCLUSIONS: Regardless of age, women have a higher risk of rehospitalization compared with men over the first year after AMI. Although the increased risk persisted after adjustment for clinical factors, the poorer health and psychosocial state of women attenuated the difference.

Regional variation in hospitalisation and mortality in heart failure: comparison of England and Lombardy using multistate modelling.

Heart failure (HF) is a common, serious chronic condition with high morbidity, hospitalisation and mortality. The healthcare systems of England and the northern Italian region of Lombardy share important similarities and have comprehensive hospital administrative databases linked to the death register. We used them to compare admission for HF and mortality for patients between 2006 and 2012 (n = 37,185 for Lombardy, 234,719 for England) with multistate models. Despite close similarities in age, sex and common comorbidities of the two sets of patients, in Lombardy, HF admissions were longer and more frequent per patient than in England, but short- and medium-term mortality was much lower. English patients had more very short stays, but their very elderly also had longer stays than their Lombardy counterparts. Using a three-state model, the predicted total time spent in hospital showed large differences between the countries: women in England spent an average of 24 days if aged 65 at first admission and 19 days if aged 85; in Lombardy these figures were 68 and 27 days respectively. Eight-state models suggested disease progression that appeared similar in each country. Differences by region within England were modest, with London patients spending more time in hospital and having lower mortality than the rest of England. Whilst clinical practice differences plausibly explain these patterns, we cannot confidently disentangle the impact of alternatives such as coding, casemix, and the availability and use of non-hospital settings. We need to better understand the links between rehospitalisation frequency and mortality.

Age Differences in Hospital Mortality for Acute Myocardial Infarction: Implications for Hospital Profiling.

BACKGROUND: Publicly reported hospital risk-standardized mortality rates (RSMRs) for acute myocardial infarction (AMI) are calculated for Medicare beneficiaries. Outcomes for older patients with AMI may not reflect general outcomes. OBJECTIVE: To examine the relationship between hospital 30-day RSMRs for older patients (aged ≥65 years) and those for younger patients (aged 18 to 64 years) and all patients (aged ≥18 years) with AMI. DESIGN: Retrospective cohort study. SETTING: 986 hospitals in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry-Get With the Guidelines. PARTICIPANTS: Adults hospitalized for AMI from 1 October 2010 to 30 September 2014. MEASUREMENTS: Hospital 30-day RSMRs were calculated for older, younger, and all patients using an electronic health record measure of AMI mortality endorsed by the National Quality Forum. Hospitals were ranked by their 30-day RSMRs for these 3 age groups, and agreement in rankings was plotted. The correlation in hospital AMI achievement scores for each age group was also calculated using the Hospital Value-Based Purchasing (HVBP) Program method computed with the electronic health record measure. RESULTS: 267 763 and 276 031 AMI hospitalizations among older and younger patients, respectively, were identified. Median hospital 30-day RSMRs were 9.4%, 3.0%, and 6.2% for older, younger, and all patients, respectively. Most top- and bottom-performing hospitals for older patients were neither top nor bottom performers for younger patients. In contrast, most top and bottom performers for older patients were also top and bottom performers for all patients. Similarly, HVBP achievement scores for older patients correlated weakly with those for younger patients (R = 0.30) and strongly with those for all patients (R = 0.92). LIMITATION: Minority of U.S. hospitals. CONCLUSION: Hospital mortality rankings for older patients with AMI inconsistently reflect rankings for younger patients. Incorporation of younger patients into assessment of hospital outcomes would permit further examination of the presence and effect of age-related quality differences. PRIMARY FUNDING SOURCE: American College of Cardiology.

Length of Stay From the Hospital Perspective: Practice of Early Discharge Is Not Associated With Increased Readmission Risk After Lung Cancer Surgery.

OBJECTIVE: To determine if hospitals that routinely discharge patients early after lobectomy have increased readmissions. BACKGROUND: Hospitals are increasingly motivated to reduce length of stay (LOS) after lung cancer surgery, yet it is unclear if a routine of early discharge is associated with increased readmissions. The relationship between hospital discharge practices and readmission rates is therefore of tremendous clinical and financial importance. METHODS: The National Cancer Database was queried for patients undergoing lobectomy for lung cancer from 2004 to 2013 at Commission on Cancer-accredited hospitals, which performed at least 25 lobectomies in a 2-year period. Facility discharge practices were characterized by a facility's median LOS relative to the median LOS for all patients in that same time period. RESULTS: In all, 59,734 patients met inclusion criteria; 2687 (4.5%) experienced an unplanned readmission. In a hierarchical logistic regression model, a routine of early discharge (defined as a facility's tendency to discharge patients faster than the population median in the same time period) was not associated with increased risk of readmission (odds ratio 1.12, 95% confidence interval 0.97-1.28, P = 0.12). In a risk-adjusted hospital readmission rate analysis, hospitals that discharged patients early did not experience more readmissions (P = 0.39). The lack of effect of early discharge practices on readmission rates was observed for both minimally invasive and thoracotomy approaches. CONCLUSIONS: It is possible for hospitals to develop early discharge practices without increasing readmissions. Further study is needed to identify the critical practice elements that have enabled hospitals to aggressively discharge patients without increasing readmission risk.

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

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.