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Hospital Revisits Within 30 Days After Discharge for Medical BMJ: First Published As 10.1136/Bmj.L4563 on 12 August 2019

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Hospital Revisits Within 30 Days After Discharge for Medical BMJ: First Published As 10.1136/Bmj.L4563 on 12 August 2019 RESEARCH Hospital revisits within 30 days after discharge for medical BMJ: first published as 10.1136/bmj.l4563 on 12 August 2019. Downloaded from conditions targeted by the Hospital Readmissions Reduction Program in the United States: national retrospective analysis Rishi K Wadhera,1 Karen E Joynt Maddox,2 Dhruv S Kazi,1 Changyu Shen,1 Robert W Yeh1 1Richard A and Susan F ABSTRACT RESULTS Smith Center for Outcomes OBJECTIVE Our study cohort included 3 038 740 total index Research in Cardiology, Division To determine any changes in total hospital revisits hospital stays from January 2012 to September of Cardiology, Beth Israel Deaconess Medical and Harvard within 30 days of discharge after a hospital stay 2015: 1 357 620 for heart failure, 634 795 for acute Medical School, 185 Pilgrim for medical conditions targeted by the Hospital myocardial infarction, and 1 046 325 for pneumonia. Road, Boston, MA 02215, USA Readmissions Reduction Program (HRRP). Counting all revisits after discharge, the total number 2 Department of Medicine, of hospital revisits per 100 patient discharges for Cardiovascular Division, DESIGN Washington University School of Retrospective cohort study. target conditions increased across the study period Medicine, St Louis, MO, USA (monthly increase 0.023 visits per 100 patient SETTING Correspondence to: discharges (95% confidence interval 0.010 to 0.035)). Hospital stays among Medicare patients for heart R K Wadhera This change was due to monthly increases in treat- [email protected] failure, acute myocardial infarction, or pneumonia and-discharge visits to an emergency department (or @rkwadhera on Twitter; between 1 January 2012 and 1 October 2015. ORCID 0000-0003-1089-3896) (0.023 (0.015 to 0.032) and observation stays (0.022 Additional material is published PARTICIPANTS (0.020 to 0.025)), which were only partly offset online only. To view please visit Medicare fee-for-service patients aged 65 or over. by declines in readmissions (−0.023 (−0.035 to the journal online. MAIN OUTCOMES −0.012)). Increases in observation stay use were more C ite this as: BMJ 2019;366:l4563 pronounced among non-white patients than white http://dx.doi.org/10.1136/bmj.l4563 Total hospital revisits within 30 days of discharge after hospital stays for medical conditions targeted by patients. No significant change was seen in mortality Accepted: 20 June 2019 the HRRP, and by type of revisit: treat-and-discharge within 30 days of discharge for target conditions visit to an emergency department, observation stay (−0.0034 (−0.012 to 0.0054)). (not leading to inpatient readmission), and inpatient CONCLUSIONS readmission. Patient subgroups (age, sex, race) were In the United States, total hospital revisits within 30 http://www.bmj.com/ also evaluated for each type of revisit. days of discharge for conditions targeted by the HRRP increased across the study period. This increase was due to a rise in post-discharge emergency department WH AT IS ALREADY KNOWN ON THIS TOPIC visits and observation stays, which exceeded the Readmission rates at 30 days are increasingly used to measure quality of care decline in readmissions. Although reductions in and evaluate provider and hospital performance under value based payment readmissions have been attributed to improvements in discharge planning and care transitions, our programs in the United States on 24 September 2021 by guest. Protected copyright. findings suggest that these declines could instead Readmission rates for medical conditions targeted by one such program, the be because hospitals and clinicians have intensified Hospital Readmissions Reduction Program (heart failure, acute myocardial efforts to treat patients who return to a hospital within infarction, and pneumonia), have declined modestly on a national scale 30 days of discharge in emergency departments and Policymakers have attributed these reductions to improved discharge planning, as observation stays. care transitions, and post-discharge care after index hospital stays, but these declines could be because clinicians and hospitals have increasingly adopted Introduction strategies to manage patients who return to a hospital within 30 days of discharge in emergency departments or as observation stays—which are not Healthcare systems around the world are intensifying efforts to deliver higher value care. Reducing included in the current readmission measure preventable hospital visits has drawn policy attention WH AT THIS STUDY ADDS as an opportunity to improve quality of care and Total hospital revisits within 30 days of discharge after a hospital admission for reduce healthcare spending in several countries, target conditions have steadily increased under the HRRP, due to a rise in treat- including the United States, England, Denmark, and 1 and-discharge visits in an emergency department and observation stays Germany. In the US, the Centers for Medicare and Although reductions in readmissions have been attributed to improvements Medicaid Services (CMS) has implemented national initiatives that aim to push clinicians and hospitals in discharge planning and transitional care, as intended by the HRRP, these to reduce readmissions for Medicare fee-for-service declines instead appear to be due to intensified efforts to manage patients who patients over the age of 65. In 2009, for example, CMS return within 30 days of discharge in emergency departments and observation began publicly reporting 30 day readmission rates as units a measure of hospital performance. One year later, the A metric to measure patients’ 30 day return to hospital that captures all post- Hospital Readmissions Reduction Program (HRRP) discharge encounters (inpatient, emergency department, and observation stays) was established, mandating that CMS impose financial could provide a more comprehensive, accurate, and fair assessment of hospital penalties on acute care hospitals in the US with higher quality and performance than expected 30 day readmission rates after a hospital the bmj | BMJ 2019;366:l4563 | doi: 10.1136/bmj.l4563 1 RESEARCH stay for common medical conditions. Penalties under (international classification of diseases, 9th revision, BMJ: first published as 10.1136/bmj.l4563 on 12 August 2019. Downloaded from the HRRP began in 2012 and are capped at 3% of clinical modification) codes used in the publicly Medicare payments to hospitals; 82% of hospitals reported CMS readmission and mortality measures. were penalized in fiscal year 2019.2 We included Medicare beneficiaries aged 65 or older Readmissions alone, however, do not capture the who were alive at discharge, and excluded patients full spectrum of hospital revisits that can occur after who were discharged against medical advice, were discharge. A return visit to an emergency department, not enrolled in Medicare fee for service for at least 30 even if it does not result in an inpatient hospital days after discharge (absent death), or were enrolled stay, might also reflect inadequate care transitions in Medicare fee for service for less than one year before or fragmented post-discharge care. In addition, hospital admission. Transfers to other hospitals were observation stays, which are short hospital stays that linked to one index hospital stay.6 Comorbidities were are reimbursed differently from full inpatient hospital defined by hierarchical condition categories based stays, are increasingly being used in the US as an on inpatient Medicare claims up to one year before alternative to inpatient hospital stays, and can occur hospital admission, and diagnosis codes per claim in an emergency department, hospital observation were limited to the first nine codes,7 as has been done unit, or a typical inpatient ward setting.3 However, in previous studies.5 6 8 9 We used outpatient claims neither of these encounters (emergency department files and previously described methods to identify or observation stays) are included as outcomes in the observation stays10 as well as treat-and-discharge 30 day readmission measure used by CMS to evaluate visits to an emergency department3 that occurred hospital care quality under the HRRP.4 within 30 days of discharge after the index hospital Understanding nationwide trends in total hospital stay. based encounters (including treat-and-discharge visits to an emergency department, observation stays, or Outcomes inpatient readmissions) within 30 days of discharge, Our primary outcome was the trend in total hospital for conditions targeted by the HRRP, is critically revisits within 30 days of discharge after a hospital stay important from a policy perspective. A reduction in for medical conditions targeted by the HRRP. We also total revisits would suggest widespread improvements evaluated revisits by type: treat-and-discharge visits to in discharge planning and transitions of care during an emergency department, observation stays (not later hospital stays, as well as care coordination and quality leading to readmission), and readmissions. For each in the post-discharge period, as intended by the HRRP. revisit, we used two different approaches: we counted http://www.bmj.com/ By contrast, if hospital revisits after discharge have only one revisit (the first event after discharge) for each not changed, or have increased, previously observed type of encounter after the index hospital stay, as CMS 4 reductions in readmissions5 might simply reflect greater does for the readmission measure ; and we counted all management of patients in emergency departments revisits within
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