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Assessment of Variability in Hospital Readmissions Among Medicare Beneficiaries in the United States

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Assessment of Variability in Hospital Readmissions Among Medicare Beneficiaries in the United States ASSESSMENT OF VARIABILITY IN HOSPITAL READMISSIONS AMONG MEDICARE BENEFICIARIES IN THE UNITED STATES A dissertation submitted to Kent State University in partial fulfillment of the requirements for the degree of Doctor of Philosophy By James K. Karichu May, 2017 © Copyright, 2017 by JAMES K. KARICHU All Rights Reserved ii Dissertation written by James K. Karichu B.S., Bowling Green State University, 2006 M.P.H., The University of Toledo, 2009 Ph.D., Kent State University, 2017 Approved by ____________________________________, Co-Chair, Doctoral Dissertation Committee John A. Hoornbeek, Ph.D ____________________________________, Co-Chair, Doctoral Dissertation Committee Jonathan B. VanGeest, Ph.D ____________________________________, Member, Doctoral Dissertation Committee Jarrod E. Dalton, Ph.D Accepted by ____________________________________, Interim Department Chair Christopher J. Woolverton, Ph.D ____________________________________, Dean, College of Public Health Sonia A. Alemagno, Ph.D iii Table of Contents List of Figures ............................................................................................................................... vii List of Tables ............................................................................................................................... viii List of Abbreviations ..................................................................................................................... ix Chapter 1 ......................................................................................................................................... 1 Introduction and Statement of the Problem .................................................................................... 1 Problem Background .................................................................................................................. 1 New Contributions to the Literature ......................................................................................... 10 Importance and Significance of the study ................................................................................. 11 Importance of this Topic to Patients, Providers, Payers, and Policy makers ............................ 14 Conceptual Framework ............................................................................................................. 17 Research Questions and Specific Aims .................................................................................... 20 Research Question # 1 .......................................................................................................... 20 Research Question # 2 .......................................................................................................... 20 Research Question # 3 .......................................................................................................... 20 Specific Aims ............................................................................................................................ 21 Specific Aim # 1 ................................................................................................................... 21 Specific Aim # 2 ................................................................................................................... 21 Specific Aim # 3 ................................................................................................................... 22 Chapter 2 ....................................................................................................................................... 24 Literature Review.......................................................................................................................... 24 Thirty-day Readmission Rates in Medicare .............................................................................. 24 Hospital Readmissions Reduction Program (HRRP) ............................................................... 28 Reasons for Hospital Readmission in Medicare ....................................................................... 31 Previously Developed Conceptual Models on Causes of Hospital Readmissions ................... 34 Hospital Readmission as a Quality Metric for Inpatient Care .................................................. 36 Validity of 30 days in Assessing Readmission Rates ............................................................... 38 Readmission Financial Penalties and Rewards as Instituted by PPACA ................................. 40 Hospital Readmissions and Mortality ....................................................................................... 42 iv Emergency Department Visits and Readmission Rates ............................................................ 43 Risk Factors for Hospital Readmission in Medicare ................................................................ 44 Patient Demographic and Medical Characteristics ............................................................... 44 Provider or Hospital Characteristics ..................................................................................... 46 Discharge, Post-discharge Transition, and Care Coordination ............................................. 50 Community level factors ....................................................................................................... 53 Healthcare System Factors .................................................................................................... 54 Current Initiatives to Lower Medicare Hospital Readmissions Rates ...................................... 56 Hospitals and Healthcare Providers ...................................................................................... 57 Legislative Efforts and National Quality Improvement Programs ....................................... 63 Ongoing Policy and Leadership Issues ................................................................................. 65 Expanded Role of Hospitals in Community Settings ........................................................... 69 Chapter 3 ....................................................................................................................................... 72 Methods......................................................................................................................................... 72 Data Sources and Study Population .......................................................................................... 72 Study Cohort ............................................................................................................................. 74 Inclusion criteria ............................................................................................................. 74 Exclusion criteria............................................................................................................ 74 Study Measures ......................................................................................................................... 75 Primary Outcome Variable ................................................................................................ 75 Explanatory County (level-2) Variables ................................................................................... 75 Per capita number of primary care physicians (PCPs) ................................................... 75 Median annual household income .................................................................................. 76 Poverty rate .................................................................................................................... 77 Black resident population ............................................................................................... 78 Per capita number of skilled nursing facilities (SNFs) .................................................. 79 Population aged 65 or older in nursing homes ............................................................... 80 Adult smoking rates ....................................................................................................... 81 Hospital (level-1) variables ....................................................................................................... 82 Ownership status ............................................................................................................ 82 Teaching status ............................................................................................................... 83 Bed size .......................................................................................................................... 83 Setting............................................................................................................................. 83 Region ............................................................................................................................ 84 v Safety-net status ............................................................................................................. 84 Length of Stay ................................................................................................................ 85 Statistical Analysis Plan ................................................................................................................ 85 Statistical Analysis Plan for Aim 1 and 2 ................................................................................. 85 Preliminary Analysis ................................................................................................................
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