Post-Discharge Services for Different Diagnoses Than Index Hospitalization Predict Decreased 30-Day Readmissions Among Medicare Beneficiaries

Abstract

BACKGROUND: Efforts to reduce hospital readmissions include post-discharge interventions related to the illness treated during the index hospitalization (IH). These efforts may be inadequate because readmissions are precipitated by a wide range of health conditions unrelated to the primary diagnosis of the IH. OBJECTIVE: To investigate the relationship between post-discharge health services utilization for the same or a different diagnosis than the IH and unplanned 30-day readmission. DESIGN AND PARTICIPANTS: The study sample included 583,199 all-cause IHs among 2014 Medicare fee-forservice beneficiaries. For all-cause IH, as well as individually for heart failure, myocardial infarction, and pneumonia IH, we used multivariable logistic regressions to investigate the association between post-discharge services utilization and readmission. MAIN MEASURES: The outcome was unplanned 30-day readmission. Primary independent variables were postdischarge services utilization, including institutional outpatient, office-based primary care, office-based specialist, office-based non-physician practitioner, emergency department, home health care, and skilled nursing facility providers. KEY RESULTS: Among all-cause IH, 11.7% resulted in unplanned 30-day readmissions, and only 18.1% of readmissions occurred for the same primary diagnosis as IH. A substantial majority of post-discharge health services were utilized for a primary diagnosis differing from IH. Compared with no visit, institutional outpatient visits for the same primary diagnosis as IH (odds ratio [OR], 0.33; 95% confidence interval [CI], 0.31-0.34) and for a different primary diagnosis than IH (OR, 0.36; 95% CI, 0.35-0.37) were similarly strongly associated with decreased unplanned 30-day readmission. Primary care physician, specialist, non-physician practitioner, and home health care showed similar patterns. IH for heart failure, myocardial infarction, and pneumonia manifested similar patterns to all-cause IH both in terms of postdischarge services utilization and in terms of its impact on readmission. CONCLUSIONS: To reduce unplanned 30-day readmission more effectively, discharge planning should include post-discharge services to address health conditions beyond the primary cause of the IH.

Luck of the draw: Role of chance in the assignment of medicare readmissions penalties

“…While these changes could change hospitals’ expectations of being penalized, our analysis suggests that these changes will not diminish the role of luck in determining readmission penalties as we find that variation in the patient population does not play an important role in explaining variation in excess readmission risk. Rather, our analysis supports other research that has found post-discharge care patterns play an important role in determining unplanned readmissions, and by not including these factors in their risk-adjustment Medicare leaves open a bigger role for luck in assigning penalties [ 20 , 21 ].…”

Usefulness of a Nurse-Led Program of Care for Management of Patients with Chronic Heart Failure

“…Prior studies from Western countries that have evaluated post-discharge programs designed to reduce rehospitalization and increase survival rates of CHF patients have demonstrated the effectiveness of such interventional strategies [6][7][8][9]. Interestingly and importantly, studies of nurse-led programs of care for CHF also confirmed these benefits, suggesting that nurses can play positive roles in the management of CHF patients after discharge [10][11][12][13][14].…”

Association of Post-discharge Service Types and Timing with 30-Day Readmissions, Length of Stay, and Costs

“…As such, this study suggests that efforts to coordinate and encourage utilization of post-discharge services may be most effective if focused on certain types of services and timepoints. This focus is particularly important given that diverse health problems such as post-discharge syndrome, varying severity of unresolved illness, and new conditions, 2,[19][20][21][22][23][24]31,32 as well as poor quality care during IA, 1,8,25,31,[33][34][35] contribute to readmissions. Of note, in our study, only 18.1% of readmissions occurred for the same primary diagnosis as IA.…”

“…2 Furthermore, 30-day readmissions occur for a wide range of diagnoses different from the primary diagnosis of IA because recently discharged patients frequently experience changes in comorbidities or develop new health conditions. 2,[19][20][21][22][23][24] Nonetheless, most prior studies have focused on the potential benefits of early follow-up care. Little is known about patients' patterns of post-discharge services utilization and their outcomes, although patients utilize post-discharge services of different types and at different times to address various health care needs, and their effects on readmission and readmission resource utilization vary.…”