Readmissions, Observation, and the Hospital Readmissions Reduction Program

Zuckerman, Rachael; Sheingold, Steven H.; Orav, E. John; Ruhter, Joel; Epstein, Arnold M.

doi:10.1056/nejmsa1513024

Cited by 727 publications

(725 citation statements)

References 5 publications

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“…The proportion was not constant over the years. Concordant with the reported national trend of increase in observations stays over the years, especially for Hospital Readmissions Reduction Program–targeted conditions, including HF,8 in the current study the observation status formed less than ≈20% of the study group in 2008 versus ≈50% of the study group in 2015.…”

Section: Introductionsupporting

confidence: 87%

“…Although rates of readmission have shown a steady decline during the past decade, the decline has been more marked since 2010. Observation stays have also shown a steady increase during the same time 8, 9. Critics of the Hospital Readmissions Reduction Program have been concerned that one strategy used by hospitals to decrease readmissions is to defer such patients to observation stays instead of admitting or readmitting them, because observations stays do not count toward the penalized admissions/readmissions.…”

Section: Introductionmentioning

confidence: 99%

“…On an even more serious note is the possibility that reducing appropriate readmissions could be associated with a potential for increased mortality. These concerns continue to be intensely debated 8, 9, 10, 11…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Observation Versus Inpatient Stay for Heart Failure: Is It Semantics?

Khalid

Deswal

2018

JAHA

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Section: Introductionsupporting

confidence: 87%

Section: Introductionmentioning

confidence: 99%

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Observation Versus Inpatient Stay for Heart Failure: Is It Semantics?

Khalid

Deswal

2018

JAHA

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“…Fourth, we did not account for observational stays in our study design. However, studies have shown that the observational stays do not correlate with change in readmission rates in Medicare beneficiaries for both targeted and nontargeted conditions under the Hospital Readmissions Reduction Program 36. Finally, we used claims data, which lack clinical detail.…”

Section: Discussionmentioning

confidence: 99%

Sex and Race Differences in the Utilization and Outcomes of Coronary Artery Bypass Grafting Among Medicare Beneficiaries, 1999–2014

Angraal

Khera

Wang

et al. 2018

JAHA

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BackgroundWith over a decade of directed efforts to reduce sex and racial differences in coronary artery bypass grafting (CABG) utilization, and post‐CABG outcomes, we sought to evaluate how the use of CABG and its outcomes have evolved in different sex and racial subgroups.Methods and ResultsUsing data on all fee‐for‐service Medicare beneficiaries undergoing CABG in the United States from 1999 to 2014, we examined differences by sex and race in calendar‐year trends for CABG utilization and post‐CABG outcomes (in‐hospital, 30‐day, and 1‐year mortality and 30‐day readmission). A total of 1 863 719 Medicare fee‐for‐service beneficiaries (33.6% women, 4.6% black) underwent CABG from 1999 to 2014, with a decrease from 611 to 245 CABG procedures per 100 000 person‐years. Men compared with women and whites compared with blacks had higher CABG utilization, with declines in all subgroups. Higher post‐CABG annual declines in mortality (95% confidence interval) were observed in women (in‐hospital, −2.70% [−2.97, −2.44]; 30‐day, −2.29% [−2.54, −2.04]; and 1‐year mortality, −1.67% [−1.88, −1.46]) and blacks (in‐hospital, −3.31% [−4.02, −2.60]; 30‐day, −2.80% [−3.49, −2.12]; and 1‐year mortality, −2.38% [−2.92, −1.84]), compared with men and whites, respectively. Mortality rates remained higher in women and blacks, but differences narrowed over time. Annual adjusted 30‐day readmission rates remained unchanged for all patient groups.ConclusionsWomen and black patients had persistently higher CABG mortality than men and white patients, respectively, despite greater declines over the time period. These findings indicate progress, but also the need for further progress.

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“…After the passage of HRRP as part of health reform in 2010, large analyses of administrative data have shown that readmission rates after AMI decreased faster than they had been decreasing before the law 4, 5, 6. Because distinguishing these types of different patients with AMI is difficult from administrative data, it is not known what specific tactics have reduced readmissions or could further improve performance in the future.…”

Section: Introductionmentioning

confidence: 99%

Clinical Profile of Acute Myocardial Infarction Patients Included in the Hospital Readmissions Reduction Program

Martin

Januzzi

Thompson

et al. 2018

JAHA

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BackgroundMedicare's Hospital Readmissions Reduction Program assesses financial penalties to hospitals based on risk‐standardized readmission rates after specific episodes of care, including acute myocardial infarction. Detailed information about the type of patients included in the penalty is unknown.Methods and ResultsStarting with administrative data from Medicare, we conducted physician‐adjudicated chart reviews of all patients considered 30‐day readmissions after acute myocardial infarction from July 2012 to June 2015. Of 197 readmissions, 68 (34.5%) received percutaneous coronary intervention and 18 (9.1%) underwent coronary artery bypass grafting on index hospitalization. The remaining 111 patients did not receive any intervention. Of the 197 patients, 56 patients (28.4%) were considered too high risk for invasive management, 23 (11.7%) had nonobstructive coronary artery disease on diagnostic catheterization and therefore no indication for revascularization, 19 patients had a type II myocardial infarction (9.6%) for which noninvasive, outpatient workup was recommended, and 13 (6.6%) declined further care. The most common readmission diagnoses were cardiac causes and noncardiac chest discomfort, infection, and gastrointestinal bleeding.ConclusionsOur results demonstrate that more than a quarter of the patients included in the penalty do not receive revascularization either because of provider assessment of risk or patient preference, and nearly one tenth have type II myocardial infarction. As such, administrative codes for prohibitive procedural risk, patient‐initiated “do not resuscitate” status, or type II myocardial infarction may improve the risk‐adjustment of the metric. Furthermore, provider organizations seeking to reduce readmission rates should focus resources on the needs of these patients, such as care coordination, hospice services when requested by patients, and treatment of noncardiac conditions.

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Readmissions, Observation, and the Hospital Readmissions Reduction Program

Abstract: Readmission trends are consistent with hospitals' responding to incentives to reduce readmissions, including the financial penalties for readmissions under the ACA. We did not find evidence that changes in observation-unit stays accounted for the decrease in readmissions.

Cited by 727 publications

References 5 publications

Observation Versus Inpatient Stay for Heart Failure: Is It Semantics?

Observation Versus Inpatient Stay for Heart Failure: Is It Semantics?

Sex and Race Differences in the Utilization and Outcomes of Coronary Artery Bypass Grafting Among Medicare Beneficiaries, 1999–2014

Clinical Profile of Acute Myocardial Infarction Patients Included in the Hospital Readmissions Reduction Program

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