Hospital revisits within 30 days after discharge for medical conditions targeted by the Hospital Readmissions Reduction Program in the United States: national retrospective analysisBMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l4563 (Published 12 August 2019) Cite this as: BMJ 2019;366:l4563
- Rishi K Wadhera, instructor in medicine1,
- Karen E Joynt Maddox, assistant professor2,
- Dhruv S Kazi, associate director1,
- Changyu Shen, associate professor1,
- Robert W Yeh, associate professor1
- 1Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, 185 Pilgrim Road, Boston, MA 02215, USA
- 2Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St Louis, MO, USA
- Correspondence to: R K Wadhera @rkwadhera on Twitter) (or
- Accepted 20 June 2019
Objective To determine any changes in total hospital revisits within 30 days of discharge after a hospital stay for medical conditions targeted by the Hospital Readmissions Reduction Program (HRRP).
Design Retrospective cohort study.
Setting Hospital stays among Medicare patients for heart failure, acute myocardial infarction, or pneumonia between 1 January 2012 and 1 October 2015.
Participants Medicare fee-for-service patients aged 65 or over.
Main outcomes Total hospital revisits within 30 days of discharge after hospital stays for medical conditions targeted by the HRRP, and by type of revisit: treat-and-discharge visit to an emergency department, observation stay (not leading to inpatient readmission), and inpatient readmission. Patient subgroups (age, sex, race) were also evaluated for each type of revisit.
Results Our study cohort included 3 038 740 total index hospital stays from January 2012 to September 2015: 1 357 620 for heart failure, 634 795 for acute myocardial infarction, and 1 046 325 for pneumonia. Counting all revisits after discharge, the total number of hospital revisits per 100 patient discharges for target conditions increased across the study period (monthly increase 0.023 visits per 100 patient discharges (95% confidence interval 0.010 to 0.035)). This change was due to monthly increases in treat-and-discharge visits to an emergency department (0.023 (0.015 to 0.032) and observation stays (0.022 (0.020 to 0.025)), which were only partly offset by declines in readmissions (−0.023 (−0.035 to −0.012)). Increases in observation stay use were more pronounced among non-white patients than white patients. No significant change was seen in mortality within 30 days of discharge for target conditions (−0.0034 (−0.012 to 0.0054)).
Conclusions In the United States, total hospital revisits within 30 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 visits and observation stays, which exceeded the decline in readmissions. Although reductions in readmissions have been attributed to improvements in discharge planning and care transitions, our findings suggest that these declines could instead be because hospitals and clinicians have intensified efforts to treat patients who return to a hospital within 30 days of discharge in emergency departments and as observation stays.
Contributors: CS and RWY contributed equally as senior authors. All authors conceived and designed the study, analyzed and interpreted the data, and critically revised the manuscript for important intellectual content. RWY acquired the data. CS and RKW carried out the statistical analysis. RKW, KEJM, and DSK drafted the manuscript. RWY, RKW, and CS supervised the study and are the guarantors. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted
Funding: This study received no support from any organization.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organization for the submitted work; RKW receives research support from the National Heart, Lung, and Blood Institute (1K23HL148525-1), and has previously served as consultant for Regeneron, outside the submitted work; KEJM receives research support from the National Heart, Lung, and Blood Institute (R01HL143421), National Institute on Aging (R01AG060935), and Commonwealth Fund; RWY receives research support from the National Heart, Lung and Blood Institute (R01HL136708) and the Richard A and Susan F Smith Center for Outcomes Research in Cardiology and received from Abiomed, personal fees from Asahi Intecc, grants from AstraZeneca, grants and personal fees from Boston Scientific, personal fees from Medtronic, and personal fees from Teleflex outside the submitted work; DSK receives research support from the Richard A and Susan F Smith Center for Outcomes Research in Cardiology; the other authors report no conflicts; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
Ethical approval: This study was reviewed and granted exemption by the institutional review board at the Beth Israel Deaconess Medical Center, including waiver of the requirement of participant informed consent because the data were deidentified.
Data sharing: No additional data are available due to data use agreement with the Centers for Medicare and Medicaid Services.
The lead author affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as originally planned have been explained.
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