Post-discharge acute care and outcomes following readmission reduction initiatives: national retrospective cohort study of Medicare beneficiaries in the United StatesBMJ 2020; 368 doi: https://doi.org/10.1136/bmj.l6831 (Published 15 January 2020) Cite this as: BMJ 2020;368:l6831
- Rohan Khera, cardiology fellow1,
- Yongfei Wang, lecturer and senior statistician2 3,
- Susannah M Bernheim, assistant clinical professor and director4 5,
- Zhenqiu Lin, senior research scientist and statistician2 3,
- Harlan M Krumholz, professor and director2 3 6
- 1Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX 75219, USA
- 2Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- 3Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
- 4Section of General Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- 5Quality Measurement Programs, Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
- 6Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Correspondence to: R Khera @rohan_khera on Twitter) (or
- Accepted 14 November 2019
Objectives To determine whether patients discharged after hospital admissions for conditions covered by national readmission programs who received care in emergency departments or observation units but were not readmitted within 30 days had an increased risk of death and to evaluate temporal trends in post-discharge acute care utilization in inpatient units, emergency departments, and observation units for these patients.
Design Retrospective cohort study.
Setting Medicare claims data for 2008-16 in the United States.
Participants Patients aged 65 or older admitted to hospital with heart failure, acute myocardial infarction, or pneumonia—conditions included in the US Hospital Readmissions Reduction Program.
Main outcome measures Post-discharge 30 day mortality according to patients’ 30 day acute care utilization; acute care utilization in inpatient and observation units and the emergency department during the 30 day and 31-90 day post-discharge period.
Results 3 772 924 hospital admissions for heart failure, 1 570 113 for acute myocardial infarction, and 3 131 162 for pneumonia occurred. The overall post-discharge 30 day mortality was 8.7% for heart failure, 7.3% for acute myocardial infarction, and 8.4% for pneumonia. Risk adjusted mortality increased annually by 0.05% (95% confidence interval 0.02% to 0.08%) for heart failure, decreased by 0.06% (−0.09% to −0.04%) for acute myocardial infarction, and did not significantly change for pneumonia. Specifically, mortality increased for patients with heart failure who did not utilize any post-discharge acute care, increasing at a rate of 0.08% (0.05% to 0.12%) per year, exceeding the overall absolute annual increase in post-discharge mortality in heart failure, without an increase in mortality in observation units or the emergency department. Concurrent with a reduction in 30 day readmission rates, stays for observation and visits to the emergency department increased across all three conditions during and beyond the 30 day post-discharge period. Overall 30 day post-acute care utilization did not change significantly.
Conclusions The only condition with increasing mortality through the study period was heart failure; the increase preceded the policy and was not present among patients who received emergency department or observation unit care without admission to hospital. During this period, the overall acute care utilization in the 30 days after discharge significantly decreased for heart failure and pneumonia, but not for acute myocardial infarction.
Contributors: All authors were responsible for the study concept and design. RK, YW, and HMK were responsible for the acquisition and analysis of data. All authors contributed to the interpretation of the data. RK drafted the manuscript. All authors critically revised the manuscript for important intellectual content and approved the final version. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. The study was conceived and conducted by the authors, and the Centers for Medicare and Medicaid Services played no role in its design and conduct; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. RK and HMK are the guarantors.
Funding: RK is supported by the National Center for Advancing Translational Sciences (UL1TR001105) of the National Institutes of Health. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: support from the National Center for Advancing Translational Sciences (UL1TR001105) of the National Institutes of Health for the submitted work; HMK is a recipient of a research grant, through Yale, from Medtronic and Johnson and Johnson (Janssen) to develop methods of clinical trial data sharing; HMK was a recipient of a research grant, through Yale, from Medtronic and the Food and Drug Administration to develop methods for post-market surveillance of medical devices; HMK was a recipient of a research agreement, through Yale, from the Shenzhen Center for Health Information for work to advance intelligent disease prevention and health promotion, and collaborates with the National Center for Cardiovascular Diseases in Beijing; HMK received payment from the Arnold and Porter Law Firm for work related to the Sanofi clopidogrel litigation and from the Ben C Martin Law Firm for work related to the Cook IVC filter litigation; HMK chairs a cardiac scientific advisory board for UnitedHealth and is a participant/participant representative of the IBM Watson Health Life Sciences Board; HMK is a member of the Advisory Board for Element Science, the Physician Advisory Board for Aetna, and the Advisory Board for Facebook; HMK is the founder of Hugo, a personal health information platform. HMK, SMB, ZL, YW work under contract with the Centers for Medicare and Medicaid Services to develop and maintain performance measures that are publicly reported; no other relationships or activities that could appear to have influenced the submitted work.
Ethical approval: The study was reviewed by the Yale University Institutional Review Board and deemed exempt from informed consent owing to the use of deidentified data.
Data sharing: The data are proprietary to the Centers for Medicare and Medicaid Services and can be obtained from them directly. The statistical code is available from the corresponding author.
The lead author affirms that this 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 planned (and, if relevant, registered) have been explained.
Dissemination to participants and related patient and public communities: The data are de-identified and, therefore, cannot be shared with the study participants directly. The authors will enlist patient and public participation in the dissemination of the results of the study.
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