Preventable readmissions within 30 days of ischemic stroke among Medicare beneficiaries

Abstract

Background and purpose: The Centers for Medicare and Medicaid Services proposes to use 30-day hospital readmissions after ischemic stroke as part of the Hospital Inpatient Quality Reporting Program for payment determination beginning in 2016. The proportion of poststroke readmissions that is potentially preventable is unknown.

Methods: Thirty-day readmissions for all Medicare fee-for-service beneficiaries aged≥65 years discharged alive with a primary diagnosis of ischemic stroke (International Classification of Diseases, Ninth Revision, Clinical Modification 433, 434, 436) between December 2005 and November 2006 were analyzed. Preventable readmissions were identified based on 14 Prevention Quality Indicators developed for use with administrative data by the US Agency for Healthcare Research and Quality. National, hospital-level, and regional preventable readmission rates were estimated. Random-effects logistic regression was also used to determine patient-level factors associated with preventable readmissions.

Results: Among 307 887 ischemic stroke discharges, 44 379 (14.4%) were readmitted within 30 days; 5322 (1.7% of all discharges) were the result of a preventable cause (eg, pneumonia), and 39 057 (12.7%) were for other reasons (eg, cancer). In multivariate analysis, older age and cardiovascular-related comorbid conditions were strong predictors of preventable readmissions. Preventable readmission rates were highest in the Southeast, Mid-Atlantic, and US territories and lowest in the Mountain and Pacific regions.

Conclusions: On the basis of Agency for Healthcare Research and Quality Prevention Quality Indicators, we found that a small proportion of readmissions after ischemic stroke were classified as preventable. Although other causes of readmissions not reflected in the Agency for Healthcare Research and Quality measures could also be avoidable, hospital-level programs intended to reduce all-cause readmissions and costs should target high-risk patients.

Keywords: outcome assessment (health care); patient readmission.

Figure 1. Distribution of Hospital-Level 30-Day Risk-Standardized Preventable Readmission Rates

The line bisecting the box and whisker plot above the distribution represents the median/50th percentile, the upper boundary of the box represents the 25th percentile, and the lower boundary represents the 75th percentile. The whiskers are set at the 5th and 95th percentiles, with circles representing outlying hospitals.

Figure 2. 30-Day Preventable Readmission Rates by US Census Regions and Territories

Panel A shows the patient-level observed 30-day preventable readmission rates, with the reference line representing the national average observed preventable readmission rate of 1.7%. Panel B shows the hospital-level distribution of 30-day risk-standardized preventable readmission rates, with the reference line representing the national average risk-standardized preventable readmission rate of 1.7%. *Region-specific risk-standardized rate significantly higher than national average. †Region-specific risk-standardized rate significantly lower than national average.

Figure 3

30-Day Risk-Standardized Preventable Readmission Rates for the 306 Hospital Referral Regions by Quartiles