Hospital readmission performance and patterns of readmission: retrospective cohort study of Medicare admissions

Abstract

Objectives: To determine whether high performing hospitals with low 30 day risk standardized readmission rates have a lower proportion of readmissions from specific diagnoses and time periods after admission or instead have a similar distribution of readmission diagnoses and timing to lower performing institutions.

Design: Retrospective cohort study.

Setting: Medicare beneficiaries in the United States.

Participants: Patients aged 65 and older who were readmitted within 30 days after hospital admission for heart failure, acute myocardial infarction, or pneumonia in 2007-09.

Main outcome measures: Readmission diagnoses were classified with a modified version of the Centers for Medicare and Medicaid Services' condition categories, and readmission timing was classified by day (0-30) after hospital discharge. Hospital 30 day risk standardized readmission rates over the three years of study were calculated with public reporting methods of the US federal government, and hospitals were categorized with bootstrap analysis as having high, average, or low readmission performance for each index condition. High and low performing hospitals had ≥ 95% probability of having an interval estimate respectively less than or greater than the national 30 day readmission rate over the three year period of study. All remaining hospitals were considered average performers.

Results: For readmissions in the 30 days after the index admission, there were 320,003 after 1,291,211 admissions for heart failure (4041 hospitals), 102,536 after 517,827 admissions for acute myocardial infarction (2378 hospitals), and 208,438 after 1,135,932 admissions for pneumonia (4283 hospitals). The distribution of readmissions by diagnosis was similar across categories of hospital performance for all three conditions. High performing hospitals had fewer readmissions for all common diagnoses. Median time to readmission was similar by hospital performance for heart failure and acute myocardial infarction, though was 1.4 days longer among high versus low performing hospitals for pneumonia (P<0.001). Findings were unchanged after adjustment for other hospital characteristics potentially associated with readmission patterns.

Conclusions: High performing hospitals have proportionately fewer 30 day readmissions without differences in readmission diagnoses and timing, suggesting the possible benefit of strategies that lower risk of readmission globally rather than for specific diagnoses or time periods after hospital stay.

Fig 1 Ten most common readmission diagnoses for high, average, and low performing hospitals after admission for heart failure. Numbers rounded to nearest percentage point. High performing hospitals have 30 day risk standardized readmission rates lower than national average rate with >95% probability. Low performing hospitals have 30 day risk standardized readmission rates higher than national average rate with >95% probability. All remaining hospitals are considered average. For each hospital, we calculated performance separately for heart failure, acute myocardial infarction, and pneumonia cohorts

Fig 2 Ten most common readmission diagnoses for high, average, and low performing hospitals after admissions for acute myocardial infarction. See also legend for fig 1

Fig 3 Ten most common readmission diagnoses for high, average, and low performing hospitals after admission for pneumonia. See also legend for fig 1

Fig 4 Weighted median time to readmission for high, average, and low performing hospitals after admission for heart failure. High performing hospitals have 30 day risk standardized readmission rates lower than national rate with >95% probability. Low performing hospitals have 30 day risk standardized readmission rates higher than national average rate with >95% probability. All remaining hospitals are considered average. For each hospital, we calculated performance separately for heart failure, acute myocardial infarction, and pneumonia cohorts. Weighted median time to readmission denoted by black diamond; interquartile range denoted by black squares; range denoted by gray bar

Fig 5 Weighted median time to readmission for high, average, and low performing hospitals after admission for acute myocardial infarction. See also legend for fig 4

Fig 6 Weighted median time to readmission for high, average, and low performing hospitals after admission for pneumonia. See also legend for fig 4