Hospital revisits within 30 days after discharge for medical conditions targeted by the Hospital Readmissions Reduction Program in the United States: national retrospective analysis

Abstract

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.

Fig 1

Risk standardized hospital revisits, treat-and-discharge visits to an emergency department, observation stays, and readmissions within 30 days of discharge for medical conditions targeted by the HRRP in the US. Spline fitted trends of hospital revisits are shown for all target conditions (heart failure, acute myocardial infarction, or pneumonia). Data based on Medicare fee-for-service patients aged 65 or over between 1 January 2012 and 1 October 2015. Yellow line=trends including only the first revisit for each type of encounter (eg, any hospital revisit, treat-and-discharge visit to an emergency department, observation stay, or inpatient readmission); purple line=trends including all revisits for each type of encounter

Fig 2

Risk standardized mortality within 30 days of discharge among Medicare patients admitted to hospital for heart failure, acute myocardial infarction, or pneumonia (medical conditions targeted by the HRRP in the US). Spline fitted trends of mortality are shown, by target condition. Data based on Medicare fee-for-service patients aged 65 or over between 1 January 2012 and 1 October 2015