Unplanned Readmissions after Hospital Discharge among Heart Failure Patients At Risk for 30-Day Readmission Using an Administrative Dataset and “Off the Shelf” Readmission Models

摘要

Background: Readmission of patients who were recently discharged after hospitalization with heart failure (HF) represents an important, expensive, and often preventable adverse outcome. The risk of readmission may be modified by the quality and type of care provided to these patients. Improving readmission rates is the joint responsibility of hospitals and clinicians. Measuring readmission will create incentives to invest in interventions to improve hospital care, better assess the readiness of patients for discharge and facilitate transitions to outpatient status. This measure is also responsive to the recent call by Medicare Payment Advisory Commission to develop readmission measures, with HF as a priority condition.Objective: Unplanned hospital readmission has emerged as a major CMS focus of quality improvement and payment reform. Coupled with national initiatives, Adventist Health West chose unplanned readmissions following an index hospitalization for HF for a major system-wide initiative for CY 2013.Methods: Given competitive heart failure readmission models, our strategy became one of using the best of three – LACE, Hansan and PARR – as the basic building blocks to find a better predictive readmissions model.Results: The ROC curve and C-statistics for the five models using the combined data from Adventist Hospitals were computed for the combined hospitals and individually for each entity. Overall, the Hasan, PARR, and AH Models (C-statistics of 0.802, 0.821 and 0.846, respectively) were superior to either the CMS or LACE prediction model (C-statistic of 0.749 and 0.547, respectively).Conclusion: Using “Off the Shelf” readmission HF models as a guide, a useful readmission model may be derived which, in this case, is slightly superior than competing readmission models. Introduction Unplanned hospital readmissions within 30 days of a prior hospitalization for heart failure (HF) are common, expensive and often preventable. These unplanned readmissions are recognized as a marker of hospital-level quality and efficiency of care and a significant contributor to rising healthcare costs. Since Heart failure is the leading cause of hospitalization among patients over the age of 65 years, the magnitude of unplanned readmissions within 30 days is enormous. Nearly one fifth of Medicare fee-for-service enrollees discharged from acute care hospitals are readmitted within 30 days, incurring additional costs of US$17.4 billion dollars annually (1). While it is unclear whether such readmissions are entirely preventable, there is evidence that targeted interventions initiated before and/or shortly after discharge can decrease the likelihood of readmission by 25% to 45% (2-7). Readmission rates are influenced by the quality of inpatient and outpatient care, availability and use of effective disease management programs, and the bed capacity of the local health care system. Some of the variation in readmissions may be attributable to delivery system characteristics (8). Also, interventions during and after a hospitalization can be effective in reducing readmission rates in geriatric populations (3, 6) and for elderly HF patients (2, 4, 9-12) Tracking readmissions also emphasizes improvement in care transitions and care coordination. Although discharge planning is required by Medicare as a condition of participation for hospitals, transitional care focuses more broadly on “hands-off” of care from one setting to another, and may have implications for quality and costs (Coleman, 2005). Despite positive results in disease management studies, many post-hospital HF management programs have been discontinued, most often due to financial considerations (13).Readmission of patients who were recently discharged after hospitalization with HF represents an important, expensive, and often preventable adverse outcome. The risk of readmission can certainly be modified by the quality and type of care provided to these patients. Improving readmission rates i