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Readmission decline may be linked to lower mortality in acute MI, HF, pneumonia
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The decrease in 30-day readmissions in Medicare fee-for-service beneficiaries with acute MI, HF and pneumonia was associated with a decrease in 30-day mortality rates after discharge, according to a study published in JAMA.
Kumar Dharmarajan, MD, MBA, assistant professor of medicine at Yale School of Medicine and faculty at the Yale-New Haven Hospital Center for Outcomes Research and Evaluation, and colleagues analyzed data from patients aged at least 65 years who were hospitalized with acute MI, HF or pneumonia from 2008 to 2014. All-cause readmissions were included in this retrospective review.
The primary outcomes were defined as 30-day risk-adjusted readmission rates and hospital 30-day risk-adjusted mortality rates after discharge for acute MI, HF and pneumonia at each hospital monthly throughout the study period. Secondary mortality outcomes included 90-day risk-adjusted mortality rates after the admission date and hospital 90-day risk-adjusted mortality rates after discharge.
Total hospitalizations
Researchers identified 1,229,939 hospitalizations for acute MI (mean age, 79 years; 52% men), 2,962,554 for HF (mean age, 81 years; 46% men) and 2,544,530 for pneumonia (mean age, 80 years; 46% men) from 2008 to 2014. Medicare fee-for-service beneficiaries were hospitalized for HF at 5,016 hospitals, whereas 4,772 hospitals cared for patients with acute MI and 5,057 hospitals treated patients with pneumonia.
Mean hospital 30-day risk-adjusted readmission rates for January 2008 were 24.6% for HF, 19.3% for acute MI and 18.3% for pneumonia, whereas 30-day risk-adjusted mortality rates were 7.6% for acute MI, 8.4% for HF and 8.5% for pneumonia.
Thirty-day risk-adjusted readmission rates for all hospitals declined between 2008 and 2014 for acute MI (–0.044%; 95% CI, –0.047 to –0.041), HF (–0.053%; 95% CI, –0.055 to –0.051) and pneumonia (–0.033%; 95% CI, –0.035 to –0.031). Monthly aggregate trends for 30-day risk-adjusted mortality rates in all hospitals differed for acute MI (–0.003%; 95% CI, –0.005 to –0.001), HF (0.008%; 95% CI, 0.007-0.01) and pneumonia (0.001%; 95% CI, –0.001 to 0.003).
Researchers observed that correlation coefficients of paired monthly trends for hospital 30-day risk-adjusted readmission rates and 30-day risk-adjusted mortality rates for acute MI (0.067; 95% CI, 0.027-0.106), HF (0.066; 95% CI, 0.036-0.096) and pneumonia (0.108; 95% CI, 0.079-0.137) were “weakly positive” from 2008 to 2014.
Secondary analyses, which included different classifications of hospital mortality, had similar findings.
Decline of readmissions
“Hospitals nationally have made significant efforts to lower readmissions through improved transitional and post-acute care,” Dharmarajan and colleagues wrote. “As these efforts have largely focused on better preparing patients and families for hospital discharge, integrating care across settings and improving the timeliness of follow-up, they may have produced salutary effects on other outcomes besides readmission.”
“This is certainly good news,” Karen E. Joynt Maddox, MD, MPH, associate physician at Brigham and Women’s Hospital and assistant professor of medicine at Harvard Medical School, wrote in a related editorial. “There is an emerging literature on strategies that hospitals are using to reduce readmissions, the majority of which relate to improving coordination, communication and cooperation among physicians and other health care professionals across all settings. These strategies are patient centered and, when successful, should be adopted by all hospitals, regardless of baseline readmission rates. The fact that these strategies do not inadvertently increase mortality rates and may even have some positive effects is even more reason to continue this important work helping patients transition safely from hospital to home.” – by Darlene Dobkowski
Disclosures: Dharmarajan reports serving as a consultant and a scientific advisory board member for Clover Health. Joynt Maddox reports previously serving as a senior adviser and continues intermittent contract-based work with HHS. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Matthew T. Roe, MD, MHS
Contemporary uncertainties for CV outcomes research include whether hospital readmission accurately reflects the quality of care for common medical disorders requiring hospitalization (acute MI, HF and pneumonia) and whether readmission rates correlate with post-discharge mortality rates. Previous analyses have not delineated whether hospital readmissions increase the risk for a subsequent fatal event, and whether mortality rates decline as a result of having fewer hospital readmissions. The present analysis demonstrates a modest correlation between temporal changes in reduced readmission rates as well as reduced post-discharge mortality rates — findings that are encouraging, but that raise more questions.
As such, it will be important to ascertain what strategies and policies will significantly reduce mortality rates for these conditions. For example, would better use of guideline-recommended therapies at the time of discharge make a difference? Would longer durations of initial hospitalization substantially reduce readmission and mortality rates? Could earlier and more frequent visits in the outpatient setting in the first few weeks after discharge make a difference?
The widespread use of electronic health records offers the opportunity to consider randomized studies to evaluate different types of algorithms or treatment pathways for patients with acute MI, HF or pneumonia. For example, hospitals could be randomized to weekly or biweekly clinic visits with a specialist during the first month after discharge vs. standard practice, which may be seeing their primary care doctor in the first week and a specialist at a later point. Many other pragmatic studies can be considered, and these studies can be executed and completed in contemporary practice to inform current medial practice rather than evaluating past administrative claims data. As these types of innovative studies are contemplated, the learning health care system model will gain traction and fundamentally change health care delivery.
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