Post-discharge Acute Care and Outcomes in the Era of Readmission Reduction

Abstract

Background: With incentives to reduce readmission rates in the United States, there are concerns that patients who need hospitalization after a recent hospital discharge may be denied access, which would increase their risk of mortality.\n\nObjective: We determined whether patients with hospitalizations for conditions covered by national readmission programs who received care in emergency department (ED) or observation units but were not hospitalized within 30 days had an increased risk of death. We also evaluated temporal trends in post-discharge acute care utilization in inpatient units, emergency department (ED) and observation units for these patients.\n\nDesign, Setting, and Participants: In this observational study of national Medicare claims data for 2008-2016, we identified patients 65 years of age and older hospitalized with heart failure (HF), acute myocardial infarction (AMI), or pneumonia, conditions included in the HRRP.\n\nMain Outcomes and Measures: Post-discharge 30-day mortality according to patients9 30-day acute care utilization. Acute care utilization in inpatient and observation units, and the ED during the 30-day and 31-90-day post-discharge period. \n\nResults: There were 3,772,924 hospitalizations for HF, 1,570,113 for AMI, and 3,131,162 for pneumonia. The overall post-discharge 30-day mortality was 8.7% for HF, 7.3% for AMI, and 8.4% for pneumonia. Risk-adjusted mortality increased annually by 0.05% (95% CI, 0.02% to 0.08%) for HF, decreased by 0.06% (95% CI, -0.09% to -0.04%) for AMI, and did not significantly change for pneumonia. Specifically, mortality increased for HF patients who did not utilize any post-discharge acute care, increasing at a rate of 0.08% per year (95% CI, 0.05% to 0.12%), exceeding the overall absolute annual increase in post-discharge mortality in heart failure, without an increase in mortality in observation units or the ED. Concurrent with a reduction in 30-day readmission rates, 30-day observation stays and visits to the ED increased across all 3 conditions during and beyond the post-discharge 30-day period. There was no significant change in overall 30-day post-acute care utilization.\n\nConclusions: The only condition with an increasing mortality through the study period was HF; the increase preceded the policy and was not present among those received ED or observation unit care without hospitalization. Overall, during this period, there was not a significant change in the overall 30-day post-discharge acute care utilization.