Amy Deutschendorf

ASSOCIATION OF SELF-REPORTED HOSPITAL DISCHARGE HANDOFFS WITH 30-DAY READMISSIONS

IMPORTANCE Poor health care provider communication across health care settings may lead to adverse outcomes. OBJECTIVE To determine the frequency with which inpatient providers report communicating directly with outpatient providers and whether direct communication was associated with 30-day readmissions. DESIGN We conducted a single-center prospective study of self-reported communication patterns by discharging health care providers on inpatient medical services from September 2010 to December 2011 at The Johns Hopkins Hospital. SETTING A 1000-bed urban, academic center. PARTICIPANTS There were 13 954 hospitalizations in this time period. Of those, 9719 were for initial visits. After additional exclusions, including patients whose outpatient health care provider was the inpatient attending physician, those who had planned or routine admissions, those without outpatient health care providers, those who died in the hospital, and those discharged to other healthcare facilities, we were left with 6635 hospitalizations for analysis. INTERVENTIONS Self-reported communication was captured from a mandatory electronic discharge worksheet field. Thirty-day readmissions, length of stay (LOS), and demographics were obtained from administrative databases. DATA EXTRACTION We used multivariable logistic regression models to examine, first, the association between direct communication and patient age, sex, LOS, race, payer, expected 30-day readmission rate based on diagnosis and illness severity, and physician type and, second, the association between 30-day readmission and direct communication, adjusting for patient and physician-level factors. RESULTS Of 6635 included hospitalizations, successful direct communication occurred in 2438 (36.7%). The most frequently reported reason for lack of direct communication was the health care providers perception that the discharge summary was adequate. Predictors of direct communication, adjusting for all other variables, included patients cared for by hospitalists without house staff (odds ratio [OR], 1.81 [95% CI, 1.59-2.08]), high expected 30-day readmission rate (OR, 1.18 [95% CI, 1.10-1.28] per 10%), and insurance by Medicare (OR, 1.35 [95% CI, 1.16-1.56]) and private insurance companies (OR, 1.35 [95% CI, 1.18-1.56]) compared with Medicaid. Direct communication with the outpatient health care provider was not associated with readmissions (OR, 1.08 [95% CI, 0.92-1.26]) in adjusted analysis. CONCLUSIONS AND RELEVANCE Self-reported direct communication between inpatient and outpatient providers occurred at a low rate but was not associated with readmissions. This suggests that enhancing interprovider communication at hospital discharge may not, in isolation, prevent readmissions.

Association between days to complete inpatient discharge summaries with all-payer hospital readmissions in Maryland.

OBJECTIVE Hospital discharge summaries can provide valuable information to future providers and may help to prevent hospital readmissions. We sought to examine whether the number of days to complete hospital discharge summaries is associated with 30-day readmission rate. PATIENTS AND METHODS This was a retrospective cohort study conducted on 87,994 consecutive discharges between January 1, 2013 and December 31, 2014, in a large urban academic hospital. We used multivariable logistic regression models to examine the association between days to complete the discharge summary and hospital readmissions while controlling for age, gender, race, payer, hospital service (gynecology-obstetrics, medicine, neurosciences, oncology, pediatrics, and surgical sciences), discharge location, length of stay, expected readmission rate in Maryland based on diagnosis and illness severity, and the Agency for Healthcare Research and Quality Comorbidity Index. Days to complete the hospital discharge summary-the primary exposure variable-was assessed using the 20th percentile (>3 vs ≤3 days) and as a continuous variable (odds ratio expressed per 3-day increase). The main outcome was all-cause readmission to any acute care hospital in Maryland within 30 days. RESULTS Among the 87,994 patients, there were 14,248 (16.2%) total readmissions. Discharge summary completion >3 days was significantly associated with readmission, with adjusted odds ratio (OR) (95% confidence interval [CI]) of 1.09 (1.04 to 1.13, P = 0.001). We also found that every additional 3 days to complete the discharge summary was associated with an increased adjusted odds of readmission by 1% (OR: 1.01, 95% CI: 1.00 to 1.01, P < 0.001). CONCLUSION Longer days to complete discharge summaries were associated with higher rates of all-cause hospital readmissions. Timely discharge summary completion time may be a quality indicator to evaluate current practice and as a potential strategy to improve patient outcomes. Journal of Hospital Medicine 2016;11:393-400. 2016 Society of Hospital Medicine.

Associations between hospital-wide readmission rates and mortality measures at the hospital level: Are hospital-wide readmissions a measure of quality?

The Centers for Medicare & Medicaid Services (CMS) have sought to reduce readmissions in the 30 days following hospital discharge through penalties applied to hospitals with readmission rates that are higher than expected. Expected readmission rates for Medicare fee-for-service beneficiaries are calculated from models that use patientlevel administrative data to account for patient morbidities. Readmitted patients are defined as those who are discharged from the hospital alive and then rehospitalized at any acute care facility within 30 days of discharge. These models explicitly exclude sociodemographic variables that may impact quality of and access to outpatient care. Specific exclusions are also applied based on diagnosis codes so as to avoid penalizing hospitals for rehospitalizations that are likely to have been planned. More recently, a hospital-wide readmission measure has been developed, which seeks to provide a comprehensive view of each hospital’s readmission rate by including the vast majority of Medicare patients. Like the conditionspecific readmission measures, the hospital-wide readmission measure also excludes sociodemographic variables and incorporates specific condition-based exclusions so as to avoid counting planned rehospitalizations (e.g., an admission for cholecystectomy following an admission for biliary sepsis). Although not currently used for payfor-performance, this measure has been included in the CMS Star Report along with other readmission measures. CMS does not currently disseminate a hospitalwide mortality measure, but does disseminate hospitallevel adjusted 30-day mortality rates for Medicare beneficiaries with discharge diagnoses of stroke, heart failure, myocardial infarction (MI), chronic obstructive pulmonary disease (COPD) and pneumonia, and principal procedure of coronary artery bypass grafting (CABG). It is conceivable that aggressive efforts to reduce readmissions might delay life-saving acute care in some scenarios, and there is prior evidence that heart failure readmissions are inversely (but weakly) related to heart failure mortality. It is also plausible that keeping tenuous patients alive until discharge might result in higher readmission rates. We sought to examine the relationship between hospital-wide adjusted 30-day readmissions and death rates across the acute care hospitals in the United States. Lacking a measure of hospital-wide death rates, we examined the relation between hospital-wide readmissions and each of the 6 condition-specific mortality measures. For comparison, we also examined the relationships between condition-specific readmission rates and mortality rates.

Unplanned 30-day hospital readmission as a quality measure in gynecologic oncology

OBJECTIVES Thirty-day readmission is used as a quality measure for patient care and Medicare-based hospital reimbursement. The primary study objective was to describe the 30-day readmission rate to an academic gynecologic oncology service. Secondary objectives were to identify risk factors and costs related to readmission. METHODS This was a retrospective, concurrent cohort study of all surgical admissions to an academic, high volume gynecologic oncology service during a two-year period (2013-2014). Data were collected on patient demographics, medical comorbidities, psychosocial risk factors, and results from a hospital discharge screening survey. Mixed logistic regression was used to identify factors associated with 30-day readmission and costs of readmission were assessed. RESULTS During the two-year study period, 1605 women underwent an index surgical admission. Among this population, a total of 177 readmissions (11.0%) in 135 unique patients occurred. In a surgical subpopulation with >1 night stay, a readmission rate of 20.9% was observed. The mean interval to readmission was 11.8days (SD 10.7) and mean length of readmission stay was 5.1days (SD 5.0). Factors associated with readmission included radical surgery for ovarian cancer (OR 2.87) or cervical cancer (OR 4.33), creation of an ostomy (OR 11.44), a Charlson score of ≥5 (OR 2.15), a language barrier (OR 3.36), a median household income in the lowest quartile (OR 6.49), and a positive discharge screen (OR 2.85). The mean cost per readmission was

Changes to inpatient versus outpatient hospitalization: Medicare's 2-midnight rule

25,416 (SD

Recovery Audit Contractor audits and appeals at three academic medical centers.

26,736), with the highest costs associated with gastrointestinal complications at

Case Study: Johns Hopkins Community Health Partnership: A model for transformation

32,432 (SD

Reconsidering Hospital Readmission Measures

32,148). The total readmission-related costs during the study period were

A Method for Attributing Patient-Level Metrics to Rotating Providers in an Inpatient Setting

4,523,959. CONCLUSIONS Readmissions to a high volume gynecologic oncology service were costly and related to radical surgery for ovarian and cervical cancer as well as to medical, socioeconomic and psychosocial patient variables. These data may inform interventional studies aimed at decreasing unplanned readmissions in gynecologic oncology surgical populations.

Hospitalizations with observation services and the Medicare Part A complex appeals process at three academic medical centers

Outpatient versus inpatient status determinations for hospitalized patients impact how hospitals bill Medicare for hospital services. Medicare policies related to status determinations and the Recovery Audit Contractor (RAC) program charged with postpayment review of such determinations are of increasing concern to hospitals and physicians. We present an overview and discussion of these policies, including the recent 2-midnight rule, the effect on status determinations by the RAC program, and other recent and pertinent legislative and regulatory activity. Finally, we discuss the future direction of Medicare status determination policies and the RAC program, so that physicians and other healthcare providers caring for hospitalized Medicare beneficiaries may better understand these important and dynamic topics.