Post-discharge Acute Care and Outcomes in the Era of Readmission Reduction: A National Retrospective Cohort Study of Medicare Beneficiaries in the United States

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. Objective 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. Design, Setting, and Participants In this observational study of national Medicare claims data for 2008-2016, we identified patients ≥65 years hospitalized with heart failure (HF), acute myocardial infarction (AMI), or pneumonia, conditions included in the HRRP. Main Outcomes and Measures Post-discharge 30-day mortality according to patients’ 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. Results 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. Conclusions 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. What is already known on this topic Among Medicare beneficiaries hospitalized for heart failure, mortality in the 30-day post-discharge period has been increasing over the past several years. However, the relationship between post-discharge acute care and mortality in the early post-discharge period remains poorly understood. Observation units and the emergency departments (ED) have increasingly been used as avenues for patient care in the United States. However, the utilization of these services in the early post-discharge period for conditions targeted in the Hospital Readmissions Reduction Program (HRRP), and the outcomes of patients in these settings, is required to appropriately evaluate the effects of the program. What this study adds Among conditions targeted in the HRRP, patients with heart failure, but not those with acute myocardial infarction or pneumonia, experienced increase in post-discharge 30-day mortality. This increase preceded the announcement of the program and was concentrated among individuals who sought no post-discharge acute care, nearly half of whom had been discharged to hospice. Despite increasing utilization of observation units and the ED in the post-discharge period, care in these settings was not associated with increased mortality risk.