Multiyear Rehospitalization Rates and Hospital Outcomes in an Integrated Health Care System
Authors: Gabriel J. Escobar, Colleen Plimier, John D. Greene, Vincent Liu, Patricia Kipnis
Journal: JAMA Network Open (2019)

<h3>Importance</h3> Since the introduction of the rehospitalization rate as a quality measure, multiple changes have taken place in the US health care delivery system. Interpreting rehospitalization rates without taking a global view of these changes and new data elements from comprehensive electronic medical records yields a limited assessment of the quality of care. <h3>Objective</h3> To examine hospitalization outcomes from a broad perspective, including the implications of numerator and denominator definitions, all adult patients with all diagnoses, and detailed clinical data. <h3>Design, Setting, and Participants</h3> This cohort study obtained data from 21 hospitals in Kaiser Permanente Northern California (KPNC), an integrated health care delivery system that serves patients with Medicare Advantage plans, Medicaid, and/or Kaiser Foundation Health Plan. The KPNC electronic medical record system was used to capture hospitalization data for adult patients who were 18 years of age or older; discharged from June 1, 2010, through December 31, 2017; and hospitalized for reasons other than childbirth. Hospital stays for transferred patients were linked using public and internal sources. <h3>Exposures</h3> Hospitalization type (inpatient, for observation only), comorbidity burden, acute physiology score, and care directives. <h3>Main Outcomes and Measures</h3> Mortality (inpatient, 30-day, and 30-day postdischarge), nonelective rehospitalization, and discharge disposition (home, home with home health assistance, regular skilled nursing facility, or custodial skilled nursing facility). <h3>Results</h3> In total, 1 384 025 hospitalizations were identified, of which 1 155 034 (83.5%) were inpatient and 228 991 (16.5%) were for observation only. These hospitalizations involved 679 831 patients (mean [SD] age, 61.4 [18.1] years; 362 582 female [53.3%]). The number of for-observation-only hospitalizations increased from 16 497 (9.4%) in the first year of the study to 120 215 (20.5%) in the last period of the study, whereas inpatient hospitalizations with length of stay less than 24 hours decreased by 33% (from 12 008 [6.9%] to 27 108 [4.6%]). Illness burden measured using administrative data or acute physiology score increased significantly. The proportion of patients with a Comorbidity Point Score of 65 or higher increased from 20.5% (range across hospitals, 18.4%-26.4%) to 28.8% (range, 22.3%-33.0%), as did the proportion with a Charlson Comorbidity Index score of 4 or higher, which increased from 28.8% (range, 24.6%-35.0%) to 38.4% (range, 31.9%-43.4%). The proportion of patients at or near critical illness (Laboratory-based Acute Physiology Score [LAPS2] ≥110) increased by 21.4% (10.3% [range across hospitals, 7.4%-14.7%] to 12.5% [range across hospitals, 8.3%-16.6%];<i>P</i> &lt; .001), reflecting a steady increase of 0.07 (95% CI, 0.04-0.10) LAPS2 points per month. Unadjusted inpatient mortality in the first year of the study was 2.78% and in the last year was 2.71%; the corresponding numbers for 30-day mortality were 5.88% and 6.15%, for 30-day postdischarge mortality were 3.94% and 4.22%, and for nonelective rehospitalization were 12.00% and 12.81%, respectively. All outcomes improved after risk adjustment. Compared with the first month, the final observed to expected ratio was 0.79 (95% CI, 0.73-0.84) for inpatient mortality, 0.86 (95% CI, 0.82-0.89) for 30-day mortality, 0.90 (95% CI, 0.85-0.95) for 30-day nonelective rehospitalization, and 0.87 (95% CI, 0.83-0.92) for 30-day postdischarge mortality. The proportion of nonelective rehospitalizations meeting public reporting criteria decreased substantially over the study period (from 58.0% in 2010-2011 to 45.2% in 2017); most of this decrease was associated with the exclusion of observation stays. <h3>Conclusions and Relevance</h3> This study found that in this integrated system, the hospitalization rate decreased and risk-adjusted hospital outcomes improved steadily over the 7.5-year study period despite worsening case mix. The comprehensive results suggest that future assessments of care quality should consider the implications of numerator and denominator definitions, display multiple metrics concurrently, and include all hospitalization types and detailed data.