Steven J. Korzeniewski, PhD-Candidate, MSc, MA, Director, Statistical Analysis Resource Group (SARG) & Chief Scientific Officer

Objective: Describe the distribution of readmissions across the lifespan, focusing on Michigan data where possible Outline: Brief History of Readmissions (since 1960) Readmissions Across the lifespan Michigan Data ReWaRD Provisional Data Medicare FFS Prevention Literature (controversies) Encouraging Evidence of Intervention Impact Preliminary findings of the MPRO Care Transitions Project Please note that slides are intentionally ‘rich’ with text, oral presentation will emphasize key points.

Early readmission literature focused almost universally on psychiatric patients. Studies published in the 1960s focused on:  Family therapy in preventing readmissions, (Berman 1966)  Alternatives to mental patient rehospitalization (Miller, 1966)  Social process and readmission to mental hospital (Rapheal, 1966)  Marital status and interpersonal dynamics and readmission (Gynther, 1967)  Ex-mental patient readmissions (Maisel, 1967)  Correlates of psychiatric readmissions (Tuckman, 1967; Arthur 1968)

Readmissions did not capture widespread national attention until the 1980s Zook and Moore reported: hospitalizations accounted for nearly half of all healthcare expenses in the United States estimated that 13% of inpatients used half of all hospital resources through repeated admissions. Zook CJ, Moore FD. High Cost Users of Medical Care. N Engl J Med. 1980;302: Medicare moved from a FFS to a prospective payment system, based reimbursement on average lengths of stay given a patient’s diagnosis caused concern that financial incentive for earlier and perhaps premature discharges would increase readmission rates.

1984, Anderson and Steinberg published their seminal study of 270,266 randomly selected Medicare beneficiaries, revealed: 22% of Medicare hospitalizations from were followed by a readmission within 60 days of discharge, Estimated annual cost to Medicare of $2.5 billion. [i] Anderson GF, Steinberg EP. Hospital Readmissions in the Medicare Population. N Engl J Med Nov 22;311(21):

Follow-up measurement of the overall Medicare population rehospitalization rate did not occur until the 2007 and 2008 Medicare Payment Advisory Commission (MedPAC) reports Noted that 17.6% of Medicare patients discharged from a hospital in 2005 were readmitted within 30 days. “Medicare Payment Advisory Commission. Payment Policy for Inpatient Readmissions,” from: Report to the Congress: Promoting Greater Efficiency in Medicare. Washington, DC; June 2007: Available at:

Medicare population 60-day readmission rate increased by 40% compared to Anderson and Steinberg’s findings published 25 years prior.  one of five (19.6%) Medicare beneficiaries discharged from a hospital from were rehospitalized within 30 days,  estimated annual unplanned rehospitalization cost of $17.4 billion for Medicare alone. Jencks SF, Williams MV, Coleman EA. Rehospitalizations Among Patients in the Medicare Fee-for-service Program. N Engl J Med. 2009;360:

Medicare rehospitalization rate was 45% greater in the five states with the highest rates than in the five states with the lowest rates. Extreme variation is likely indicative of differences in healthcare quality and patient population characteristics across the US. As noted by Jenck’s et al., further study is necessary to understand these differences and discern whether prevention strategies in low-risk settings are exportable to high-risk settings. Figure: Rates of Rehospitalization within 30 Days of Hospital Discharge, Medicare Fee-For-Service Beneficiaries Discharged 10/1/2003-9/30/2004, United States

40% of Medicare beneficiaries are discharged from an acute care hospital stay to a post-acute care setting; of those, roughly half enter a nursing home for skilled nursing care or rehabilitation services. HCUPnet [cited 2009 July 21]; Available from: Mor et al. (2010) report that on average 23.5% of SNF residents are rehospitalized within 30 days of an acute care hospital discharge amounting to a total annual cost of $4.35 billion for Medicare alone based on analysis of CMS data from ; their study further noted a 29% increase in rehospitalizations during this time period. Michigan has the sixth greatest SNF resident readmission rate (25.8%) in the US, accounting for an estimated $175 million Medicare expenditure annually. Michigan also has the fifth greatest rate of prior nursing home use among rehospitalized residents. Figure 1: Rehospitalization Rates in Total and by Prior Nursing Home Use among Medicare Beneficiaries, ( Mor, V., et al., The Revolving Door Of Rehospitalization From Skilled Nursing Facilities. Health Affairs, (1): p )

Readmissions are not isolated among the Medicare population, they are prevalent across the lifespan. About 15% of preterm infants require at least one rehospitalization within the first year of life; average cost per readmission $8468, average annual cost in excess of $41 million. (Underwood et al.) 16.7% of the 186,856 pediatric patients discharged from 38 US children’s hospitals from were readmitted within one year. (Feudtner et al.)

after admission for a PQI condition were rehospitalized within six months; readmission rates increased linearly with age. 1 of 5 Pediatric Patients PQI Conditions Diabetes short-term complication admission rate Perforated appendix admission rate Diabetes long-term complication admission rate Chronic obstructive pulmonary disease admission rate Hypertension admission rate Congestive heart failure admission rate Low Birth Weight Dehydration admission rate Bacterial pneumonia admission rate Urinary tract infection admission rate Angina admission without procedure Uncontrolled diabetes admission rate Adult asthma admission rate Rate of lower-extremity amputation among patients with diabetes

Goldfield et al. applied definition of ‘preventable readmissions’ to greater than four million admissions from 234 Florida hospitals from % were followed by a potentially preventable readmission within 15 days. -preventable readmission rates were linearly associated with age. Readmissions are not only prevalent across the lifespan, many are preventable.

Provisional Multi-Payer Data, 2008

Reporting Template: Day All Cause Readmissions- Time Period: CY2008- PROVISIONAL DATA Payers: HAP, Health Plus, Medicaid, Priority Health, Medicare, BCN, BCBSM PRODUCT Line See Data Definitions for Column Descriptions abcdefghI AGE GROUP Type of Index Admission Discharges at Risk RA to the Same HospitalRA to a Different HospitalRA to Any Hospital NN%N%N% Commercial Adult M81,7358, %2,8443.5%11, % S84,8784,4805.3%1,1231.3%5,6036.6% O41, %1740.4%1,1712.8% Pediatric M11, %1941.7%9688.6% S3, %320.9%2136.0% O %61.1%264.8% Post-neonatal M3, %581.8%2548.0% S %242.7%768.7% Neonatal M24, %1490.6%4351.7% S %102.6%369.3% Total 252,99615,6716.2%4,6141.8%20,2878.0% Medicaid FFS (managed care data not shown for presentation purposes) Adult M64,0175,2348.2%2,1343.3%7, % S18,5131,0135.5%3171.7%1,3307.2% O31, %2030.7%1,1433.7% Pediatric M7,0391, %1041.5%1, % S1, %131.0% % O1, %131.1%484.2% Post-neonatal M2, %863.5% % S %113.1%6217.5% Neonatal M31, %4031.3%7502.4% S7356.9% % Total 157,6149,3956.0%3,2892.1%12,6848.1% Medicare (FFS) Adult M280,01245, %11,6574.2%56, % S117,3119,7978.4%2,7122.3%12, % Total 398,83655, %14,5733.7%69, % Total by Age Group Adult737,54478, %21,8843.0%100, % Pediatric26,3782,5919.8%3691.4%2, % Post-neonatal7, %1832.5% % Neonatal58, %5811.0%1,2832.2% Grand Total829,76882,5429.9%23,0172.8%105, % Adult Medical Discharges Pediatric Medical Discharges Overall Rate

Michigan Medicare FFS Patient 30-Day All Cause Readmission Rates (%) by County, 2010 CMS 7.2 Care Transitions Counties Readmission Rate=18% Statewide Medicare FFS Patient Readmission Rate= ~19% Readmission Rates are Greatest in Southeast Michigan Medicare FFS Inpatient Data, ISAT Database, Not for General Distribution, Provisional Data

30-Day All Cause Readmission Rate by Age, Race & Sex, Michigan Medicare (FFS) Beneficiaries Discharged from a Michigan hospital from January 1, 2008 through June 30, 2010

30-Day All Cause Readmission Rate by Selected Diagnoses, Michigan Medicare (FFS) Beneficiaries Discharged from a Michigan hospital from January 1, 2008 through June 30, 2010

Urban vs. Rural Hospital 30-Day All Cause Readmission Rate, Michigan Medicare (FFS) Beneficiaries Discharged from a Michigan hospital from January 1, 2008 through June 30, 2010

30-Day All Cause Readmission Rate by Physician Follow-up Prior to Readmission or 30 days, Michigan Medicare (FFS) Beneficiaries Discharged from a Michigan hospital from January 1, 2008 through June 30, 2010 Adjusted for time to readmission

Descriptive Characteristics and Rate of 30-day All-Cause Readmission among Medicare FFS Beneficiaries Admitted to an Acute Care Hospital in Central Michigan, 1/1/08 - 3/31/10 (NOT FOR GENERAL DISTRIBUTION) Population Segment Total Discharges Eligible for Readmission Readmission Within 30-days of Discharge N%N% Race White* Black Other Age < >75* Sex M F* Length of Stay < 4 days* days > 8 days Diagnosis CHF AMI PNE COPD OTHER* Physician Follow-up within 30 days of discharge or prior to readmission No Yes* Number of Admissions in 180 Days Prior to Index Admission 0* ≥ Post Discharge Care Self* HHA SNF Other Total Recent Admission history was by far the most significant predictor of readmission; adjusted HR 3.18 (CI: ) Patients having >3 admissions in the past 6 months accounted for 40% fewer admissions, yet 8% more readmissions than patients admitted for CHF, AMI, PNE or COPD COMBINED…..

Declining number of admissions resulted in less improvement when rates were denominated to eligible readmissions. When denominated to eligible Medicare FFS beneficiaries, we observed an 18% RIR.

If the number of admissions declines at the same ‘pace’ as readmissions, the rate denominated to discharges appears constant.

Debate continues about the degree of preventability; To date, there is no accepted case definition for ‘preventable’ readmission. Ashton and Wray’s systematic (1996) review draw attention to limitations of past studies concluding that it is impossible to say with confidence that early readmission is or is not a valid and useful quality indicator based on current evidence. Reported relationship is confounded by: improper study design, omission of important variables, and mis-specification of variables. Ashton et al.’s meta-analysis (1997) and Benbassat and Taragin’s review (2000) report that approximately 9%-55% of readmissions are preventable. The latter study further noted that findings from prospective randomized trials suggest that 12%-75% of all readmissions can be prevented. More recently (2010), LaMantia et al.’s systematic review of interventions to improve transitional care between nursing homes and hospitals also reported that further research is necessary to better define target populations and outcome measures for high-quality transitional care.

Readmissions have been studied for over fifty years; early studies focused on psychiatric patients Anderson and Steinberg’s seminal study and Medicare payment reform created widespread national attention readmissions during the 1980s. MedPAC & Jencks et al.’s studies reinvigorated attention towards readmissions. Much has yet to be learned about how to prevent readmissions based on past literature, although much encouraging evidence exists. The MPRO CT project findings suggest that patients with greater numbers of past admissions account for fewer admissions yet more readmissions than patients admitted for CHF, AMI, PNE or COPD COMBINED.

This material was prepared by MPRO, the Medicare Quality Improvement Organization for Michigan, which is under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 9SOW-MI

While past findings per intervention impact are heterogeneous overall, encouraging evidence exists. 2strategies stand out for having undergone significant evaluation over the past decade that resulted in encouraging evidence of impact on readmissions: Care Transitions Intervention (CTI sm ) CTI sm basically consists of cross-site communication tools, engagement of patients in their care, and implementation of transition coaches; studies suggest that these strategies nearly halve the readmission rate, increase appropriate medication use and reduce healthcare costs among chronically ill and high-risk Medicare patients.(Coleman, Smith et al. 2004; Coleman, Parry et al. 2006; Parry, Min et al. 2009) INTERACT (Interventions to reduce Acute Care Transfers). INTERACT is a set of strategies focused on communication across care settings, care paths and advance care planning developed by CMS and the QIO for Georgia to reduce potentially avoidable acute care transfers from nursing homes. Ouslander et al.’s pilot study in three nursing homes characterized by high readmission rates reported a 50% reduction in the overall rate of potentially avoidable hospitalizations during a six month intervention period relative to baseline.(Ouslander, Perloe et al. 2009)

In 2009, CMS initiated the Care Transitions Project to reduce community-wide rates of rehospitalizations among 14 selected communities, including one in central Michigan. Findings to date include: an 18.4% decrease in the number of 30-day all-cause readmissions per 1,000 eligible Medicare FFS beneficiaries residing in the target area weighted for days of observation in the 9 th quarter relative to baseline. Regression analysis revealed a marginally significant reduction in the hazard of readmission by calendar year quarter during the study period (p=0.11), suggesting that the decline would not necessarily be expected by chance alone. While a strong association was observed between post discharge physician visit and readmission, 25% of patients lacking a claim for post discharge physician visit were readmitted within 3 days meaning many had little time to enact the visit.