Date Presented 04/06/19
This study is the first in examining the relationship between PAC utilization, Medicare HRRP, and 30-day unplanned RSRR for HRRP targeted and nontargeted impairment conditions. The study finding provides healthcare policy makers with preliminary information to understand the impact of PAC utilization on RSRRs.
Primary Author and Speaker: Chih-Ying Li
Additional Authors and Speakers: Amol Karmarkar, Yu-Li Lin, Yong-Fang Kuo, Kenneth Ottenbacher
PURPOSE: The Centers for Medicare and Medicaid Services (CMS) had reported lower readmission rates after the passage and implementation of the Medicare Hospital Readmissions Reduction Program (HRRP) for three targeted conditions: acute myocardial infarction (AMI), congestive heart failure (CHF) and pneumonia [1-2]. However, the relative impact of post-acute care (PAC) utilization on readmission rates before/after HRRP passage and implementation remains unknown. It is also unclear whether HRRP affected readmission rates for the non-HRRP targeted conditions (e.g. stroke). To understand whether HRRP truly reduced readmission rate and the functionality of HRRP across the course of care continuum, this study aims to partition out the impact of PAC utilization on hospital readmission, and extend the care spectrum to non-HRRP targeted conditions. It is crucial for occupational therapists to understand how healthcare policy affects hospital readmission or care provision, particularly, across PAC settings.
DESIGN: Longitudinal data analyses by quarter were conducted to estimate and compare readmission trends with versus without PAC utilization, across three periods: (1) before law passage (March 2010), (2) after law passage and before HRRP implementation (after March 2010-October, 2012) and (3) after HRRP implementation (after October 2012). We used 100% Medicare claims data (2008-2015) for three HRRP-targeted conditions: AMI, CHF and pneumonia; and three non-targeted (or transition) conditions: ischemic stroke, lower extremity joint replacement (LEJR), and hip/femur fractures (HFF).
METHODS: From the Medicare Provider Analysis and Review (MedPAR) files, we first selected hospital discharges for a condition or procedure of interest based on the Medicare Severity-Diagnosis Related Group (MS-DRG), including AMI: 280-282; CHF: 291-293; pneumonia: 193-195; stroke: 61-66; LEJR: 469-470; HFF: 480-482, 533-536. This study followed the CMS inclusion/exclusion criteria on condition- and procedure-specific hospital-level 30-day risk-standardized readmission (RSRR) measures [3-4] to identify the inclusion sample. The sample was selected for those aged 66-100 at admission, with continuous Part A coverage and not enrolled in the managed care in the year before admission and 30 days after discharge, survived 30 days post discharge, and whose admission was either elective, urgent, or for emergency. Those were excluded if they were discharged against medical advice, transferred from skilled nursing facilities, with an admission of the same condition/procedure in the prior 30 days, or transferred to another hospital.
RESULTS: While PAC utilization was a significant predictor for RSRR in all conditions except pneumonia (p<0.05), PAC utilization did not affect RSRR trends between both periods 1-2 and periods 2-3. The effect of PAC utilization on RSRR is significant for AMI, pneumonia, and HFF; but the magnitude of the effect size were minimal, ranging from -0.0128 (-0.0137, -0.0119) to 0.0002 (0.0001, 0.0002). Non-targeted conditions were found with similar RSRRs trends as targeted conditions, across three periods.
CONCLUSION: The effects of PAC utilization on RSRR were significant but minimal for AMI, pneumonia and HFF. Non-targeted conditions had similar RSRRs trends as targeted conditions, indicating potential chain effect on RSRRs due to HRRP. Future study should explore whether other carry-over effects on other service utilizations due to HRRP passage and implementation. It is also crucial to identify whether other mediators on RSRRs existed, to validate the true effect of HRRP on RSRRs across the care continuum. The study finding provides healthcare policy makers preliminary information to understand the impact of PAC utilization on RSRRs.
References
1. Zuckerman, R. B., Sheingold, S. H., Orav, E. J., Ruhter, J., Epstein, A. M. (2016). Readmissions, observation, and the Hospital Readmissions Reduction Program. N Engl J Med, 374, 1543-51. doi:10.1056/NEJMsa1513024.
2. U.S. Department of Health and Human Services (2107). New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved Care and Savings. 8 June 2017. Accessed at http://innovation.cms.gov/Files/reports/patient-safety-results.pdf on 21 January 2016.
3. Centers for Medicare and Medicaid Services (2016). Condition-Specific Measures Updates and Specifications Report Hospital-Level 30-Day Risk-Standardized Readmission Measures. Access at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Measure-Methodology.html on 21 December 2017.
4. Centers for Medicare and Medicaid Services (2016). Procedure-Specific Measures Updates and Specifications Report Hospital-Level 30-Day Risk-Standardized Readmission Measures. Access at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Measure-Methodology.html on 21 December 2017.
