Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, 185 Pilgrim Road, Boston, MA 02215, USA
Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St Louis, MO, USA.
BMJ. 2019 Aug 12;366:l4563. doi: 10.1136/bmj.l4563.
To determine any changes in total hospital revisits within 30 days of discharge after a hospital stay for medical conditions targeted by the Hospital Readmissions Reduction Program (HRRP).
Retrospective cohort study.
Hospital stays among Medicare patients for heart failure, acute myocardial infarction, or pneumonia between 1 January 2012 and 1 October 2015.
Medicare fee-for-service patients aged 65 or over.
Total hospital revisits within 30 days of discharge after hospital stays for medical conditions targeted by the HRRP, and by type of revisit: treat-and-discharge visit to an emergency department, observation stay (not leading to inpatient readmission), and inpatient readmission. Patient subgroups (age, sex, race) were also evaluated for each type of revisit.
Our study cohort included 3 038 740 total index hospital stays from January 2012 to September 2015: 1 357 620 for heart failure, 634 795 for acute myocardial infarction, and 1 046 325 for pneumonia. Counting all revisits after discharge, the total number of hospital revisits per 100 patient discharges for target conditions increased across the study period (monthly increase 0.023 visits per 100 patient discharges (95% confidence interval 0.010 to 0.035)). This change was due to monthly increases in treat-and-discharge visits to an emergency department (0.023 (0.015 to 0.032) and observation stays (0.022 (0.020 to 0.025)), which were only partly offset by declines in readmissions (-0.023 (-0.035 to -0.012)). Increases in observation stay use were more pronounced among non-white patients than white patients. No significant change was seen in mortality within 30 days of discharge for target conditions (-0.0034 (-0.012 to 0.0054)).
In the United States, total hospital revisits within 30 days of discharge for conditions targeted by the HRRP increased across the study period. This increase was due to a rise in post-discharge emergency department visits and observation stays, which exceeded the decline in readmissions. Although reductions in readmissions have been attributed to improvements in discharge planning and care transitions, our findings suggest that these declines could instead be because hospitals and clinicians have intensified efforts to treat patients who return to a hospital within 30 days of discharge in emergency departments and as observation stays.
确定在医院住院后 30 天内出院后的总医院复诊情况，这些医院住院是针对医院再入院减少计划（HRRP）所针对的医疗条件。
回顾性队列研究。
2012 年 1 月至 2015 年 10 月 1 日期间，医疗保险患者因心力衰竭、急性心肌梗死或肺炎住院。
年龄在 65 岁或以上的医疗保险自费患者。
在 HRRP 针对的医疗条件住院后 30 天内出院后的总医院复诊，以及按复诊类型：急诊科治疗和出院就诊、观察住院（未导致住院再入院）和住院再入院。还评估了每个复诊类型的患者亚组（年龄、性别、种族）。
我们的研究队列包括 2012 年 1 月至 2015 年 9 月期间的 3038740 例总指数住院治疗：心力衰竭 1357620 例，急性心肌梗死 634795 例，肺炎 1046325 例。出院后所有复诊计算在内，目标条件下每 100 例出院患者的总医院复诊次数在整个研究期间呈上升趋势（每月增加 0.023 次/100 例出院患者（95%置信区间 0.010 至 0.035））。这种变化是由于每月急诊科治疗和出院就诊（0.023（0.015 至 0.032）和观察住院（0.022（0.020 至 0.025））的就诊次数增加所致，而住院再入院的减少部分抵消了这一增长（-0.023（-0.035 至-0.012））。非白人患者观察住院使用率的增加比白人患者更为明显。出院后 30 天内目标条件的死亡率没有明显变化（-0.0034（-0.012 至 0.0054））。
在美国，HRRP 针对的条件出院后 30 天内的总医院复诊次数在整个研究期间呈上升趋势。这一增长是由于出院后急诊科就诊和观察住院的增加所致，超过了再入院的减少。尽管再入院的减少归因于出院计划和护理过渡的改善，但我们的研究结果表明，这些减少可能是因为医院和临床医生加大了努力，在 30 天内将返回医院的患者在急诊科和观察病房进行治疗。
