Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas.
Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa.
JAMA Cardiol. 2021 Feb 1;6(2):169-176. doi: 10.1001/jamacardio.2020.4928.
Thirty-day home time, defined as time spent alive and out of a hospital or facility, is a novel, patient-centered performance metric that incorporates readmission and mortality.
To characterize risk-adjusted 30-day home time in patients discharged with heart failure (HF) as a hospital-level quality metric and evaluate its association with the 30-day risk-standardized readmission rate (RSRR), 30-day risk-standardized mortality rate (RSMR), and 1-year RSMR.
DESIGN, SETTING, AND PARTICIPANTS: This hospital-level cohort study retrospectively analyzed 100% of Medicare claims data from 2 968 341 patients from 3134 facilities from January 1, 2012, to November 30, 2017.
Home time, defined as time spent alive and out of a short-term hospital, skilled nursing facility, or intermediate/long-term facility 30 days after discharge.
For each hospital, a risk-adjusted 30-day home time for HF was calculated similar to the Centers for Medicare & Medicaid Services risk-adjustment models for 30-day RSRR and RSMR. Hospitals were categorized into quartiles (lowest to highest risk-adjusted home time). The correlations between hospital rates of risk-adjusted 30-day home time and 30-day RSRR, 30-day RSMR, and 1-year RSMR were estimated using the Pearson correlation coefficient. Distribution of days lost from a perfect 30-day home time were calculated. Reclassification of hospital performance using 30-day home time vs 30-day RSRR was also evaluated.
Overall, 2 968 341 patients (mean [SD] age, 81.0 [8.3] years; 53.6% female) from 3134 hospitals were included in this study. The median hospital risk-adjusted 30-day home time for patients with HF was 21.77 days (range, 8.22-28.41 days). Hospitals in the highest quartile of risk-adjusted 30-day home time (best-performing hospitals) were larger (mean [SD] number of beds, 285 [275]), with a higher volume of patients with HF (median, 797 patients; interquartile range, 395-1484) and were more likely academic hospitals (59.9%) with availability of cardiac surgery (51.1%) and cardiac rehabilitation (68.8%). A total of 72% of home time lost was attributable to stays in an intermediate- or long-term care facility (mean [SD], 2.65 [6.44] days) or skilled nursing facility (mean [SD], 3.96 [9.04] days), 13% was attributable to short-term readmissions (mean [SD], 1.25 [3.25] days), and 15% was attributable to death (mean [SD], 1.37 [6.04] days). Among 30-day outcomes, the 30-day RSRR and 30-day RSMR decreased in a graded fashion across increasing 30-day home time categories (correlation coefficients: 30-day RSRR and 30-day home time, -0.23, P < .001; 30-day RSMR and 30-day home time, -0.31, P < .001). Similar patterns of association were also noted for 1-year RSMR and 30-day home time (correlation coefficient, -0.35, P < .001). Thirty-day home time meaningfully reclassified hospital performance in 30% of the hospitals compared with 30-day RSRR and in 25% of hospitals compared with 30-day RSMR.
In this study, 30-day home time among patients discharged after a hospitalization for HF was objectively assessed as a hospital-level quality metric using Medicare claims data and was associated with readmission and mortality outcomes and with reclassification of hospital performance compared with 30-day RSRR and 30-day RSMR.
30 天家庭时间，定义为活着并离开医院或医疗机构的时间，是一种新颖的、以患者为中心的绩效衡量标准，它结合了再入院率和死亡率。
将心力衰竭（HF）出院患者的风险调整 30 天家庭时间特征化为医院层面的质量指标，并评估其与 30 天风险标准化再入院率（RSRR）、30 天风险标准化死亡率（RSMR）和 1 年 RSMR 的关系。
设计、地点和参与者：这项医院层面的队列研究使用来自 2012 年 1 月 1 日至 2017 年 11 月 30 日的 3134 家医疗机构的 3134 家医疗机构的 100%医疗保险索赔数据，回顾性地分析了 2968341 名 Medicare 患者的数据。
家庭时间，定义为出院后 30 天内活着并离开短期医院、熟练护理设施或中/长期设施的时间。
对于每个医院，使用与 Medicare & Medicaid Services 用于 30 天 RSRR 和 RSMR 的风险调整模型相似的方法计算 HF 的风险调整 30 天家庭时间。将医院按风险调整 30 天家庭时间的四分位数（从最低到最高）进行分类。使用 Pearson 相关系数估计医院风险调整 30 天家庭时间与 30 天 RSRR、30 天 RSMR 和 1 年 RSMR 的相关率。计算了从完美的 30 天家庭时间中损失的天数分布。还评估了使用 30 天家庭时间与 30 天 RSRR 重新分类医院绩效的情况。
共有 2968341 名（平均[标准差]年龄，81.0[8.3]岁；53.6%为女性）来自 3134 家医院的患者纳入本研究。HF 患者的医院中位风险调整 30 天家庭时间为 21.77 天（范围，8.22-28.41 天）。风险调整 30 天家庭时间最高四分位数（表现最佳的医院）的医院规模更大（平均[标准差]床位数量，285[275]），HF 患者数量更多（中位数，797 例；四分位数间距，395-1484），更有可能是学术医院（59.9%），并提供心脏手术（51.1%）和心脏康复（68.8%）。总共有 72%的家庭时间损失归因于中/长期护理设施（平均[标准差]，2.65[6.44]天）或熟练护理设施（平均[标准差]，3.96[9.04]天）的停留，13%归因于短期再入院（平均[标准差]，1.25[3.25]天），15%归因于死亡（平均[标准差]，1.37[6.04]天）。在 30 天的结果中，30 天 RSRR 和 30 天 RSMR 随着 30 天家庭时间类别的增加呈分级下降（相关系数：30 天 RSRR 和 30 天家庭时间，-0.23，P<0.001；30 天 RSMR 和 30 天家庭时间，-0.31，P<0.001）。对于 1 年 RSMR 和 30 天家庭时间，也观察到类似的关联模式（相关系数，-0.35，P<0.001）。与 30 天 RSRR 相比，30 天家庭时间在 30%的医院中显著重新分类了医院的表现，与 30 天 RSMR 相比，在 25%的医院中也显著重新分类了医院的表现。
在这项研究中，使用医疗保险索赔数据客观评估了心力衰竭出院患者的 30 天家庭时间作为医院层面的质量衡量标准，并与再入院率和死亡率结果相关，并与 30 天 RSRR 和 30 天 RSMR 相比，重新分类了医院的表现。
