Department of Emergency Medicine, University of Washington School of Medicine, Seattle.
Center for Health Economics and Policy, Institute for Public Health, Washington University in St Louis, St Louis, Missouri.
JAMA Netw Open. 2022 Nov 1;5(11):e2242587. doi: 10.1001/jamanetworkopen.2022.42587.
Decreases in 30-day readmissions following the implementation of the Medicare Hospital Readmissions Reduction Program (HRRP) have occurred against the backdrop of increasing hospital observation stay use, yet observation stays are not captured in readmission measures.
To examine whether the HRRP was associated with decreases in 30-day readmissions after accounting for observation stays.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included a 20% sample of inpatient admissions and observation stays among Medicare fee-for-service beneficiaries from January 1, 2009, to December 31, 2015. Data analysis was performed from November 2021 to June 2022. A differences-in-differences analysis assessed changes in 30-day readmissions after the announcement of the HRRP and implementation of penalties for target conditions (heart failure, acute myocardial infarction, and pneumonia) vs nontarget conditions under scenarios that excluded and included observation stays.
Thirty-day inpatient admissions and observation stays.
The study included 8 944 295 hospitalizations (mean [SD] age, 78.7 [8.2] years; 58.6% were female; 1.3% Asian; 10.0% Black; 2.0% Hispanic; 0.5% North American Native; 85.0% White; and 1.2% other or unknown). Observation stays increased from 2.3% to 4.4% (91.3% relative increase) of index hospitalizations among target conditions and 14.1% to 21.3% (51.1% relative increase) of index hospitalizations for nontarget conditions. Readmission rates decreased significantly after the announcement of the HRRP and returned to baseline by the time penalties were implemented for both target and nontarget conditions regardless of whether observation stays were included. When only inpatient hospitalizations were counted, decreasing readmissions accrued into a -1.48 percentage point (95% CI, -1.65 to -1.31 percentage points) absolute reduction in readmission rates by the postpenalty period for target conditions and -1.13 percentage point (95% CI, -1.30 to -0.96 percentage points) absolute reduction in readmission rates by the postpenalty period for nontarget conditions. This reduction corresponded to a statistically significant differential change of -0.35 percentage points (95% CI, -0.59 to -0.11 percentage points). Accounting for observation stays more than halved the absolute decrease in readmission rates for target conditions (-0.66 percentage points; 95% CI, -0.83 to -0.49 percentage points). Nontarget conditions showed an overall greater decrease during the same period (-0.76 percentage points; 95% CI, -0.92 to -0.59 percentage points), corresponding to a differential change in readmission rates of 0.10 percentage points (95% CI, -0.14 to 0.33 percentage points) that was not statistically significant.
The findings of this study suggest that the reduction of readmissions associated with the implementation of the HRRP was smaller than originally reported. More than half of the decrease in readmissions for target conditions appears to be attributable to the reclassification of inpatient admission to observation stays.
在医疗保险医院再入院减少计划（HRRP）实施的背景下，30 天再入院率有所下降，而观察住院的使用量却在增加，但观察住院并未纳入再入院率的衡量标准。
在考虑观察住院的情况下，研究 HRRP 是否与 30 天再入院率的下降有关。
设计、地点和参与者：本回顾性队列研究纳入了 2009 年 1 月 1 日至 2015 年 12 月 31 日期间，医疗保险按服务收费受益人的 20%的住院和观察住院样本。数据分析于 2022 年 11 月至 6 月进行。采用差异中的差异分析评估了 HRRP 公布和对目标条件（心力衰竭、急性心肌梗死和肺炎）和非目标条件实施处罚后 30 天再入院率的变化情况，在排除和纳入观察住院的情况下进行分析。
30 天内的住院和观察住院。
本研究共纳入了 8944295 例住院治疗（平均[标准差]年龄，78.7[8.2]岁；58.6%为女性；1.3%为亚洲人；10.0%为黑人；2.0%为西班牙裔；0.5%为北美原住民；85.0%为白人；1.2%为其他或未知）。目标条件下的索引住院观察住院比例从 2.3%增加到 4.4%（相对增加 91.3%），而非目标条件下的索引住院观察住院比例从 14.1%增加到 21.3%（相对增加 51.1%）。在 HRRP 公布后，再入院率显著下降，在对目标和非目标条件实施处罚之前，再入院率已恢复到基线水平。无论是否包括观察住院，仅计算住院治疗时，目标条件下的再入院率在处罚后期间绝对减少了 1.48 个百分点（95%CI，-1.65 至-1.31 个百分点），非目标条件下的再入院率绝对减少了 1.13 个百分点（95%CI，-1.30 至-0.96 个百分点）。这一减少对应着统计学上显著的差异变化，为 0.35 个百分点（95%CI，-0.59 至-0.11 个百分点）。考虑到观察住院，目标条件下的再入院率绝对降幅减少了一半以上（-0.66 个百分点；95%CI，-0.83 至-0.49 个百分点）。同期非目标条件的下降幅度总体更大（-0.76 个百分点；95%CI，-0.92 至-0.59 个百分点），这对应着再入院率差异变化为 0.10 个百分点（95%CI，-0.14 至 0.33 个百分点），但无统计学意义。
本研究结果表明，与 HRRP 实施相关的再入院率下降幅度比最初报告的要小。目标条件下再入院率下降的一半以上似乎归因于将住院治疗重新分类为观察住院。
