Resumen de Thirty-Day Hospital Readmission Following Discharge From Postacute Rehabilitation in Fee-for-Service Medicare Patients
Kenneth J. Ottenbacher, Amol Karmarkar, James E. Graham, Yong Fang Kuo
Importance The Centers for Medicare & Medicaid Services recently identified 30-day readmission after discharge from inpatient rehabilitation facilities as a national quality indicator. Research is needed to determine the rates and factors related to readmission in this patient population.
Objective To determine 30-day readmission rates and factors related to readmission for patients receiving postacute inpatient rehabilitation.
Design, Setting, and Patients Retrospective cohort study of records for 736 536 Medicare fee-for-service beneficiaries (mean age, 78.0 [SD, 7.3] years) discharged from 1365 inpatient rehabilitation facilities to the community in 2006 through 2011. Sixty-three percent of patients were women, and 85.1% were non-Hispanic white.
Main Outcomes and Measures Thirty-day readmission rates for the 6 largest diagnostic impairment categories receiving inpatient rehabilitation. These included stroke, lower extremity fracture, lower extremity joint replacement, debility, neurologic disorders, and brain dysfunction.
Results Mean rehabilitation length of stay was 12.4 (SD, 5.3) days. The overall 30-day readmission rate was 11.8% (95% CI, 11.7%-11.8%). Rates ranged from 5.8% (95% CI, 5.8%-5.9%) for patients with lower extremity joint replacement to 18.8% (95% CI, 18.8%-18.9%). for patients with debility. Rates were highest in men (13.0% [ 95% CI, 12.8%-13.1%], vs 11.0% [95% CI, 11.0%-11.1%] in women), non-Hispanic blacks (13.8% [95% CI, 13.5%-14.1%], vs 11.5% [95% CI, 11.5%-11.6%] in whites, 12.5% [95% CI, 12.1%-12.8%] in Hispanics, and 11.9% [95% CI, 11.4%-12.4%] in other races/ethnicities), beneficiaries with dual eligibility (15.1% [95% CI, 14.9%-15.4%], vs 11.1% [95% CI, 11.0%-11.2%] for no dual eligibility), and in patients with tier 1 comorbidities (25.6% [95% CI, 24.9%-26.3%], vs 18.9% [95% CI, 18.5%-19.3%] for tier 2, 15.1% [95% CI, 14.9%-15.3%] for tier 3, and 9.9% [95% CI, 9.9%-10.0%] for no tier comorbidities). Higher motor and cognitive functional status were associated with lower hospital readmission rates across the 6 impairment categories. Adjusted readmission rates by state ranged from 9.2% to 13.6%. Approximately 50% of patients rehospitalized within the 30-day period were readmitted within 11 days of discharge. Medicare Severity Diagnosis-Related Group codes for heart failure, urinary tract infection, pneumonia, septicemia, nutritional and metabolic disorders, esophagitis, gastroenteritis, and digestive disorders were common reasons for readmission.
Conclusions and Relevance Among postacute rehabilitation facilities providing services to Medicare fee-for-service beneficiaries, 30-day readmission rates ranged from 5.8% to 18.8% for selected impairment groups. Further research is needed to understand the causes of readmission.
The Patient Protection and Affordable Care Act1 created the hospital readmission reduction program to reduce readmissions and improve patient transitions from acute care. Research examining 30-day readmission has focused on patients discharged from acute care hospitals.2,3 Patients discharged to postacute care institutional settings have been excluded from previous research on hospital readmission.3- 6 Little research on hospital readmission has been reported for patients receiving postacute services.
The Medicare Payment Advisory Commission (MedPAC)7 recently began tracking hospital readmission for postacute care settings. In 2010, 12% of patients discharged from inpatient rehabilitation facilities to the community were readmitted to acute care hospitals within 30 days.7 The MedPAC report did not stratify these cases by impairment categories.7 It is important to study readmission after discharge from postacute rehabilitation for 3 reasons. First, it is known that certain patients at high risk for readmission are commonly referred to postacute rehabilitation (eg, stroke and hip fracture).4,6 Second, the Centers for Medicare & Medicaid Services (CMS) recently identified 30-day readmission as a national quality indicator for inpatient rehabilitation facilities.8,9 Reporting will be required by the CMS and is consistent with the Affordable Care Act.1,8 Third, the CMS has proposed bundled payment models (acute and postacute care) to align performance incentives and contain costs.10,11 Understanding the ramifications of bundling requires accurate information regarding readmission rates for patients receiving postacute services.
We examined records for patients from the 6 largest impairment categories receiving postacute inpatient rehabilitation. These include patients with stroke, lower extremity fracture, lower extremity joint replacement, debility, neurologic disorders, and brain dysfunction.4 Debility as a rehabilitation impairment category is defined as generalized deconditioning not attributable to neurologic, orthopedic, or cardiopulmonary diagnoses. We were interested in answering the following questions: What is the 30-day readmission rate following discharge from inpatient rehabilitation? Are there differences in readmission rates across impairment categories? Are readmissions associated with patient sociodemographics, clinical characteristics, functional status, or facility factors?
