Hospital revisits within 30 days after discharge for medical conditions targeted by the Hospital Readmissions Reduction Program in the United States: national retrospective analysis
Hospital revisits within 30 days after discharge for medical conditions targeted by the Hospital Readmissions Reduction Program in the United States: national retrospective analysis
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DOI：
10.1136/bmj.l4563
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发表时间：
2019-08-12
影响因子：
105.7
通讯作者：
Yeh, Robert W.
中科院分区：
文献类型：
--
作者：
Wadhera, Rishi K.;Maddox, Karen E. Joynt;Yeh, Robert W.
目的 确定因医院再入院减少计划 (HRRP) 所针对的医疗状况而出院后 30 天内重新就诊总数的变化。设计回顾性队列研究。设置 2012 年 1 月 1 日至 2015 年 10 月 1 日期间因心力衰竭、急性心肌梗塞或肺炎而参加医疗保险的患者住院。参与者年龄为 65 岁或以上的医疗保险付费患者主要结果 因 HRRP 指定的医疗状况而出院后 30 天内重新就诊的医院总数，按复诊类型划分：治疗后出院到急诊室就诊、留院观察（不会导致患者再次入院）以及患者再入院。还针对每种类型的复诊对患者亚组（年龄、性别、种族）进行了评估。 结果我们的研究队列包括 2012 年 1 月至 2015 年 9 月期间总指数住院的 3 038 740 例患者：1 357 620 例心力衰竭患者、634 795 例急性心肌梗死患者和 1 046 325 例肺炎患者。计算出院后的所有复诊次数，在整个研究期间，每 100 名出院患者因目标病情而再次就诊的总数有所增加（每 100 名患者出院每月增加 0.023 次就诊（95% 置信区间 0.010 至 0.035））。这一变化是由于急诊科治疗和出院就诊次数每月增加（0.023（0.015至0.032）和观察住院次数（0.022（0.020至0.025）），但仅部分被再入院人数下降（-0.023（-0.035至-0.012））所抵消。非白人患者中观察住院使用率的增加更为明显白人患者出院后 30 天内的目标疾病死亡率没有显着变化（-0.0034（-0.012 至 0.0054））。 结论 在美国，在整个研究期间，出院后 30 天内因 HRRP 目标疾病再次就诊的总数有所增加，这是由于出院后急诊科就诊和留院观察的增加，超过了再入院的下降。虽然归因于出院计划和护理过渡的改进，但我们的研究结果表明，这些下降可能是因为医院和临床医生加大了治疗力度，对出院后 30 天内在急诊科和观察期间返回医院的患者进行治疗。
OBJECTIVETo 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).DESIGNRetrospective cohort study.SETTINGHospital stays among Medicare patients for heart failure, acute myocardial infarction, or pneumonia between 1 January 2012 and 1 October 2015.PARTICIPANTSMedicare fee-for-service patients aged 65 or over.MAIN OUTCOMESTotal 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.RESULTSOur 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)).CONCLUSIONSIn 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.