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Programs from the Centers for Medicare and Medicaid Services simultaneously promote strategies to lower hospital admissions and readmissions. However, there is concern that hospitals in communities that successfully reduce admissions may be penalized, as patients that are ultimately hospitalized may be sicker and at higher risk of readmission. We therefore examined the relationship between changes from 2010 to 2013 in admission rates and thirty-day readmission rates for elderly Medicare beneficiaries. We found that communities with the greatest decline in admission rates also had the greatest decline in thirty-day readmission rates, even though hospitalized patients did grow sicker as admission rates declined. The relationship between changing admission and readmission rates persisted in models that measured observed readmission rates, risk-standardized readmission rates, and the combined rate of readmission and death. Our findings suggest that communities can reduce admission rates and readmission rates in parallel, and that federal policy incentivizing reductions in both outcomes does not create contradictory incentives., (Project HOPE—The People-to-People Health Foundation, Inc.)

Background: Despite its large clinical and economic significance, measuring and improving the outcomes of patients hospitalized for chronic obstructive pulmonary disease (COPD) is only beginning to emerge as a national priority for policy makers and payers., Objective: To facilitate the public reporting of hospital outcomes, we developed a risk-standardized measure of hospital 30-day mortality for patients admitted with exacerbation of COPD., Design: Hierarchical logistic regression model., Setting/patients: Medicare Part A and Part B claims in a random sample of half of all admissions for patients admitted to acute care hospitals in 2008 (development cohort) and remaining 2008 admissions (validation cohort). We also assessed model performance and predictive ability in 2007 and 2009 data., Measurements: Hospital risk-standardized 30-day mortality rates., Results: The model development sample consisted of 150,035 admissions at 4537 nonfederal acute care US hospitals, with a mean unadjusted hospital 30-day mortality rate of 8.6%. The mean risk-standardized mortality rate was 8.6% and ranged from 5.9% to 13.5%. The development and validation models had good discrimination (areas under the receiver operating characteristic curve 0.72 and 0.72, respectively) and predictive ability (predicted mortality at the 1st and 10th deciles 1.5%, 23.7%, and 1.6%, 23.8%, respectively) and showed no evidence of over-fitting., Conclusions: A 30-day mortality model based on administrative claims had similar discrimination to other public reporting models and can be used to compare risk-adjusted outcomes for patients with exacerbations of COPD and to track changes in outcomes over time. The high mortality and variation in rates across institutions suggest opportunities to improve quality of care., (Copyright © 2013 Society of Hospital Medicine.)

Importance: The Centers for Medicare & Medicaid Services publicly reports hospital 30-day, all-cause, risk-standardized mortality rates (RSMRs) and 30-day, all-cause, risk-standardized readmission rates (RSRRs) for acute myocardial infarction, heart failure, and pneumonia. The evaluation of hospital performance as measured by RSMRs and RSRRs has not been well characterized., Objective: To determine the relationship between hospital RSMRs and RSRRs overall and within subgroups defined by hospital characteristics., Design, Setting, and Participants: We studied Medicare fee-for-service beneficiaries discharged with acute myocardial infarction, heart failure, or pneumonia between July 1, 2005, and June 30, 2008 (4506 hospitals for acute myocardial infarction, 4767 hospitals for heart failure, and 4811 hospitals for pneumonia). We quantified the correlation between hospital RSMRs and RSRRs using weighted linear correlation; evaluated correlations in groups defined by hospital characteristics; and determined the proportion of hospitals with better and worse performance on both measures., Main Outcome Measures: Hospital 30-day RSMRs and RSRRs., Results: Mean RSMRs and RSRRs, respectively, were 16.60% and 19.94% for acute myocardial infarction, 11.17% and 24.56% for heart failure, and 11.64% and 18.22% for pneumonia. The correlations between RSMRs and RSRRs were 0.03 (95% CI, -0.002 to 0.06) for acute myocardial infarction, -0.17 (95% CI, -0.20 to -0.14) for heart failure, and 0.002 (95% CI, -0.03 to 0.03) for pneumonia. The results were similar for subgroups defined by hospital characteristics. Although there was a significant negative linear relationship between RSMRs and RSRRs for heart failure, the shared variance between them was only 2.9% (r2 = 0.029), with the correlation most prominent for hospitals with RSMR <11%., Conclusion and Relevance: Risk-standardized mortality rates and readmission rates were not associated for patients admitted with an acute myocardial infarction or pneumonia and were only weakly associated, within a certain range, for patients admitted with heart failure.

Background: Hospital-level, 30-day risk-standardized mortality and readmission rates are publicly reported for Medicare patients admitted with acute myocardial infarction (AMI), heart failure (HF), and pneumonia, but the correlations among mortality rates and among readmission rates within US hospitals for these conditions are unknown. Correlation among measures within the same hospital would suggest that there are common hospital-wide quality factors., Methods: We designed a cross-sectional study of US hospital 30-day risk-standardized mortality and readmission rates for Medicare fee-for-service beneficiaries from July 2007 to June 2009. We assessed the correlation between pairs of risk-standardized mortality rates and pairs of risk-standardized readmission rates for AMI, HF, and pneumonia., Results: The mortality cohort included 4559 hospitals, and the readmission cohort included 4468 hospitals. Every mortality measure was significantly correlated with every other mortality measure (range of correlation coefficients, 0.27-0.41, P < 0.0001 for all correlations). Every readmission measure was significantly correlated with every other readmission measure (range of correlation coefficients, 0.32-0.47, P < 0.0001 for all correlations). For each condition pair and outcome, one-third or more of hospitals were in the same quartile of performance. Correlations were highest within large, nonprofit, urban, and/or Council of Teaching Hospitals members. For any given condition pair, the correlation between readmission rates was significantly higher than the correlation between mortality rates (P < 0.01 for all pairs)., Conclusion: Risk-standardized readmission rates are moderately correlated with each other within hospitals, as are risk-standardized mortality rates. This suggests that there may be common hospital-wide factors affecting hospital outcomes., (Copyright © 2012 Society of Hospital Medicine.)

Background: In-hospital mortality measures, which are widely used to assess hospital quality, are not based on a standardized follow-up period and may systematically favor hospitals with shorter lengths of stay (LOSs)., Objective: To assess the agreement between performance measures of U.S. hospitals by using risk-standardized in-hospital and 30-day mortality rates., Design: Observational study., Setting: Nonfederal acute care hospitals in the United States with at least 30 admissions for acute myocardial infarction (AMI), heart failure (HF), and pneumonia from 2004 to 2006., Patients: Medicare fee-for-service patients admitted for AMI, HF, or pneumonia from 2004 to 2006., Measurements: The primary outcomes were in-hospital and 30-day risk-standardized mortality rates (RSMRs)., Results: Included patients comprised 718,508 admissions to 3135 hospitals for AMI, 1,315,845 admissions to 4209 hospitals for HF, and 1,415,237 admissions to 4498 hospitals for pneumonia. The hospital-level mean patient LOS varied across hospitals for each condition, ranging from 2.3 to 13.7 days for AMI, 3.5 to 11.9 days for HF, and 3.8 to 14.8 days for pneumonia. The mean RSMR differences (30-day RSMR minus in-hospital RSMR) were 5.3% (SD, 1.3) for AMI, 6.0% (SD, 1.3) for HF, and 5.7% (SD, 1.4) for pneumonia; distributions varied widely across hospitals. Performance classifications differed between the in-hospital and 30-day models for 257 hospitals (8.2%) for AMI, 456 (10.8%) for HF, and 662 (14.7%) for pneumonia. Hospital mean LOS was positively correlated with in-hospital RSMRs for all 3 conditions., Limitation: Medicare claims data were used for risk adjustment., Conclusion: In-hospital mortality measures provide a different assessment of hospital performance than 30-day mortality and are biased in favor of hospitals with shorter LOSs., Primary Funding Source: The Centers for Medicare & Medicaid Services and National Heart, Lung, and Blood Institute.

Background: Patient outcomes provide a critical perspective on quality of care. The Centers for Medicare and Medicaid Services (CMS) is publicly reporting hospital 30-day risk-standardized mortality rates (RSMRs) and risk-standardized readmission rates (RSRRs) for patients hospitalized with acute myocardial infarction (AMI) and heart failure (HF). We provide a national perspective on hospital performance for the 2010 release of these measures., Methods and Results: The hospital RSMRs and RSRRs are calculated from Medicare claims data for fee-for-service Medicare beneficiaries, 65 years or older, hospitalized with AMI or HF between July 1, 2006, and June 30, 2009. The rates are calculated using hierarchical logistic modeling to account for patient clustering, and are risk-adjusted for age, sex, and patient comorbidities. The median RSMR for AMI was 16.0% and for HF was 10.8%. Both measures had a wide range of hospital performance with an absolute 5.2% difference between hospitals in the 5th versus 95th percentile for AMI and 5.0% for HF. The median RSRR for AMI was 19.9% and for HF was 24.5% (3.9% range for 5th to 95th percentile for AMI, 6.7% for HF). Distinct regional patterns were evident for both measures and both conditions., Conclusions: High RSRRs persist for AMI and HF and clinically meaningful variation exists for RSMRs and RSRRs for both conditions. Our results suggest continued opportunities for improvement in patient outcomes for HF and AMI.

Background: Pneumonia is a leading cause of hospitalization and death in the elderly, and remains the subject of both local and national quality improvement efforts., Objective: To describe patterns of hospital and regional performance in the outcomes of elderly patients with pneumonia., Design: Cross-sectional study using hospital and outpatient Medicare claims between 2006 and 2009., Setting: A total of 4,813 nonfederal acute care hospitals in the United States and its organized territories., Patients: Hospitalized fee-for-service Medicare beneficiaries age 65 years and older who received a principal diagnosis of pneumonia., Intervention: None., Measurements: Hospital and regional level risk-standardized 30-day mortality and readmission rates., Results: Of the 1,118,583 patients included in the mortality analysis 129,444 (11.6%) died within 30 days of hospital admission. The median (Q1, Q3) hospital 30-day risk-standardized mortality rate for patients with pneumonia was 11.1% (10.0%, 12.3%), and despite controlling for differences in case mix, ranged from 6.7% to 20.9%. Among the 1,161,817 patients included in the readmission analysis 212,638 (18.3%) were readmitted within 30 days of hospital discharge. The median (Q1, Q3) 30-day risk-standardized readmission rate was 18.2% (17.2%, 19.2%) and ranged from 13.6% to 26.7%. Risk-standardized mortality rates varied across hospital referral regions from a high of 14.9% to a low of 8.7%. Risk-standardized readmission rates varied across hospital referral regions from a high of 22.2% to a low of 15%., Conclusions: Risk-standardized 30-day mortality and, to a lesser extent, readmission rates for patients with pneumonia vary substantially across hospitals and regions and may present opportunities for quality improvement, especially at low performing institutions and areas., ((c) 2010 Society of Hospital Medicine.)

Background: The association between hospital volume and the death rate for patients who are hospitalized for acute myocardial infarction, heart failure, or pneumonia remains unclear. It is also not known whether a volume threshold for such an association exists., Methods: We conducted cross-sectional analyses of data from Medicare administrative claims for all fee-for-service beneficiaries who were hospitalized between 2004 and 2006 in acute care hospitals in the United States for acute myocardial infarction, heart failure, or pneumonia. Using hierarchical logistic-regression models for each condition, we estimated the change in the odds of death within 30 days associated with an increase of 100 patients in the annual hospital volume. Analyses were adjusted for patients' risk factors and hospital characteristics. Bootstrapping procedures were used to estimate 95% confidence intervals to identify the condition-specific volume thresholds above which an increased volume was not associated with reduced mortality., Results: There were 734,972 hospitalizations for acute myocardial infarction in 4128 hospitals, 1,324,287 for heart failure in 4679 hospitals, and 1,418,252 for pneumonia in 4673 hospitals. An increased hospital volume was associated with reduced 30-day mortality for all conditions (P<0.001 for all comparisons). For each condition, the association between volume and outcome was attenuated as the hospital's volume increased. For acute myocardial infarction, once the annual volume reached 610 patients (95% confidence interval [CI], 539 to 679), an increase in the hospital volume by 100 patients was no longer significantly associated with reduced odds of death. The volume threshold was 500 patients (95% CI, 433 to 566) for heart failure and 210 patients (95% CI, 142 to 284) for pneumonia., Conclusions: Admission to higher-volume hospitals was associated with a reduction in mortality for acute myocardial infarction, heart failure, and pneumonia, although there was a volume threshold above which an increased condition-specific hospital volume was no longer significantly associated with reduced mortality., (2010 Massachusetts Medical Society)

Background: The rankings of "America's Best Hospitals" by U.S. News & World Report are influential, but the performance of ranked hospitals in caring for patients with routine cardiac conditions such as heart failure is not known., Methods and Results: Using hierarchical regression models based on medical administrative data from the period July 1, 2005, to June 30, 2006, we calculated risk-standardized mortality rates and risk-standardized readmission rates for ranked and nonranked hospitals in the treatment of heart failure. The mortality analysis examined 14 813 patients in 50 ranked hospitals and 409 806 patients in 4761 nonranked hospitals. The readmission analysis included 16 641 patients in 50 ranked hospitals and 458 473 patients in 4627 nonranked hospitals. Mean 30-day risk-standardized mortality rates were lower in ranked versus nonranked hospitals (10.1% versus 11.2%, P<0.01), whereas mean 30-day risk-standardized readmission rates were no different between ranked and nonranked hospitals (23.6% versus 23.8%, P=0.40). The 30-day risk-standardized mortality rates varied widely for both ranked and nonranked hospitals, ranging from 7.9% to 12.4% for ranked hospitals and from 7.1% to 17.5% for nonranked hospitals. The 30-day risk-standardized readmission rates also spanned a large range, from 18.7% to 29.3% for ranked hospitals and from 19.2% to 29.8% for nonranked hospitals., Conclusions: Hospitals ranked by U.S. News & World Report as "America's Best Hospitals" in "Heart & Heart Surgery" are more likely than nonranked hospitals to have a significantly lower than expected 30-day mortality rate, but there was much overlap in performance. For readmission, the rates were similar in ranked and nonranked hospitals.

Background: In 2009, the Centers for Medicare & Medicaid Services is publicly reporting hospital-level risk-standardized 30-day mortality and readmission rates after acute myocardial infarction (AMI) and heart failure (HF). We provide patterns of hospital performance, based on these measures., Methods and Results: We calculated the 30-day mortality and readmission rates for all Medicare fee-for-service beneficiaries ages 65 years or older with a primary diagnosis of AMI or HF, discharged between July 2005 and June 2008. We compared weighted risk-standardized mortality and readmission rates across Hospital Referral Regions and hospital structural characteristics. The median 30-day mortality rate was 16.6% for AMI (range, 10.9% to 24.9%; 25th to 75th percentile, 15.8% to 17.4%; 10th to 90th percentile, 14.7% to 18.4%) and 11.1% for HF (range, 6.6% to 19.8%; 25th to 75th percentile, 10.3% to 12.0%; 10th to 90th percentile, 9.4% to 13.1%). The median 30-day readmission rate was 19.9% for AMI (range, 15.3% to 29.4%; 25th to 75th percentile, 19.5% to 20.4%; 10th to 90th percentile, 18.8% to 21.1%) and 24.4% for HF (range, 15.9% to 34.4%; 25th to 75th percentile, 23.4% to 25.6%; 10th to 90th percentile, 22.3% to 27.0%). We observed geographic differences in performance across the country. Although there were some differences in average performance by hospital characteristics, there were high and low hospital performers among all types of hospitals., Conclusions: In a recent 3-year period, 30-day risk-standardized mortality rates for AMI and HF varied among hospitals and across the country. The readmission rates were particularly high.