Center Public Health Initiatives IDEAS SCIENCE ACTION Medicare Patient Readmission Rates in Thirteen Philadelphia Hospitals This report uses available Philadelphia data provided by the US Department of Health and Human Services Medicare Hospital Compare Tool Website. Report prepared by: Laurel Johnson & Jeannette Schroeder With support from: Marjorie Bowman, Amy Hillier, Jana Hirsch, & Wendy Voet Summer 2009 This report was developed by the Center for Public Health Initiatives at the University of Pennsylvania. For more information regarding the CPHI, please visit our website at www.cphi.upenn.edu.
Introduction This report provides a comparison of thirteen Philadelphia hospitals readmission rates for heart attack, heart failure, and pneumonia patients. These percentages were calculated from Medicare data on patients discharged between July 1, 2005 and June 30, 2008. They don't include people in Medicare Advantage Plans (like an HMO or PPO) or people who don t have Medicare. For each of the three principal discharge diagnoses (heart attack, heart failure, and pneumonia), the model includes admissions to all short-stay acute-care hospitals for people age 65 years or older who are enrolled in Original Medicare (traditional fee-for-service Medicare) and who have a complete claims history for 12 months prior to admission. Four hospitals listed within the city of Philadelphia did not have a readmission rate listed by the Hospital Compare Tool Website: Cancer Treatment Centers of America, Children s Hospital of Philadelphia, Fox Chase Cancer Center, and Kensington Hospital. This was either because the survey population was too small or no data was collected. All data contained in this report taken from the U.S Department of Health and Human Services- Medicare Hospital Compare Tool Website (http://www.hospitalcompare.hhs.gov/hospital/search/welcome.asp?version=default&browser=ie 6 WinXP&language=English &defaultstatus=0&pagelist=home) Readmission Readmission is when patients who have had a recent hospital stay need to go back into a hospital again. Medicare looks at how many heart attack/heart failure/pneumonia patients need to be readmitted to the hospital within 30 days of their discharge. Each hospital s rate of readmission is risk-adjusted. Data Collection Methods For each of the three principal discharge diagnoses (heart attack, heart failure, and pneumonia), the model includes admissions to all short-stay acute-care hospitals for people age 65 years or older who are enrolled in Original Medicare (traditional fee-for-service Medicare) and who have a complete claims history for 12 months prior to admission. The 2009 public reporting of readmission rates will be based on hospital admissions with discharges from July 1, 2005, through June 30, 2008. Excluded Admissions For the heart attack, heart failure, and pneumonia readmission measures, admissions are excluded if they meet any of the following criteria: Admissions for patients with an in-hospital death are excluded because they are not eligible for readmission. Admissions for patients subsequently transferred to another acute care facility are excluded because we are focusing on discharges to non-acute care settings. Medicare Patient Readmission Rates in Thirteen Philadelphia Hospitals 1
Admissions for patients who are discharged against medical advice (AMA) are excluded because providers did not have the opportunity to deliver full care and prepare the patient for discharge. Admissions for patients without at least 30 days post-discharge enrollment in fee-forservice Medicare are excluded because the 30-day readmission outcome cannot be assessed in this group. If a patient has one or more additional admissions for the given condition (heart attack, heart failure, or pneumonia) within 30 days of discharge from an index admission, we do not consider the additional admissions as index admissions (they are considered as readmissions). Thus, any admission is either an index admission or a readmission, but not both. For the heart attack readmission measure only, the following exclusion criterion also applies: Admissions are excluded for patients who are discharged alive on the same day that they are admitted because these patients are unlikely to have had a heart attack. Admissions Not Counted As Readmissions The measure does not count as readmissions claims for same-day readmissions to the same hospital for the same condition. This is done to put all hospitals on an even playing field, as CMS rules already require Prospective Payment System (PPS) acute-care hospitals to combine sameday, same condition readmissions into one claim (so the readmission would appear as part of the initial stay in the administrative data). For the heart attack readmission measure only, readmissions within 30 days for percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft (CABG) procedures are not counted as readmissions if they likely represent planned readmissions that are part of the same episode of care as the index admission. Use of a 30-Day Period to Assess Readmissions The model tracks readmissions that occur within 30 days of a hospital discharge, rather than readmission over some other post-discharge period. Thirty-day readmission was chosen over longer windows (such as 90 days), because readmission over longer periods may have less to do with the care received in the hospital and more to do with other complicating illnesses, patients own behavior, or the care they received after discharge. Use of Administrative Claims Data Administrative claims data, rather than medical record data, are used to predict 30-day readmission. These data are widely available for people with Original Medicare (traditional feefor-service), are relatively inexpensive to acquire, and are timely. Using administrative data makes it possible to calculate readmission without having to do chart reviews or requiring hospitals to report additional data. Research conducted when the measures were being developed demonstrated that the administrative claims-based models perform well in predicting readmission compared with models based on chart reviews. Statistical Methods Used to Calculate Rates Calculation of 30-Day Risk-Standardized Mortality Rates and Rates of Readmission The three readmission models estimate hospital-specific, risk-standardized, all-cause 30-day readmission rates for patients discharged alive to a non-acute care setting with a principal Medicare Patient Readmission Rates in Thirteen Philadelphia Hospitals 2
diagnosis of heart attack, heart failure, and pneumonia. For each condition, the risk-standardized ("adjusted" or "risk-adjusted") hospital readmission rate can be used to compare performance across hospitals. The readmission measures for heart attack, heart failure, and pneumonia have been endorsed by the National Quality Forum (NQF). Hierarchical Regression Model The statistical model for computing the 30-day risk-standardized readmission rates is a "hierarchical regression model." This type of model is based on the assumption that any heart attack, heart failure, or pneumonia patient treated at a particular hospital will experience a level of quality of care that applies to all patients treated for the same condition in that hospital. In other words, the expected risk of readmission for two similar heart attack, heart failure, or pneumonia patients treated in the same hospital would be more alike than the risk of readmission for the same two patients treated in two different hospitals. The likelihood that an individual patient will be readmitted is therefore a combination of: his or her individual risk characteristics (for example, gender, comorbidities, and past medical history) and the hospital s unique quality of care for all patients treated for that condition in that hospital. The model estimates the effects of both of these components on on risk of readmission. Calculating Readmission Rates Each hospital s 30-day risk-standardized readmission rate (RSRR) is computed in several steps. First, the predicted 30-day readmission for a particular hospital obtained from the hierarchical regression model is divided by the expected readmission for that hospital, which is also obtained from the regression model. Predicted readmission is the number of readmissions (following discharge for heart attack, heart failure, or pneumonia) that would be anticipated in the particular hospital during the study period, given the patient case mix and the hospital s unique quality of care effect on readmission. Expected readmission is the number of readmissions (following discharge for heart attack, heart failure, or pneumonia) that would be expected if the same patients with the same characteristics had instead been treated at an average hospital, given the average hospital s quality of care effect on readmission for patients with that condition. This ratio is then multiplied by the national unadjusted readmission rate for the condition for all hospitals to compute an RSRR for the hospital. So, the higher a hospital s predicted 30-day readmission rate, relative to expected readmission for the hospital s particular case mix of patients, the higher its adjusted readmission rate will be. Hospitals with better quality will have lower rates. (Predicted 30-day readmission/expected readmission) * U.S. National readmission rate = RSRR Adjusting for Small Hospitals or a Small Number of Cases The hierarchical regression model also adjusts readmission rate results for small hospitals or hospitals with few heart attack, heart failure, or pneumonia cases in a given reference period. This reduces the chance that such hospitals performance will fluctuate wildly from year to year or that they will be wrongly classified as either a worse or a better performer. For these hospitals, the model not only considers readmissions among patients treated for the condition in the small sample size of cases, but pools together patients from all hospitals treated for the given condition, to make the result more reliable. In essence, the predicted readmission rate for a hospital with a small number of cases is moved toward the overall U.S. National readmission rate for all Medicare Patient Readmission Rates in Thirteen Philadelphia Hospitals 3
hospitals. The estimates of readmission for hospitals with few patients will rely considerably on the pooled data for all hospitals, making it less likely that small hospitals will fall into either of the outlier categories. This pooling affords a "borrowing of statistical strength" that provides more confidence in the results. For classifying hospital performance, extremely small hospitals will be reported separately, as described below. Significance Testing and Interval Estimates The model also calculates how precise the estimates of the adjusted readmission rate are, and determines upper and lower bounds (Interval Estimates) for each hospital s risk-standardized readmission rate. Interval estimates, which are like confidence intervals, describe how much uncertainty there is around the rate how much bigger or smaller the rate might really be. Larger hospitals typically have more precise estimates and smaller interval estimates, since more data are available to estimate readmission. The smaller the sample size, the greater the difference in readmission rates between a hospital and the national rate must be in order for that difference to be statistically meaningful. Comparing Readmission Rates Among Hospitals The risk-standardized hospital rate with its interval estimate can be compared to the U.S. National crude readmission rate. If the interval estimate includes (overlaps with) the national crude readmission rate, the hospital s performance is in the no different than U.S. National rate category. If the entire interval estimate is below the national crude readmission rate, then the hospital is performing better than U.S. National rate. If the entire interval estimate is above the national crude readmission rate, it is worse than U.S. National rate. Hospitals with extremely few cases those with fewer than 25 qualifying cases in the 3-year period will be reported separately as: number of cases too small (fewer than 25) to reliably tell how the hospital is performing. Medicare Patient Readmission Rates in Thirteen Philadelphia Hospitals 4
Philadelphia Hospitals Readmission Rates This table is a comparison of the thirteen Philadelphia hospitals estimated readmission rates (risk adjusted) for patients of heart attack, heart failure and pneumonia. The red cells represent hospital readmission rates, which within their respective ranges of uncertainty, are worse than the national rate. The green cells represent hospital readmission rates, which within their respective ranges of uncertainty, are better than the national rate. The white cells represent hospital readmission rates, which within their respective ranges of uncertainty, are no different than the national rate. Estimated Patient Readmission Rate Hospital Heart Attack Heart Failure Pneumonia Albert Einstein 23.6% 26.7% 20.7% Aria Health 23.9% 27.7% 20.3% Chestnut Hill Hospital 20.2% 25.5% 21.5% Hahnemann University Hospital 19.2% 26.7% 20.7% HUP 20.9% 23.2% 18.3% Jeanes Hospital 21.0% 20.8% 19.8% Nazareth Hospital 21.5% 25.7% 19.6% Northeastern 20.0% 29.2% 21.1% Penn Presbyterian Medical Center 18.6% 22.6% 18.2% Pennsylvania Hospital (UPHS) 20.1% 24.6% 19.0% St Joseph s 21.3% 27.1% 19.2% Temple 23.8% 27.7% 18.6% Thomas Jefferson 21.4% 28.4% 21.0% The Following Philadelphia hospitals have no available data: Cancer Treatment Centers of America, CHOP, Fox Chase Cancer Center, and Kensington Hospital. Red = worse than national rate Green = better than national rate White = no different than national rate Medicare Patient Readmission Rates in Thirteen Philadelphia Hospitals 5
Heart Attack Patients The below chart shows a side-by-side comparison of thirteen Philadelphia hospitals readmission rates for heart attack patients with Original Medicare. The blue dotted line represents the United States national rate for heart attack patient readmission (19.9%). Rate of Readmission for Heart Attack Patients with Medicare 30 25 % Readmitted 20 15 10 AE ARIA CH HAN HUP JH NAZ NE PRESB PENN StJ TEMP TJ Philadelphia Hospitals Medicare Patient Readmission Rates in Thirteen Philadelphia Hospitals 6
Heart Failure Patients The below chart shows a side-by-side comparison of the thirteen Philadelphia hospitals readmission rates for heart failure patients with Original Medicare. The blue dotted line represents the United States national rate for heart failure patient readmission (24.5%). Rate of Readmission for Heart Failure Patients with Medicare 35 % Readmitted 30 25 20 15 AE ARIA CH HAN HUP JH NAZ NE PRESB PENN StJ TEMP TJ Philadelphia Hospitals Medicare Patient Readmission Rates in Thirteen Philadelphia Hospitals 7
Pneumonia Patients The below chart shows a side-by-side comparison of the thirteen Philadelphia hospitals readmission rates for pneumonia patients with Original Medicare. The blue dotted line represents the United States national rate for pneumonia patient readmission (18.2%). Rate of Readmission for Pneumonia Patients with Medicare 30 % Readmitted 25 20 15 10 AE ARIA CH HAN HUP JH NAZ NE PRESB PENN StJ TEMP TJ Philadelphia Hospitals Medicare Patient Readmission Rates in Thirteen Philadelphia Hospitals 8
Philadelphia Hospital Heart Attack Patient Readmission Rates Compared to the National Average This chart shows the percentage of Philadelphia hospitals with heart attack patient readmission rates better than, no different than, and worse than the national average. The fourth category represents the percentage of hospitals lacking data in this category. 24% 18% Better Than Worse Than No Different Than No Data 59% Medicare Patient Readmission Rates in Thirteen Philadelphia Hospitals 9
Philadelphia Hospital Heart Failure Patient Readmission Rates Compared to the National Average This chart shows the percentage of Philadelphia hospitals with heart failure patient readmission rates better than, no different than, and worse than the national average. The fourth category represents the percentage of hospitals lacking data in this category. 24% 1% 19% Better Than Worse Than No Different Than No Data 53% Medicare Patient Readmission Rates in Thirteen Philadelphia Hospitals 10
Philadelphia Hospital Pneumonia Patient Readmission Rates Compared to the National Average This chart shows the percentage of Philadelphia hospitals with pneumonia patient readmission rates better than, no different than, and worse than the national average. The fourth category represents the percentage of hospitals lacking data in this category. 24% 18% Better Than Worse Than No Different Than No Data 59% Medicare Patient Readmission Rates in Thirteen Philadelphia Hospitals 11
Philadelphia Hospitals Total Readmission Rate Score in Order of Rank This table shows a total score measure for each hospital s combined readmission rates for heart attack, heart failure and pneumonia. A score of 0.0 was awarded for each readmission rate that was better than the national average; a score of 1.0 was awarded for each readmission rate that was no different than the national average; a score of 2.0 was awarded for each readmission rate that was worse than the national average. The lower the score is, the better the score. (For example a hospital with readmission rates of no different than the national average for each of heart attack, heart failure, and pneumonia patients, would receive a score of 1.0+1.0+1.0= 3.0. Hospital Score Jeanes Hospital 2.0 Hahnemann University Hospital 3.0 Hospital of the University of Pennsylvania 3.0 Nazareth Hospital 3.0 Penn Presbyterian Medical Center 3.0 Pennsylvania Hospital (UPHS) 3.0 St Joseph s 3.0 Albert Einstein 4.0 Chestnut Hill Hospital 4.0 Temple 4.0 Aria Health 5.0 Northeastern 5.0 Thomas Jefferson 5.0 No data available: Cancer Treatment Centers of America, CHOP, Fox Chase Cancer Center, Kensington Hospital Medicare Patient Readmission Rates in Thirteen Philadelphia Hospitals 12
Graduated Medicare Patient Readmission Scores by Hospital and Total Population This map shows the seventeen Philadelphia hospitals on top of a map of Philadelphia with a color gradient showing total population. The map shows that there is no clear correlation between hospital readmission score and total population of the surrounding area. Data Source: US Department of Health and Human Services Medicare Hospital Compare Tool Website Map by: Laurel Johnson, 2009 Medicare Patient Readmission Rates in Thirteen Philadelphia Hospitals 13
Graduated Medicare Patient Readmission Scores and Percentage African American Population This map shows the seventeen Philadelphia hospitals on top of a map of Philadelphia with a color gradient showing percentage of African Americans making up the population. The map shows that there is no clear correlation between hospital readmission score and African American population percentage of the surrounding area s population. Data Source: US Department of Health and Human Services Medicare Hospital Compare Tool Website Map by: Laurel Johnson, 2009 Medicare Patient Readmission Rates in Thirteen Philadelphia Hospitals 14
Graduated Medicare Patient Readmission Scores by Hospital and Percentage White Population This map shows the seventeen Philadelphia hospitals on top of a map of Philadelphia with a color gradient showing percentage of white people making up the population. The map shows that there is no clear correlation between hospital readmission score and white population percentage of the surrounding area s population. Data Source: US Department of Health and Human Services Medicare Hospital Compare Tool Website Map by: Laurel Johnson, 2009 Medicare Patient Readmission Rates in Thirteen Philadelphia Hospitals 15
Graduated Medicare Patient Readmission Scores by Hospital and Median Household Income This map shows the seventeen Philadelphia hospitals on top of a map of Philadelphia with a color gradient showing median household income of the surrounding population. The map shows that there is no clear correlation between hospital readmission score and median household income of the surrounding area s population. Data Source: US Department of Health and Human Services Medicare Hospital Compare Tool Website Map by: Laurel Johnson, 2009 Medicare Patient Readmission Rates in Thirteen Philadelphia Hospitals 16
Future Implications This report relied heavily on the information found on the United States Department of Health and Human Services-Medicare Hospital Compare Tool website. This website was designed with the hope that the data contained would be used to examine factors that possibly contribute to a hospital s readmission rate (for example, a lack of primary and hospice care or transportation challenges for patients getting to follow-up appointments). It was anticipated that hospitals would begin to both understand the reasons why patients are readmitted so soon after they are initially treated, and then not only make the necessary changes to address these reasons, but also work to prevent instances of readmission. 4 Arnold Epstein of the Harvard School of Public Health proposed a few theories as to why readmission rates are running so high. He states that hospitals are not planning properly for their patients discharges and that they are not communicating well enough with patients primary doctors to ensure that post hospital recommendations are followed. He adds that while hospitals can be assigned some of the blame that primary physicians are also at fault, for too liberally hospitalizing patients. MedPac, a group that provides Congress with Medicare policy advice, proposed that Medicare introduce an initiative that would provide hospitals with an incentive to reduce their readmission rates. Under this policy plan, patients payments for their initial hospital stay would also cover the thirty days immediately following discharge from the hospital. This way, if a patient was readmitted during the month after his discharge, the hospital would receive no additional payment, thereby encouraging hospitals to reduce their readmission rates. The final details of this program have yet to be completed. 5 Initiatives that target those deemed super users are beginning to be examined in many hospitals. These super users are those people who repeatedly seek emergency room treatment or who take advantage of hospital care for extended periods of time. Because hospitals are required by federal law to treat everybody, these super users (most of whom cannot afford regular physician visits) consistently show up at hospitals, seeking medical care. Though this system does provide these patients with the care they desire and need, it is a huge drain on government money. State charity care funds and government insurance shoulder the cost burden that the super users without health insurance place on hospitals for their emergency room visits. Jeff Brenner, a doctor at Cooper Hospital in Camden, New Jersey, used a Robert Wood Johnson Foundation grant to put an idea into action for reducing super users readmission rates. This project offers free in-home healthcare, social services and personal attention, to those patients who most frequently enter emergency rooms. Brenner believes that by taking care of these patients in their own homes, the number of costly readmission visits will be reduced. He believes that reducing these readmission visits will not only save money, but will also relieve overcrowding in hospitals, as well as improve the health of the patients. The program has been in effect for about a year now and the data is currently being reviewed to learn how the program is impacting hospital costs. 2 Brian W. Jack et al. organized an alternate hospital patient discharge program to attempt to decrease readmission rates. In this study, a person deemed a nurse discharge advocate arranged follow-up appointments with patients, confirmed medical treatment plans, educated patients with an easy-to-read instruction booklet, and sent the instruction booklet to primary care providers upon patients discharge. The discharge advocates created after-hospital care plans (AHCPs), containing medical provider contact information, dates for appointments and tests, an appointment calendar, a color-coded medication schedule, a list of tests with pending results at Medicare Patient Readmission Rates in Thirteen Philadelphia Hospitals 17
discharge, an illustrated description of the discharge diagnosis, and information about what to do if a problem arises. The nurse discharge advocates overall task was to both educate and prepare participants for their dismissal from the hospital. The patients were assigned to two different groups- one group received this reengineered discharge (RED), and the other group, (the control group) did not receive the RED. After analyzing the results, the study found that the intervention reduced the total number of emergency department visits and readmissions per discharged participant in the RED group by about 30%. The patients in the RED group also reported a higher level of preparedness for their discharge. 3 Another study by Courtney et al. examined the possibilities for reducing readmission rates in a hospital in Brisbane, Australia. In this intervention, one hundred and twenty eight patients were recruited for the study: sixty four for the control group and sixty four for the intervention group. Patients in the intervention group received a comprehensive physiotherapy assessment and individualized program of exercise strategies and nurse-conducted home visit and telephone follow-up, commencing in the hospital and continuing for 24 weeks after discharge. Patients in the control group had the normal pre-discharge care. This study found that those patients receiving the intervention not only required significantly fewer emergency hospital readmissions visits, but also reported better health-related quality of life. 1 This information shows that hospital readmission rates are a big problem, but that much work is being dedicated to dealing with them. Hopefully a complete intervention for reducing hospital readmission rates will be both designed and implemented in the near future. Works Cited 1 Courtney, Mary, Helen Edwards, Anne Chang, Anthony Parker, Kathleen Finlayson, and Kyra Hamilton. "Fewer Emergency Readmissions and Better Quality of Life for Older Adults at Risk of Hospital Readmission: A Randomized Controlled Trial to Determine the Effectiveness of a 24-Week Exercise and Telephone Follow-Up Program." The American Geriatrics Society 57(2009) 395-402. Web.30 Jul 2009. 2 Hirsch, Deborah. "Medical plan aids patients, hospitals," Courier Post 13 10 2008. Web.30 Jul 2009. 3 Jack, Brian, Veerappa Chetty, David Anthony, Jeffrey Greenwald, Gali Sanchez, Anna Johnson, Shaula Forsythe, Julie O. "A Reengineered Hospital Discharge Program to Decrease Rehospitalization." Annals of Internal Medicine 15003 02 2009 Web.30 Jul 2009. 4 "Hospital Compare." HHS.gov. 20 04 2009. Medicare. 30 Jul 2009 <http://www.hospitalcompare.hhs.gov/hospital/search/searchmethod.asp?pagelist=home&dest=nav%7chome% 7CSearch%7CSearchMethod%7CWelcome&search_dest=NAV%7CHome%7CSearch%7CWelcome&version=defaul t&browser=firefox%7c3.5%7cwinxp&language=english&btnfindhosp=find+and+compare+hospitals>. 5 "Hospital Doors Revolve for Many Medicare Patients," The Wall Street Journal 02 04 2009. Web.30 Jul 2009. <http://blogs.wsj.com/health/2009/04/02/hospital-doors-revolve-for-many-medicare-patients/...>. Medicare Patient Readmission Rates in Thirteen Philadelphia Hospitals 18