FutureFocus November 28, 2018: Seven and Thirty Day Readmission Patterns by Payor

Lisa Remington

In this week’s FutureFocus we provide 7-day and 30-day readmission patterns by payer. We continue to focus on this topic for a number of reasons. First, the data is analysis for your organization to examine internally. Secondly, your organization can work more closely with other stakeholders to compare and partner on diagnosis.

Lisa Remington, President, Remington Health Strategy Group

By: Lisa Remington, President Remington Health Strategy Group, Publisher, The Remington Report

Readmission Pattern Highlights

In 2014, 14 percent of inpatient stays were readmitted within 30-days. More than one-third of these readmissions occurred within 7-days, reflecting a 7-day readmission rate of 5 percent.

Diagnoses at index stays with the highest 7-day and 30-day readmission rates were similar. Schizophrenia, alcohol-related disorders, and congestive heart failure were among the leading diagnoses with both the highest 7-day and 30-day readmission rates.

For both 7-day and 30-day readmissions, the rate of readmission was highest among patients with Medicare, followed by patients with Medicaid, no insurance, and private insurance.

Among Medicaid patients who were discharged with congestive heart failure or schizophrenia at the index stay, nearly 1 in 10 stays resulted in readmission within 7-days.

Among patients readmitted within 30 days of an index stay for septicemia or schizophrenia, uninsured patients were more likely than patients with insurance to return within 7-days.

Readmissions Occur More Within 7-Days than 30-Days

Overall, 36.1 percent of all 30-day readmissions occurred within 7 days. This ranged from 30.5 percent to 43.6 percent among index diagnoses with the highest 7-day readmission rates.

For example, a larger proportion of patients with intestinal obstruction without hernia at the index stay were readmitted within 7-days than were patients with other diagnoses: 43.6 percent of all 30-day readmissions following index stays with this diagnosis occurred within 7 days. Similarly, among patients with an index stay for acute myocardial infarction, 43.0 percent of all 30-day readmissions occurred within 1 week of discharge. 

In comparison, only 30.5 percent of patients readmitted within 30 days for chronic obstructive pulmonary disease returned to the hospital within 7 days following discharge.


Top five principal diagnoses with the highest 7-day and 30-day readmission rates, by expected payer, 2014

Principal diagnosis

Index stays 

7-day readmissions

30-day readmissions

Rank

Ratea

Rank

Ratea

Medicare

         

Schizophrenia and other psychotic disorders

150,743

1

9.3

3

23.9

Pleurisy; pneumothorax; pulmonary collapse

50,119

2

8.9

1

24.5

Alcohol-related disorders

67,838

3

8.3

2

24.4

Heart valve disorders

85,682

4

7.9

14

19.9

Hypertension with complications, secondary hypertension

141,206

5

7.7

8

22.6

Deficiency and other anemia

103,430

13

7.1

4

23.3

Congestive heart failure; non-hypertensive

613,829

9

7.4

5

23.3

Medicaid

         

Schizophrenia and other psychotic disorders

151,794

1

9.9

6

24.9

Sickle cell anemia

50,187

2

9.8

1

34.4

Alcohol-related disorders

123,583

3

9.3

3

26.1

Congestive heart failure; non-hypertensive

78,938

4

9.0

2

28.5

Hypertension with complications, secondary hypertension

33,068

5

8.9

4

25.0

Complication of device; implant or graft

71,974

6

8.5

5

25.0

Private

         

Acute and unspecified renal failure

54,314

1

6.4

3

17.2

Regional enteritis and ulcerative colitis

42,829

2

6.4

4

16.2

Schizophrenia and other psychotic disorders

35,493

3

6.2

5

15.8

Congestive heart failure; non-hypertensive

67,683

4

6.0

1

18.7

Deficiency and other anemia

29,565

5

6.0

2

17.6

Uninsured

         

Schizophrenia and other psychotic disorders

23,574

1

7.4

4

17.3

Abdominal pain

9,104

2

6.8

8

16.2

Alcohol-related disorders

56,753

3

6.5

1

18.2

Mood disorders

82,318

4

6.5

11

15.3

Complications of surgical procedures or medical care

11,261

5

6.3

7

16.8

Regional enteritis and ulcerative colitis

6,630

b

b

2

18.1

Complication of device; implant or graft

8,777

7

6.1

3

18.1

Congestive heart failure; non-hypertensive

21,986

12

5.2

5

17.0

a Rate per 100 index inpatient stays
b Data are suppressed because cell contains fewer than 11 readmissions.
Note: Diagnoses are grouped using the Clinical Classification Software (CCS). Only CCS with at least 50,000 Medicare index stays, 20,000 Medicaid index stays, 25,000 privately insured index stays, and 5,000 uninsured index stays are shown. "Other" CCS that group a nonspecific set of diagnoses, as well as diagnoses related to cancer and pregnancy, are excluded. Highlighting indicates diagnoses that were not ranked in the top five for either 7-day or 30-day readmissions.
Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), Nationwide Readmissions Database (NRD), 2014


Readmissions by Payer: Medicare, Medicaid and Private Insurance and Unisured

For both 7-day and 30-day readmissions, the rate of readmission was highest among patients covered by:

  • Medicare (6.1 and 17.3 per 100 index stays, respectively),
  • Medicaid (5.0 and 13.7),
  • no insurance (4.5 and 11.5), and
  • private insurance (3.3 and 8.9)

Across each expected payer, slightly more than one-third of 30-day readmissions occurred within 7 days. The percentage of 7-day readmissions, out of total 30-day readmissions, was similar across payers, ranging from 35.2 among patients with Medicare (6.1 out of 17.3) to 38.7 among those without insurance (4.5 out of 11.5).

The diagnoses with the highest 7-day readmission rates differed from those with the highest 30-day readmission rates for all payers, except for those with private insurance. 

Although rankings differed, the top five diagnoses with the highest 7-day readmission rates were the same as those with the highest 30-day readmission rates for patients with private insurance: acute and unspecified renal failure, regional enteritis and ulcerative colitis, schizophrenia and other psychotic disorders, CHF, and deficiency and other anemia. 

Medicare

For patients with Medicare, heart valve disorders and hypertension with complications were among the top five diagnoses with the highest 7-day readmission rates, but these diagnoses did not rank in the top five for 30-day readmissions. Instead, deficiency and other anemia and CHF ranked among the top five diagnoses with the highest 30-day readmission rates.

Medicaid

For patients with Medicaid, schizophrenia was among the top five diagnoses with the highest 7-day readmission rates, but this diagnosis did not rank in the top five for 30-day readmissions. Instead, complication of device, implant or graft ranked among the top five diagnoses with the highest 30-day readmission rates. 

Uninsured

For patients without insurance, three of the five diagnoses with the highest 7-day readmission rates were related to mental health: schizophrenia, alcohol-related disorders, and mood disorders. In comparison, mood disorders did not rank in the top five diagnoses with the highest 30-day readmission rates. With respect to diagnoses that were unrelated to mental health, abdominal pain and complications of surgical procedures or medical care ranked in the top five diagnoses with the highest 7-day readmission rates, but these diagnoses did not rank in the top five for 30-day readmissions. Instead, regional enteritis and ulcerative colitis; complication of device, implant or graft; and CHF ranked among the top five diagnoses with the highest 30-day readmission rates for patients who were uninsured.

By Diagnosis/Payer 

  • For septicemia, CHF, and schizophrenia, the pattern of 7-day readmissions across categories of expected payer was consistent with the pattern of 30-day readmissions.
  • For both 7-day and 30-day readmissions, the rate of readmission for septicemia, CHF, and schizophrenia was highest for patients with Medicare and Medicaid and lowest for patients with private insurance and those who were uninsured.

For all Three Conditions, 7-day and 30-day Readmission Rates were Particularly High Among Ppatients with Medicare or Medicaid

Among patients with Medicare or Medicaid who were discharged with one of these three conditions at the index stay, between 1 in 4 and 1 in 5 stays resulted in readmission within 30 days. The 7-day readmission rate was also highest for patients with Medicare or Medicaid. In particular, nearly 1 in 10 stays paid by Medicaid for patients with CHF or schizophrenia resulted in readmission within 7 days.

  • The percentage of 30-day readmissions that occurred within 7 days was higher for index stays with septicemia or schizophrenia than for those with CHF. 
    Across payers, the percentage of 30-day readmissions that occurred within 1 week of initial discharge ranged from 36 to 41 percent for index stays with septicemia and 39 to 43 percent for those with schizophrenia and other psychotic disorders. In comparison, 31-32 percent of 30-day readmissions for CHF occurred within 7 days across payers.

 

  • Among patients who were readmitted within 30 days of an index stay for septicemia or schizophrenia, those who were uninsured were readmitted earlier than patients with any type of health insurance coverage.
    The percentage of 30-day readmissions related to septicemia and schizophrenia that occurred within 7 days was highest for uninsured patients (41.4 and 42.7 percent, respectively) and lowest for patients with Medicare (35.5 and 38.8 percent, respectively).

Remington Takeaways

Should Your Organization Be Looking at Readmissions Prior to 30 Days?

30-day risk-standardized, all-cause, unplanned readmission rates have become widely used to measure hospitals’ performance for public reporting and to impose financial penalties on facilities with excess readmissions. The question now asked: Is 30-days the right interval?

What Time Interval is the Highest Risk Factor for Readmissions?
A recent study of  66,741,340 hospital discharge records examined risk-standardized 30- day risk of unplanned inpatient readmission at the hospital level for Medicare patients ages sixty-five and older in four states and for three conditions: acute myocardial infarction, heart failure, and pneumonia. The states: Arizona, California, Florida, and New York.

Four Key Findings About Readmissions:

  1. Hospital-level readmissions were low at the 30-day cutoff.
  2. Readmissions were higher within the first several days after discharge reaching the lowest point around seven days. This suggest that a five-to-seven-day interval would better capture hospital-attributable readmissions, particularly when compared to intervals of 30, 60, or 90 days.
  3. The hospital quality signal is higher in the first five days after discharge than at longer time periods, such as 30-days. This suggests that hospitals’ practices with respect to care coordination and post-discharge follow-up could have the greatest impact within the first few days after discharge.