Efforts to reduce hospital readmissions include post-discharge interventions related to the illness treated during the index hospitalization (IH). These efforts may be inadequate because readmissions are precipitated by a wide range of health conditions unrelated to the primary diagnosis of the IH.
To investigate the relationship between post-discharge health services utilization for the same or a different diagnosis than the IH and unplanned 30-day readmission.
Design and Participants
The study sample included 583,199 all-cause IHs among 2014 Medicare fee-for-service beneficiaries. For all-cause IH, as well as individually for heart failure, myocardial infarction, and pneumonia IH, we used multivariable logistic regressions to investigate the association between post-discharge services utilization and readmission.
The outcome was unplanned 30-day readmission. Primary independent variables were post-discharge services utilization, including institutional outpatient, office-based primary care, office-based specialist, office-based non-physician practitioner, emergency department, home health care, and skilled nursing facility providers.
Among all-cause IH, 11.7% resulted in unplanned 30-day readmissions, and only 18.1% of readmissions occurred for the same primary diagnosis as IH. A substantial majority of post-discharge health services were utilized for a primary diagnosis differing from IH. Compared with no visit, institutional outpatient visits for the same primary diagnosis as IH (odds ratio [OR], 0.33; 95% confidence interval [CI], 0.31–0.34) and for a different primary diagnosis than IH (OR, 0.36; 95% CI, 0.35–0.37) were similarly strongly associated with decreased unplanned 30-day readmission. Primary care physician, specialist, non-physician practitioner, and home health care showed similar patterns. IH for heart failure, myocardial infarction, and pneumonia manifested similar patterns to all-cause IH both in terms of post-discharge services utilization and in terms of its impact on readmission.
To reduce unplanned 30-day readmission more effectively, discharge planning should include post-discharge services to address health conditions beyond the primary cause of the IH.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418–28.
Crosson F, Christianson J, Miller M. Report to the Congress: Medicare and the Health Care Delivery System. Washington, D.C:Medicare Payment Advisory Commission; 2017.
Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178–87.
Leppin AL, Gionfriddo MR, Kessler M, et al. Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Intern Med. 2014;174(7):1095–107.
Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med. 2011;155(8):520–8.
Kansagara D, Englander H, Salanitro A, et al. Risk prediction models for hospital readmission: a systematic review. JAMA. 2011;306(15):1688–98.
van Walraven C, Jennings A, Forster AJ. A meta-analysis of hospital 30-day avoidable readmission rates. J Eval Clin Pract. 2012;18(6):1211–8.
Nuckols TK, Keeler E, Morton S, et al. Economic evaluation of quality improvement interventions designed to prevent hospital readmission: a systematic review and meta-analysis. JAMA Intern Med. 2017;177(7):975–85.
Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013;173(22):2039–46.
Pannick S, Davis R, Ashrafian H, et al. Effects of interdisciplinary team care interventions on general medical wards: a systematic review. JAMA Intern Med. 2015;175(8):1288–98.
Dharmarajan K, Krumholz HM. Strategies to reduce 30-day readmissions in older patients hospitalized with heart failure and acute myocardial infarction. Curr Geriatr Rep. 2014;3(4):306–15.
Peikes D, Chen A, Schore J, Brown R. Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. JAMA. 2009;301(6):603–18.
Ballard J, Rankin W, Roper KL, Weatherford S, Cardarelli R. Effect of ambulatory transitional care management on 30-day readmission rates. Am J Med Qual. 2018 33(6):583-589
Bindman AB, Cox DF. Changes in health care costs and mortality associated with transitional care management services after a discharge among Medicare beneficiaries. JAMA Intern Med. 2018;178(9):1165–71.
van Walraven C, Bennett C, Jennings A, Austin PC, Forster AJ. Proportion of hospital readmissions deemed avoidable: a systematic review. CMAJ. 2011;183(7):E391–402.
Krumholz HM. Post-hospital syndrome--an acquired, transient condition of generalized risk. N Engl J Med. 2013;368(2):100–2.
Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355–63.
Hoyer EH, Needham DM, Atanelov L, Knox B, Friedman M, Brotman DJ. Association of impaired functional status at hospital discharge and subsequent rehospitalization. J Hosp Med. 2014;9(5):277–82.
Nguyen HQ, Chu L, Amy Liu IL, et al. Associations between physical activity and 30-day readmission risk in chronic obstructive pulmonary disease. Ann Am Thorac Soc. 2014;11(5):695–705.
Brownlee SA, Blackwell RH, Blanco BA, et al. Impact of post-hospital syndrome on outcomes following elective, ambulatory surgery. Ann Surg. 2017;266(2):274–9.
Ashton CM, Wray NP. A conceptual framework for the study of early readmission as an indicator of quality of care. Soc Sci Med. 1996;43(11):1533–41.
Horwitz LI, Grady JN, Dorsey KB, et al. 2014 Measure Updates and Specification Report: Hospital-Wide All-Cause Unplanned Readmission –Version 3.0. Prepared for the Centers for Medicare and Medicaid Services. New Haven, CT: Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation; 2014.
Horwitz LI, Partovian C, Lin Z, et al. Hospital-Wide (All-Condition) 30-Day Risk-Standardized Readmission Measure: Measure Methodology Report. Prepared for the Centers for Medicare and Medicaid Services. New Haven, CT: Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation; 2011.
Hosmer DW, Jr., Lemeshow SA, Sturdivant RX. Applied Logistic Regression. 3rd ed. Hoboken, NJ: Wiley; 2013.
Gill TM, Allore HG, Gahbauer EA, Murphy TE. Change in disability after hospitalization or restricted activity in older persons. JAMA. 2010;304(17):1919–28.
Kangovi S, Grande D, Meehan P, Mitra N, Shannon R, Long JA. Perceptions of readmitted patients on the transition from hospital to home. J Hosp Med. 2012;7(9):709–12.
Kortebein P. Rehabilitation for hospital-associated deconditioning. Am J Phys Med Rehabil. 2009;88(1):66–77.
Reed RL, Pearlman RA, Buchner DM. Risk factors for early unplanned hospital readmission in the elderly. J Gen Intern Med. 1991;6(3):223–8.
Chin MH, Goldman L. Factors contributing to the hospitalization of patients with congestive heart failure. Am J Public Health. 1997;87(4):643–8.
Hernandez AF, Greiner MA, Fonarow GC, et al. Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA. 2010;303(17):1716–22.
Sharma G, Kuo YF, Freeman JL, Zhang DD, Goodwin JS. Outpatient follow-up visit and 30-day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease. Arch Intern Med. 2010;170(18):1664–70.
Weinberger M, Oddone EZ, Henderson WG. Does increased access to primary care reduce hospital readmissions? Veterans affairs cooperative study group on primary care and hospital readmission. N Engl J Med. 1996;334(22):1441–7.
Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE, Carney RM. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med. 1995;333(18):1190–5.
Sochalski J, Jaarsma T, Krumholz HM, et al. What works in chronic care management: the case of heart failure. Health Aff (Millwood). 2009;28(1):179–89.
Davidson PL, Andersen RM, Wyn R, Brown ER. A framework for evaluating safety-net and other community-level factors on access for low-income populations. Inquiry. 2004;41(1):21–38.
Koehler F, Winkler S, Schieber M, et al. Telemedical interventional monitoring in heart failure (TIM-HF), a randomized, controlled intervention trial investigating the impact of telemedicine on mortality in ambulatory patients with heart failure: study design. Eur J Heart Fail. 2010;12(12):1354–62.
Wadhera RK, Joynt Maddox KE, Wasfy JH, Haneuse S, Shen C, Yeh RW. Association of the hospital readmissions reduction program with mortality among Medicare beneficiaries hospitalized for heart failure, acute myocardial infarction, and pneumonia. JAMA. 2018;320(24):2542–52.
Bueno H, Ross JS, Wang Y, et al. Trends in length of stay and short-term outcomes among Medicare patients hospitalized for heart failure, 1993-2006. JAMA. 2010;303(21):2141–7.
Vest JR, Gamm LD, Oxford BA, Gonzalez MI, Slawson KM. Determinants of preventable readmissions in the United States: a systematic review. Implement Sci. 2010;5:88.
Kaboli PJ, Go JT, Hockenberry J, et al. Associations between reduced hospital length of stay and 30-day readmission rate and mortality: 14-year experience in 129 Veterans Affairs hospitals. Ann Intern Med. 2012;157(12):837–45.
Ibrahim AM, Nathan H, Thumma JR, Dimick JB. Impact of the hospital readmission reduction program on surgical readmissions among Medicare beneficiaries. Ann Surg. 2017;266(4):617–24.
Zuckerman RB, Sheingold SH, Orav EJ, Ruhter J, Epstein AM. Readmissions, observation, and the hospital readmissions reduction program. N Engl J Med. 2016;374(16):1543–51.
Hackbarth G, Berenson R, Miller M. Report to the Congress: Medicare and the Health Care Delivery Sytem. Washington, D.C.: Medicare Payment Advisory Comission; 2013.
CMS Measure Information Form. 2015 Measure Information about the 30-Day All-Cause Hospital Readmission Measure, Calculated for the Value-Based Payment Modifier Program. Baltimore, MD: Centers for Medicare and Medicaid Services; 2017.
CMS Detailed Methodology. Detailed Methodology for the 2017 Value Modifier and the 2015 Quality and Resource Use Report. Baltimore, MD: Centers for Medicare and Medicaid Services; 2017.
Crosson F, Christianson J, Miller M. Report to the Congress: Medicare Payment Policy. Washington, D.C.: Medicare Payment Advisory Commission; 2017.
Carey K, Stefos T. The cost of hospital readmissions: evidence from the VA. Health Care Manag Sci. 2016;19(3):241–8.
Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281(7):613–20.
Koehler BE, Richter KM, Youngblood L, et al. Reduction of 30-day postdischarge hospital readmission or emergency department (ED) visit rates in high-risk elderly medical patients through delivery of a targeted care bundle. J Hosp Med. 2009;4(4):211–8.
Calvillo-King L, Arnold D, Eubank KJ, et al. Impact of social factors on risk of readmission or mortality in pneumonia and heart failure: systematic review. J Gen Intern Med. 2013;28(2):269–82.
Compliance with Ethical Standards
The University of Nebraska Medical Center Institutional Review Board approved this study.
Conflict of Interest
The authors declare that they do not have a conflict of interest.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Tak, H.J., Chen, L., Wilson, F.A. et al. Post-Discharge Services for Different Diagnoses Than Index Hospitalization Predict Decreased 30-Day Readmissions Among Medicare Beneficiaries. J GEN INTERN MED 34, 1766–1774 (2019). https://doi.org/10.1007/s11606-019-05115-2
- all-cause index hospitalization
- 30-day readmission
- post-discharge services utilization
- service diagnosis
- Hospital Readmission Reduction Program