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Original Investigation
October 28, 2020

Evaluation of Risk-Adjusted Home Time After Hospitalization for Heart Failure as a Potential Hospital Performance Metric

Author Affiliations
  • 1Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
  • 2Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
  • 3Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City
  • 4Division of Cardiology, Northwestern University, Chicago, Illinois
  • 5Associate Editor, JAMA Cardiology
  • 6Division of Cardiology, Ronald Reagan–UCLA (University of California, Los Angeles) Medical Center, Los Angeles
  • 7Deputy Editor, JAMA Cardiology
  • 8Division of Cardiovascular Diseases, Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City
JAMA Cardiol. Published online October 28, 2020. doi:10.1001/jamacardio.2020.4928
Key Points

Question  How does risk-adjusted 30-day home time, defined as time a patient spends alive and out of a hospital or facility after discharge, compare with 30-day readmission and mortality as a hospital-level performance metric for patients hospitalized for heart failure?

Findings  In this cohort study of 2 968 341 patients from 3134 facilities, 30-day readmission, 30-day mortality, and 1-year mortality decreased in a graded fashion across increasing 30-day home time categories. Thirty-day home time was inversely correlated with 30-day risk-standardized readmission rate and 30-day risk-standardized mortality rate and was associated with meaningful reclassification in 30.6% of hospitals compared with 30-day risk-standardized mortality rate and 30-day risk-standardized readmission rate.

Meaning  In this study, 30-day home time was a viable hospital-level quality metric and was associated with 30-day readmission, 30-day mortality, and 1-year mortality outcomes.

Abstract

Importance  Thirty-day home time, defined as time spent alive and out of a hospital or facility, is a novel, patient-centered performance metric that incorporates readmission and mortality.

Objectives  To characterize risk-adjusted 30-day home time in patients discharged with heart failure (HF) as a hospital-level quality metric and evaluate its association with the 30-day risk-standardized readmission rate (RSRR), 30-day risk-standardized mortality rate (RSMR), and 1-year RSMR.

Design, Setting, and Participants  This hospital-level cohort study retrospectively analyzed 100% of Medicare claims data from 2 968 341 patients from 3134 facilities from January 1, 2012, to November 30, 2017.

Exposures  Home time, defined as time spent alive and out of a short-term hospital, skilled nursing facility, or intermediate/long-term facility 30 days after discharge.

Main Outcomes and Measures  For each hospital, a risk-adjusted 30-day home time for HF was calculated similar to the Centers for Medicare & Medicaid Services risk-adjustment models for 30-day RSRR and RSMR. Hospitals were categorized into quartiles (lowest to highest risk-adjusted home time). The correlations between hospital rates of risk-adjusted 30-day home time and 30-day RSRR, 30-day RSMR, and 1-year RSMR were estimated using the Pearson correlation coefficient. Distribution of days lost from a perfect 30-day home time were calculated. Reclassification of hospital performance using 30-day home time vs 30-day RSRR was also evaluated.

Results  Overall, 2 968 341 patients (mean [SD] age, 81.0 [8.3] years; 53.6% female) from 3134 hospitals were included in this study. The median hospital risk-adjusted 30-day home time for patients with HF was 21.77 days (range, 8.22-28.41 days). Hospitals in the highest quartile of risk-adjusted 30-day home time (best-performing hospitals) were larger (mean [SD] number of beds, 285 [275]), with a higher volume of patients with HF (median, 797 patients; interquartile range, 395-1484) and were more likely academic hospitals (59.9%) with availability of cardiac surgery (51.1%) and cardiac rehabilitation (68.8%). A total of 72% of home time lost was attributable to stays in an intermediate- or long-term care facility (mean [SD], 2.65 [6.44] days) or skilled nursing facility (mean [SD], 3.96 [9.04] days), 13% was attributable to short-term readmissions (mean [SD], 1.25 [3.25] days), and 15% was attributable to death (mean [SD], 1.37 [6.04] days). Among 30-day outcomes, the 30-day RSRR and 30-day RSMR decreased in a graded fashion across increasing 30-day home time categories (correlation coefficients: 30-day RSRR and 30-day home time, −0.23, P < .001; 30-day RSMR and 30-day home time, −0.31, P < .001). Similar patterns of association were also noted for 1-year RSMR and 30-day home time (correlation coefficient, −0.35, P < .001). Thirty-day home time meaningfully reclassified hospital performance in 30% of the hospitals compared with 30-day RSRR and in 25% of hospitals compared with 30-day RSMR.

Conclusions and Relevance  In this study, 30-day home time among patients discharged after a hospitalization for HF was objectively assessed as a hospital-level quality metric using Medicare claims data and was associated with readmission and mortality outcomes and with reclassification of hospital performance compared with 30-day RSRR and 30-day RSMR.

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