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Original Investigation |

Thirty-Day Hospital Readmission Following Discharge From Postacute Rehabilitation in Fee-for-Service Medicare Patients

Kenneth J. Ottenbacher, PhD, OTR1; Amol Karmarkar, PhD, MPH1; James E. Graham, PhD, DC1; Yong-Fang Kuo, PhD2; Anne Deutsch, RN, PhD, CRRN3; Timothy A. Reistetter, PhD, OTR4; Soham Al Snih, MD, PhD1; Carl V. Granger, MD5,6
[+] Author Affiliations
1Division of Rehabilitation Sciences, University of Texas Medical Branch (UTMB), Galveston
2Department of Preventive Medicine and Community Health, UTMB
3RTI International, Washington, DC, and Rehabilitation Institute of Chicago, Chicago, Illinois
4Department of Occupational Therapy, UTMB
5Uniform Data System for Medical Rehabilitation, Buffalo, New York
6Department of Medicine, University at Buffalo, Buffalo, New York
JAMA. 2014;311(6):604-614. doi:10.1001/jama.2014.8.
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Importance  The Centers for Medicare & Medicaid Services recently identified 30-day readmission after discharge from inpatient rehabilitation facilities as a national quality indicator. Research is needed to determine the rates and factors related to readmission in this patient population.

Objective  To determine 30-day readmission rates and factors related to readmission for patients receiving postacute inpatient rehabilitation.

Design, Setting, and Patients  Retrospective cohort study of records for 736 536 Medicare fee-for-service beneficiaries (mean age, 78.0 [SD, 7.3] years) discharged from 1365 inpatient rehabilitation facilities to the community in 2006 through 2011. Sixty-three percent of patients were women, and 85.1% were non-Hispanic white.

Main Outcomes and Measures  Thirty-day readmission rates for the 6 largest diagnostic impairment categories receiving inpatient rehabilitation. These included stroke, lower extremity fracture, lower extremity joint replacement, debility, neurologic disorders, and brain dysfunction.

Results  Mean rehabilitation length of stay was 12.4 (SD, 5.3) days. The overall 30-day readmission rate was 11.8% (95% CI, 11.7%-11.8%). Rates ranged from 5.8% (95% CI, 5.8%-5.9%) for patients with lower extremity joint replacement to 18.8% (95% CI, 18.8%-18.9%). for patients with debility. Rates were highest in men (13.0% [ 95% CI, 12.8%-13.1%], vs 11.0% [95% CI, 11.0%-11.1%] in women), non-Hispanic blacks (13.8% [95% CI, 13.5%-14.1%], vs 11.5% [95% CI, 11.5%-11.6%] in whites, 12.5% [95% CI, 12.1%-12.8%] in Hispanics, and 11.9% [95% CI, 11.4%-12.4%] in other races/ethnicities), beneficiaries with dual eligibility (15.1% [95% CI, 14.9%-15.4%], vs 11.1% [95% CI, 11.0%-11.2%] for no dual eligibility), and in patients with tier 1 comorbidities (25.6% [95% CI, 24.9%-26.3%], vs 18.9% [95% CI, 18.5%-19.3%] for tier 2, 15.1% [95% CI, 14.9%-15.3%] for tier 3, and 9.9% [95% CI, 9.9%-10.0%] for no tier comorbidities). Higher motor and cognitive functional status were associated with lower hospital readmission rates across the 6 impairment categories. Adjusted readmission rates by state ranged from 9.2% to 13.6%. Approximately 50% of patients rehospitalized within the 30-day period were readmitted within 11 days of discharge. Medicare Severity Diagnosis-Related Group codes for heart failure, urinary tract infection, pneumonia, septicemia, nutritional and metabolic disorders, esophagitis, gastroenteritis, and digestive disorders were common reasons for readmission.

Conclusions and Relevance  Among postacute rehabilitation facilities providing services to Medicare fee-for-service beneficiaries, 30-day readmission rates ranged from 5.8% to 18.8% for selected impairment groups. Further research is needed to understand the causes of readmission.

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Figure.
Rate of Hospital Readmission Within 30 Days of Discharge From Rehabilitation

State-specific risk-standardized readmission rates were calculated using hierarchical generalized linear mixed models to account for clustering of patients within states. The models adjusted for 8 patient demographic and clinical variables: age, sex, race/ethnicity, living situation, rehabilitation impairment category, tier comorbidities, and admission motor and cognitive functioning. Final rates were obtained by taking the ratio of predicted to expected readmissions for each state and multiplying by the global unadjusted rate.

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