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. 2022 May 2;5(5):e2214586.
doi: 10.1001/jamanetworkopen.2022.14586.

Analysis of Hospital-Level Readmission Rates and Variation in Adverse Events Among Patients With Pneumonia in the United States

Yun Wang  1   2   3   4 , Noel Eldridge  5   6 , Mark L Metersky  7 , David Rodrick  5 , Constance Faniel  8   9 , Sheila Eckenrode  1 , Jasie Mathew  1 , Deron H Galusha  2 , Anila Tasimi  10 , Shih-Yieh Ho  1 , Lisa Jaser  11 , Andrea Peterson  12   13 , Sharon-Lise T Normand  4   14 , Harlan M Krumholz  1   2   15
Affiliations

Analysis of Hospital-Level Readmission Rates and Variation in Adverse Events Among Patients With Pneumonia in the United States

Yun Wang et al. JAMA Netw Open. .

Abstract

Importance: It is known that hospitalized patients who experience adverse events are at greater risk of readmission; however, it is unknown whether patients admitted to hospitals with higher risk-standardized readmission rates had a higher risk of in-hospital adverse events.

Objective: To evaluate whether patients with pneumonia admitted to hospitals with higher risk-standardized readmission rates had a higher risk of adverse events.

Design, setting, and participants: This cross-sectional study linked patient-level adverse events data from the Medicare Patient Safety Monitoring System (MPSMS), a randomly selected medical record abstracted database, to the hospital-level pneumonia-specific all-cause readmissions data from the Centers for Medicare & Medicaid Services. Patients with pneumonia discharged from July 1, 2010, through December 31, 2019, in the MPSMS data were included. Hospital performance on readmissions was determined by the risk-standardized 30-day all-cause readmission rate. Mixed-effects models were used to examine the association between adverse events and hospital performance on readmissions, adjusted for patient and hospital characteristics. Analysis was completed from October 2019 through July 2020 for data from 2010 to 2017 and from March through April 2022 for data from 2018 to 2019.

Exposures: Patients hospitalized for pneumonia.

Main outcomes and measures: Adverse events were measured by the rate of occurrence of hospital-acquired events and the number of events per 1000 discharges.

Results: The sample included 46 047 patients with pneumonia, with a median (IQR) age of 71 (58-82) years, with 23 943 (52.0%) women, 5305 (11.5%) Black individuals, 37 763 (82.0%) White individuals, and 2979 (6.5%) individuals identifying as another race, across 2590 hospitals. The median hospital-specific risk-standardized readmission rate was 17.0% (95% CI, 16.3%-17.7%), the occurrence rate of adverse events was 2.6% (95% CI, 2.54%-2.65%), and the number of adverse events per 1000 discharges was 157.3 (95% CI, 152.3-162.5). An increase by 1 IQR in the readmission rate was associated with a relative 13% higher patient risk of adverse events (adjusted odds ratio, 1.13; 95% CI, 1.08-1.17) and 5.0 (95% CI, 2.8-7.2) more adverse events per 1000 discharges at the patient and hospital levels, respectively.

Conclusions and relevance: Patients with pneumonia admitted to hospitals with high all-cause readmission rates were more likely to develop adverse events during the index hospitalization. This finding strengthens the evidence that readmission rates reflect the quality of hospital care for pneumonia.

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Conflict of interest statement

Conflict of Interest Disclosures: Drs Krumholz and Normand and Mss Mathew and Eckenrode reported working under contract with the Centers for Medicare & Medicaid Services to develop and maintain performance measures outside the submitted work. Dr Metersky reported working on quality improvement and patient safety projects with the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality, with remuneration paid to his employer, outside the submitted work. Dr Normand reported having a patent with the National Center for Cardiovascular Disease in China prediction model pending. Dr Krumholz reported receiving in the past 3 years expenses and/or personal fees from UnitedHealth, Element Science, Aetna, Reality Labs, Tesseract/4Catalyst, F-Prime, the Siegfried and Jensen law firm, Arnold and Porter law firm, and Martin/Baughman law firm; being cofounder of Refactor Health and HugoHealth; and being associated with contracts through Yale University from Johnson & Johnson outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Distribution of Hospital-Specific Risk-Standardized 30-Day All-Cause Readmission Rates and Number of Adverse Events per 1000 Discharges for Pneumonia
A, The mean (SD) and median (IQR) of the hospitals’ readmission rate was 17.0% (1.1) and 17.0% (16.3%-17.7%), respectively. One IQR represents a 1.5 percentage point difference between the low and high categories. A total of 2590 hospitals were included. B, The number of adverse events per 1000 discharges was 157.3 (95% CI 152.3-162.5). Line in center of boxes represents the median, with the box boundaries indicating the IQR. Dots indicate individual hospitals.
Figure 2.
Figure 2.. Observed Occurrence Rates of Adverse Events and Adverse Events per 1000 Discharges, by Age Group and Hospital-Specific Risk-Standardized 30-Day All-Cause Admission Rates
The hospital-specific risk-standardized 30-day all-cause readmissions category was low if the readmission rate was less than the 25th percentile of the overall rate, high if the readmission rate was greater than the 75th percentile of the overall rate, and average if otherwise. The national occurrence rates of adverse events were 2.6% (95% CI, 2.54%-2.65%) and 2.8% (95% CI, 2.76%-2.91%) for patients aged 18 years and older and 65 years and older, respectively. The national number of adverse events per 1000 discharges were 157.3 (95% CI, 152.3-162.5) and 181.0 (175.7-185.6) for those aged 18 years and older and 65 years and older, respectively.
Figure 3.
Figure 3.. Association Between Hospital-Specific Risk-Standardized 30-Day All-Cause Readmission Rate and Hospital-Specific Risk-Standardized Number of Adverse Events per 1000 Discharges
Observed slopes (SE) of regression lines were 4.7 (0.77) for patients aged 18 years and older and 5.0 (0.71) for patients aged 65 years and older. Dots represent individual hospitals.
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