Showing papers by "Kumar Dharmarajan published in 2018"

Association of the Hospital Readmissions Reduction Program With Mortality During and After Hospitalization for Acute Myocardial Infarction, Heart Failure, and Pneumonia.

Abstract: Importance The US Hospital Readmissions Reduction Program (HRRP) was associated with reduced readmissions among Medicare beneficiaries hospitalized for acute myocardial infarction (AMI), heart failure (HF), and pneumonia. It is important to assess whether there has been a signal for concomitant harm with an increase in mortality. Objective To evaluate whether the announcement or the implementation of HRRP was associated with an increase in either in-hospital or 30-day postdischarge mortality following hospitalization for AMI, HF, or pneumonia. Design, Setting, and Participants In this cohort study, using Medicare data, all hospitalizations for AMI, HF, and pneumonia were identified among fee-for-service Medicare beneficiaries aged 65 years and older from January 1, 2006, to December 31, 2014. These were assessed for changes in trends for risk-adjusted rates of in-hospital and 30-day postdischarge mortality after announcement and implementation of the HRRP using an interrupted time series framework. Analyses were done in November 2017 and December 2017. Exposures Announcement of the HRRP in March 2010, and implementation of its penalties in October 2012. Main Outcomes and Measures Monthly risk-adjusted rates of in-hospital and 30-day postdischarge mortality. Results The sample included 1.7 million AMI, 4 million HF, and 3.5 million pneumonia hospitalizations. Between 2006 and 2014, in-hospital mortality decreased for the 3 conditions (AMI, from 10.4% to 9.7%; HF, from 4.3% to 3.5%; pneumonia, from 5.3% to 4.0%) while 30-day postdischarge mortality decreased from 7.4% to 7.0% for AMI (Pfor trend .05 for all). In contrast, there were significant negative deflections in slopes for readmission rates at HRRP announcement for all conditions. Conclusions and Relevance Among Medicare beneficiaries, there was no evidence for an increase in in-hospital or postdischarge mortality associated with HRRP announcement or implementation—a period with substantial reductions in readmissions. The improvement in readmission was therefore not associated with any increase in in-hospital or 30-day postdischarge mortality.

Is Posthospital Syndrome a Result of Hospitalization-Induced Allostatic Overload?

Abstract: After discharge from the hospital, patients face a transient period of generalized susceptibility to disease as well as an elevated risk for adverse events, including hospital readmission and death. The term posthospital syndrome (PHS) has been used to describe this time of enhanced vulnerability. Based on data from bench to bedside, this narrative review examines the hypothesis that hospitalrelated allostatic overload is a plausible etiology of PHS. Resulting from extended exposure to stress, allostatic overload is a maladaptive state driven by overuse and dysregulation of the hypothalamic-pituitary-adrenal axis and the autonomic nervous system that ultimately generates pathophysiologic consequences to multiple organ systems. Markers of allostatic overload, including elevated levels of cortisol, catecholamines, and inflammatory markers, have been associated with adverse outcomes after hospital discharge. Based on the evidence, we suggest a possible mechanism for postdischarge vulnerability, encourage critical contemplation of traditional hospital environments, and suggest interventions that might improve outcomes.

Evaluating Readmission-Need for More Clarity on Methods.

Abstract: Evaluating Readmission— Need for More Clarity on Methods We have several questions about the study by Gupta et al1 that are central to interpreting their evaluation of the Hospital Readmissions Reduction Program (HRRP). The Medicare Hospital Quality Chartbooks,2,3 based on national Medicare data, showed that the 30-day mortality of heart failure (HF) rose annually as early as 2006 (before implementation of the HRRP) before leveling off after 2012. Thus, understanding their sample is important. It would be useful to know how many American Heart Association GetWithTheGuidelines(GWTG)–HFhospitalswerecontinuously enrolling throughout the study period and how their characteristics compare with the nation’s hospitals. Moreover, the authors included 115 245 HF hospitalizations from 416 hospitals over 9 years1—on average, 2 to 3 hospitalizations per hospital per month. Because many hospitals in the GWTG-HF program, a voluntary registry, are large, this small number per hospital is unexpected. Therefore, it would also be helpful to know the extent to which includedGWTG-HFhospitals(andalsoamongthosecontinuously enrolling) were enrolling all of their patients with HF into the registry.Specifically,whatpercentageoftheMedicarefee-for-service patients hospitalized with HF at these GWTG-HF hospitals (as documented in Medicare Provider and Analysis Review files) were entered into the GWTG-HF program during the study period? This information differs from the percentage of GWTG-HF patients matched to Medicare data (also of interest). Another point relates to the analysis. Because the HRRP was introduced at the hospital level with consideration of random hospital-specific effects, the study also requires random hospital-specific effects in the interrupted time series; policy effects should be determined by averaging over the hospital effects. It is important to report both marginal estimates and between-hospital variation in the different periods. Finally, the article’s conclusion contrasts with our earlier JAMA publication4 focusing on Medicare patients. While we also found declining readmission rates and modestly rising postdischarge mortality rates for HF across hospitals from 2008 through 2014, we also found that individual hospitals with declining readmission rates were more likely to have, if anything, declining mortalityrates.ThisiscontrarytowhatonewouldexpectifHRRP caused hospitals to reduce readmissions at the expense of increasing mortality. It would be useful to know if this association was also found in the hospitals and patients in the GWTG-HF program. The answers to these queries will assist readers to better interpret the published study and place the comprehensiveness of the results from this voluntary registry in context.

Regional variation in hospitalisation and mortality in heart failure: comparison of England and Lombardy using multistate modelling

Abstract: Heart failure (HF) is a common, serious chronic condition with high morbidity, hospitalisation and mortality. The healthcare systems of England and the northern Italian region of Lombardy share important similarities and have comprehensive hospital administrative databases linked to the death register. We used them to compare admission for HF and mortality for patients between 2006 and 2012 (n = 37,185 for Lombardy, 234,719 for England) with multistate models. Despite close similarities in age, sex and common comorbidities of the two sets of patients, in Lombardy, HF admissions were longer and more frequent per patient than in England, but short- and medium-term mortality was much lower. English patients had more very short stays, but their very elderly also had longer stays than their Lombardy counterparts. Using a three-state model, the predicted total time spent in hospital showed large differences between the countries: women in England spent an average of 24 days if aged 65 at first admission and 19 days if aged 85; in Lombardy these figures were 68 and 27 days respectively. Eight-state models suggested disease progression that appeared similar in each country. Differences by region within England were modest, with London patients spending more time in hospital and having lower mortality than the rest of England. Whilst clinical practice differences plausibly explain these patterns, we cannot confidently disentangle the impact of alternatives such as coding, casemix, and the availability and use of non-hospital settings. We need to better understand the links between rehospitalisation frequency and mortality.

Reply to Soo Hoo and Esquinas: Risk Trajectories of Readmission and Death in the First Year after Hospitalization for Chronic Obstructive Pulmonary Disease: Don't Shortchange Noninvasive Ventilation.

Abstract: 1) Institute for Healthcare Delivery and Population Science, and Department of Medicine, University of Massachusetts Medical School Baystate, Springfield, MA 2) Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA 3) Clover Health, Jersey City, NJ 4) Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT 5) Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT 6) Department of Health Policy and Management, Yale University School of Public Health, New Haven, CT