Association Between Quality Improvement for Care Transitions in Communities and Rehospitalizations Among Medicare Beneficiaries

Study Questions:

Is implementation of enhanced care coordination through quality improvement organizations (QIOs) for patients with Medicare fee-for-service (FFS) insurance associated with reduced re-hospitalizations and hospitalizations?

Methods:

QIOs were implemented in 14 geographically defined community populations (vs. 50 control communities). The interventions facilitated community-wide, evidence-based quality improvement activities that engaged a multidisciplinary team of clinical and social service practitioners and organizations to improve care transitions. The primary outcome measure was all-cause 30-day re-hospitalizations per 1,000 Medicare FFS beneficiaries and was assessed before (2006-2008) and during (2009-2010) implementation. Secondary outcome measures were all-cause hospitalizations per 1,000 Medicare FFS beneficiaries and all-cause 30-day re-hospitalizations as a percentage of hospital discharges.

Results:

The mean rate of 30-day all-cause re-hospitalizations per 1,000 beneficiaries per quarter was 15.21 in 2006-2008 and 14.34 in 2009-2010 in the intervention communities and was 15.03 in 2006-2008 and 14.72 in 2009-2010 in the 50 comparison communities, with the pre-post between-group difference showing larger reductions in re-hospitalizations in intervention communities (by 0.56/1,000 per quarter; 95% confidence interval [CI], 0.05-1.07; p = 0.03). Mean community-wide rates of re-hospitalizations as a percentage of hospital discharges in the intervention communities were 18.97% in 2006-2008 and 18.91% in 2009-2010 and were 18.76% in 2006-2008 and 18.91% in 2009-2010 in the comparison communities, with no significant difference in the pre-post between-group differences (0.22%; 95% CI, -0.08% to 0.51%; p = 0.14).

Conclusions:

Implementation of the Centers for Medicare and Medicaid Services-funded QIOs was associated with decreased rates of all-cause 30-day re-hospitalizations per 1,000 Medicare beneficiaries and decreased rates of hospitalizations per 1,000 Medicare beneficiaries. There were no significant reductions in the rates of 30-day re-hospitalizations per hospital discharge (i.e., 30-day re-hospitalization rates for hospitals).

Perspective:

Following implementation of QIOs, the widely used metric of re-hospitalization as a percentage of hospital discharge did not change, even though the independent measures of all-cause 30-day re-hospitalizations per 1,000 Medicare beneficiaries and rates of hospitalizations per 1,000 Medicare beneficiaries were impacted. While the findings are meaningful, implementation of the QIOs was, as the authors write in their discussion, ‘context dependent, complicated, and iterative.’ It would be difficult for others to replicate the QIOs. Future work should describe well-defined interventions that build on community-wide, evidence-based quality improvement transitional care programs.

Keywords: Outcome Assessment (Health Care), Quality Improvement, Health Services, Cardiology, Centers for Medicare and Medicaid Services (U.S.), Medicare, Hospitalization, United States


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