Supplemental Digital Content for “National Trends in Readmission Following Inpatient Surgery in the Hospital Readmissions Reduction Program Era”
Winta T. Mehtsun MD MPH Irene Papanicolas PhD
Jie Zheng PhD E. John Orav PhD Keith D. Lillemoe MD Ashish K. Jha MD MPH
Contents
Supplemental Digital Content Table 1 Procedure ICD-9 Codes Included in Analysis Supplemental Digital Content Table 2 Characteristics of Medicare Patients Undergoing Targeted and Non-Targeted Surgical Procedures in 2005 and 2014
Supplemental Digital Content Table 3 Annual Change in Readmission Rates Among Medicare Beneficiaries in Pre-ACA, HRRP Implementation, and HRRP Penalty Era
Supplemental Digital Content Table 4 Procedure Specific National Readmission Trends
Among Medicare Beneficiaries in Pre-ACA, HRRP Implementation, and HRRP Penalty Era
Supplemental Digital Content Table 5 National Readmission Trends Among Medicare
Beneficiaries in Pre-ACA, HRRP Implementation, and HRRP Penalty Era Across Quartiles of
Baseline Readmission
Supplemental Digital Content Table 1 Procedure ICD-9 Codes Included in Analysis
Procedure ICD-9 Procedure Code
Coronary artery bypass graft 3610, 3611, 3612, 3613, 3614, 3615, 3617, 3619 Abdominal aortic aneurysm repair 3864, 3834, 3844, 3973, 3971
Pulmonary lobe resection/segmentectomy 3241, 3249, 3230, 3239
Colorectal resection 1731-1736, 1739, 4503, 4526, 4541, 4549, 4571-4576, 4579, 4581, 4582, 4583
Hip replacement 8151, 8152
Appendectomy 4709, 4720, 4791, 4701
Cholecystectomy 5120, 5122, 5121, 5103, 5104, 5123, 5124
Knee replacement 8154
Supplemental Digital Content Table 2 Characteristics of Medicare patients Undergoing Targeted and Non-Targeted Surgical Procedures in 2005 and 2014
Targeted Non-Targeted
2005 2014 2005 2014
(N=517,148) (N=458,456) (N=266,498) (N=182,821)
Index Admission Characteristics
Elective Admission (%) 70 78.6 47.5+ 47.4+
Length of Stay (days, median) 5 4 8 6
Discharge Location
Home (%) 19.7 20.9 63.3 60.4
Home with VNA (%) 26.0 34.0 15.7 17.3
Skilled nursing facility
(%) 30.2 32.5 15.1+ 15.3+
Rehabilitation Facility
(%) 21.1 10.2 2.5 2.9
Patient Characteristics
Age (year, median) + 75.1+ 75.0+ 75.4+ 75.7+
Male (%)+ 41.2 40.6 46.8 48.5
Non-white race (%)+ 8.8+ 8.2+ 11.4+ 12.0+
Hypertension (%) 65.5 67.7 54.2 57.2
Diabetes (%) 19.4 21.3 17.6 20.5
Renal Failure (%) 2.7 7.7 3.7 8.7
Liver Disease (%) 0.4 0.7 1.8 2.4
Obesity (%) 6.1 14.2 3.2 8.7
Hospital Characteristics
Hospital Size +
Small (%) 25.7 25.8 28.2 26.6
Medium (%) 61.0 60.4 59.1 59.9
Large (%) 13.4 13.8 12.7 13.4
Teaching Status+
Major Teaching (%) 9.0 9.1 8.6 9.0
Minor (%) 12.8 13.1 12.5 12.9
Non-Teaching (%) 78.2 77.8 78.9 78.1
Targeted procedures included CABG, hip replacement, and knee replacement. Non-targeted procedures include colectomy, pulmonary lobectomy, AAA repair, cholecystectomy, and appendectomy. All comparisons between targeted procedures in 2005 vs. 2014 and non-targeted procedures in 2005 vs. 2014 are significant at p<0.001 except those denoted with +, which where p>0.05.
Supplemental Digital Content Table 3 Annual Change in Readmission Rates Among Medicare Beneficiaries in Pre-ACA, HRRP Implementation, and HRRP Penalty Era
Non-targeted Conditions Targeted Conditions All Conditions
-0.60% -0.50% -0.40% -0.30% -0.20% -0.10% 0.00% 0.10%
-0.51%
-0.03%
-0.23%
-0.41%
-0.53%
-0.52%
0.10%
-0.40%
-0.24%
HRRP Penalty Period Annual Risk Adjusted Change in Readmission RatesHRRP Implementation Period Pre-ACA Period
Supplemental Digital Content Table 4 Procedure Specific National Readmission Trends Among Medicare Beneficiaries in Pre- ACA, HRRP Implementation, and HRRP Penalty Era
2005 Unadjusted Readmission
Rate
Pre-ACA Period HRRP Implementation Period HRRP Penalty Period (Q1 2005 – Q1 2010) (Q2 2010 – Q2 2012) (Q3 2012 – Q4 2014)
Quarterly Slope Quarterly Slope Change in slope
from Pre- ACA Quarterly Slope
Change in slope from implementation of
ACA
[95% CI] [95% CI] [95% CI] [95% CI] [95% CI]
Targeted Procedures
CABG 18.8% -0.078% -0.232% -0.155% -0.269% -0.036%
+
[-0.098, -0.058] [-0.275, -0.189] [-0.207, -0.102] [-0.318, -0.219] [-0.117, 0.044]
Hip Replacement 11.9% -0.104% -0.107% -0.00003
+ -0.105% 0.002%+
[-0.126, -0.083] [-0.131, -0.084] [-0.041, 0.035] [-0.128, -0.082] [-0.039, 0.044]
Knee Replacement 7.0% -0.075% -0.058% 0.00017
+ -0.075% -0.017%+
[-0.094, -0.056] [-0.074, -0.042] [-0.011, 0.046] [-0.090, -0.059] [-0.044, 0.010]
Non - Targeted Procedures
AAA Repair 13.0% 0.01%
+ -0.122% -0.131%* -0.151% -0.029%+
[-0.019, 0.038] [-0.182, -0.061] [-0.211, -0.051] [-0.224, -0.078] [-0.147, 0.089]
Lobectomy 13.3% -0.035%
* -0.04% -0.00001 -0.193% -0.157%*
[-0.068, -0.002] [-0.096, 0.024] [-0.085, 0.082] [-0.260, -0.126] [-0.271, -0.043]
Colectomy 15.0% 0.057% -0.093% -0.149% -0.102% -0.009%
+
[0.041, 0.072] [-0.127, -0.058] [-0.195, -0.104] [-0.145, -0.058] [-0.080, 0.061]
Appendectomy 10.1% 0.01%
+ -0.068%* -0.08%+ -0.05%+ 0.019%+
[-0.022, 0.038] [-0.131, -0.004] [-0.160, 0.010] [-0.129, 0.031] [-0.110, 0.147]
Cholecystectomy 12.8% 0.019%
* -0.134% -0.153%* -0.077% 0.056%+
[0.005, 0.033] [-0.165, -0.102] [-0.193, -0.112] [-0.117, -0.037] [-0.007, 0.12]
All comparisons are significant at p<0.001 except those denoted with *, which where 0.001< p <0.05, and +, which where p>0.05.
Supplemental Digital Content Table 5 National Readmission Trends Among Medicare Beneficiaries in Pre-ACA, HRRP Implementation, and HRRP Penalty Era Across Quartiles of Baseline Readmission
Quartiles of Baseline Readmission Rates
Procedures
Pre-ACA Period HRRP Implementation Period HRRP Penalty Period
(Q1 2005 – Q1
2010) (Q2 2010 – Q2 2012) (Q3 2012 – Q4 2014)
Quarterly Slope [95% CI]
Quarterly Slope [95% CI]
Change in slope from Pre- ACA
[95% CI]
P-Value Quarterly Slope [95% CI]
Change in slope from implementation of
ACA [95% CI]
P-Value
Lowest Quartile (5.5%)a
Targeted
Procedures 0.005%+ -0.10% -0.10% <0.001 -0.08% 0.02%+ 0.45
[-0.01%, 0.02%] [-0.13%, -0.07%] [-0.14%, -0.07%] [-0.11%, -0.05%] [-0.03%, 0.07%]
Non - Targeted Procedures
0.11% -0.17% -0.28%
<0.001 -0.10%* 0.07%+
[0.09%, 0.14%] [-0.23%, -0.11%] [-0.36%, -0.20%] [-0.17%, -0.03%] [-0.05%, 0.18%] 0.25
2nd Quartile (12.6%)a
Targeted
Procedures 0.05% -0.14% -0.09% <0.001 -0.10% 0.04%+ 0.06
[-0.06%, -0.04%] [-0.16%, -0.11%] [-0.12%, -0.05%] [-0.12%, -0.07%] [-0.002%, 0.08%]
Non - Targeted Procedures
0.03%* -0.14% -0.17%
<0.001 -0.06%* 0.08%*
[0.01%, 0.04%] [-0.18%, -0.10%] [-0.22%, -0.12%] [-0.10%, -0.02%] [0.01%, 0.16%] 0.02
3rd Quartile (20.0%)a
Targeted
Procedures [-0.13%, -0.09%]-0.11% [-0.21%, -0.15%]-0.18% [-0.11%, -0.03%]-0.07% <0.001 [-0.15%, -0.10%]-0.13% [0.01%, 0.11%] 0.06%* 0.03 Non - Targeted
Procedures [-0.02%, 0.01%] -0.01%+ [-0.13%, -0.06%]-0.09% [-0.13%, -0.04%]-0.09% <0.001 [-0.15%, -0.05%]-0.10% [-0.08%, 0.07%]-0.01%+ 0.89
Highest Quartile (38.8)a
Targeted Procedures
-0.23% -0.07% 0.15%
<0.001 -0.14% -0.07%*
[-0.28%, -0.18%] [-0.11%, -0.04%] [0.08%, 0.22%] [-0.17%, -0.11%] [-0.12%, -0.01%] 0.02 Non - Targeted
Procedures [-0.02%, 0.02%]0.002%+ [-0.14%, -0.06%]-0.10% [-0.15%, -0.05%]-0.10% <0.001 [-0.17%, -0.06%]-0.12% [-0.10%, 0.07%]-0.02%+ 0.70 Targeted procedures include CABG, hip replacement, and knee replacement. Non-targeted procedures include colectomy, pulmonary lobectomy, AAA repair, cholecystectomy, and appendectomy.
All comparisons are significant at p<0.001 except those denoted with *, which where 0.001< p <0.05, and +, which where p>0.05.
a Mean readmission rate across hospitals in the given quartile in 2005.