HOSPITAL-WIDE ADULT ALL-PAYER READMISSIONS...A readmission is defined as an unplanned...

HOSPITAL-WIDEADULT ALL-PAYERREADMISSIONSIN MASSACHUSETTS: SFY 2011-2018

CENTER FOR HEALTH INFORMATION AND ANALYSIS

D EC EM B ER 2019

Hospital-Wide Adult All-Payer Readmissions In Massachusetts: SFY 2011-2018 | December 2019i center for health information and analysis CHIA

Unplanned hospital readmissions within 30 days of an inpatient discharge are a measure of health system performance.

In service of its mission to objectively report reliable and meaningful information about the quality, affordability, utilization,

access, and outcomes of the Massachusetts health care system, the Massachusetts Center for Health Information and

Analysis (CHIA) annually reports on hospital-wide all-payer readmissions.

Massachusetts historically has had readmission rates higher than the national average. Under the Centers for Medicare

and Medicaid Services (CMS) Hospital Readmissions Reduction Program, CMS will penalize 94% of the Commonwealth’s

hospitals in Federal Fiscal Year (FFY) 2020 for having higher than expected readmission rates. Both the percentage of

hospitals fined and the average level of fines imposed are greater in Massachusetts than in most other states.1

To monitor readmissions in the Commonwealth, CHIA adapted the Yale/CMS Hospital-Wide All-Cause Unplanned 30-day

Readmission Measure.2 Though the Yale/CMS readmission measure was originally developed for use within the Medicare

population, CHIA adapted the measure for an all-payer population.3 The readmission analyses presented in this report

are based on data from CHIA’s Hospital Inpatient Discharge Database.4

This report is the sixth in CHIA’s annual series of all-payer readmission reports and updates previous reports with

State Fiscal Year (SFY) 2018 data and presents statewide trends in readmission rates from SFY 2011 to 2018. Due to

technical changes, the rates presented in this report differ from earlier publications. n

Executive Summary

center for health information and analysisHospital-Wide Adult All-Payer Readmissions In Massachusetts: SFY 2011-2018 | December 2019ii CHIA

Key Findings

The unplanned, all-payer readmission rate for

Massachusetts acute care hospitals is unchanged from

last year (15.4% in both 2017 and 2018).

Medicare and Medicaid beneficiaries had higher

readmission rates than patients with commercial insurance (17.8%, 16.4% and 9.8%,

respectively).

Medicare patients aged 65 and over had the highest

total number of readmissions; Medicare patients under 65

had the highest rate of readmission (22.0%).

Readmission rates for patients discharged to skilled nursing facilities or rehabilitation have

increased in the last three years.

Frequently hospitalized patients (patients hospitalized

four or more times in the previous 12 months) accounted

for over half (52%) of all readmissions.

Over one-third (35%) of readmissions occur within one

week of initial discharge.

Hospital-Wide Adult All-Payer Readmissions In Massachusetts: SFY 2011-2018 | December 2019iii center for health information and analysis CHIA

Introduction ................................................................................................................................................. 1

Overall Trends in All-Payer Readmissions ................................................................................................ 3Key Findings ................................................................................................................................................................3

Trends in Statewide All-Payer Readmission Rate, Discharges, and Readmissions ..........................................4

Trend in Average Length of Stay (ALOS) by Readmission Status .......................................................................5

All-Payer Readmissions by Characteristics of Patients and Hospitalizations ...................................... 6Key Findings ................................................................................................................................................................6

All-Payer Readmissions by Days Since Discharge .................................................................................................7

All-Payer Readmissions by Patient Age ...................................................................................................................8

Trends in All-Payer Readmissions by Patient Age ..................................................................................................9

All-Payer Readmissions by Payer Type ................................................................................................................. 10

All-Payer Readmissions by Payer Type and Patient Age .................................................................................... 11

Trends in All-Payer Readmissions by Payer Type and Patient Age ................................................................... 12

All-Payer Readmissions by Discharge Setting ..................................................................................................... 13

Discharge Diagnoses with the Highest Numbers of Readmissions .................................................................. 14

Trends in Discharge Diagnoses with the Highest Numbers of Readmissions ................................................. 15

Discharge Diagnoses with the Highest Rates of Readmissions ........................................................................ 16

All-Payer Readmissions Among Frequently Hospitalized Patients ................................................................... 17

Contents

Hospital-Wide Adult All-Payer Readmissions In Massachusetts: SFY 2011-2018 | December 2019iv center for health information and analysis CHIA

Frequently Hospitalized Patients by Payer Type and Age .................................................................................. 18

Percentage of Frequently Hospitalized Patients by Patient Region ................................................................. 19

All-Payer Readmissions by Hospital ....................................................................................................... 20Key Findings ............................................................................................................................................................. 20

All-Payer Risk-Standardized Readmission Rates of Acute Care Hospitals ..................................................... 21

Hospitals Consistently in Highest and Lowest Risk-Standardized Readmission Rate Quartiles ................. 22

All-Payer Risk-Standardized Readmission Rates by Hospital Type .................................................................. 23

All-Payer Risk-Standardized Readmission Rates by Hospital System ............................................................. 24

All-Payer Observed and Risk-Standardized Readmission Rates by Hospital Region ................................... 25

About the Readmissions Methodology ................................................................................................... 26

Notes .......................................................................................................................................................... 28

1 CHIAcenter for health information and analysisHospital-Wide Adult All-Payer Readmissions In Massachusetts: SFY 2011-2018 | December 2019

Unplanned hospital readmissions are a measure of health system performance. Massachusetts has historically had

higher than average readmission rates compared to the national average for Medicare fee-for-service beneficiaries. In

Federal Fiscal Year (FFY) 2020 (October 2019 to September 2020), 94% of Massachusetts hospitals will be penalized for

higher than expected readmission rates.5

To monitor readmissions in the Commonwealth, the Center for Health Information and Analysis (CHIA) adapted the

Yale/CMS Hospital-Wide All-Cause Unplanned 30-day Readmission Measure.6 Though initially developed for use within

the Medicare population, CHIA adapted the Yale/CMS measure for an all-payer population.7 The readmission analyses

presented in this report were conducted using CHIA’s Hospital Inpatient Discharge Database.8 An analysis of statewide

and hospital-specific all-payer, all-cause readmission rates provides the public, providers and policymakers a complete

view of adult readmissions in the Commonwealth of Massachusetts. An all-payer analysis is helpful as strategies to

control the growing cost of health care remain public policy priorities in Massachusetts.

This report is the sixth in CHIA’s annual series of readmission reports. This year’s report updates previous reports with

State Fiscal Year (SFY) 2018 data and reports on trends in readmission rates from SFY 2011 to 2018 (July 2010 through

June 2018). Additionally, this year’s report uses an enhanced methodology to identify and link patient records, utilizing a

probabilistic patient identifier instead of Social Security Number. This enhanced methodology allows for more discharges

and readmissions to be kept in the final analytic dataset. Furthermore, this year’s report incorporates the 2019 CMS

readmission measure methodology (version 8.0), which updates the planned readmission algorithm.9 The historical

figures presented in this report were recalculated using the enhanced patient identifier and version 8.0 of the CMS

readmission measure, and will not match those from earlier reports. See the technical appendix for more information.

Introduction

http://www.chiamass.gov/assets/docs/r/pubs/19/Readmissions-Technical-Appendix-2011-2018.pdf

Hospital-Wide Adult All-Payer Readmissions In Massachusetts: SFY 2011-2018 | December 20192 center for health information and analysis CHIA

This report presents the overall trend in statewide all-payer readmissions for the past eight years, examines

readmissions by characteristics of patients and hospitalizations, and provides readmission rates for individual

hospitals and groups of hospitals. n


Overall Trends in All-Payer Readmissions

This section presents the overall trend in all-payer readmissions for acute care hospitals in Massachusetts for the eight-

year study period spanning July 1, 2010 to June 30, 2018. A readmission is defined as an unplanned hospitalization for

any reason within 30 days of an eligible discharge. This measure excludes certain categories of hospitalizations, such as

obstetric and primary psychiatric admissions.

This report presents readmission rates as both observed and risk-standardized figures. Observed or “raw” readmission

rates are calculated as the number of readmissions that occurred in a year as a proportion of all eligible discharges in

that year. With observed hospital readmission rates, some portion of differences among hospitals may be attributable to

differing service mix and patient case mix. Observed rates are useful for identifying opportunities for improvement and

tracking performance over time within individual hospitals. Unless otherwise noted, the readmission rates presented in

this report are observed or “raw” readmission rates.

The risk-standardized readmission rates (RSRRs) presented are adjusted observed rates calculated for hospitals and for

groups of hospitals. RSRRs take into account the differences across hospitals in patient age, patient comorbidities, and

the profile of conditions that each hospital treats, allowing for a more accurate comparison across hospitals. RSRRs are

used in this report to compare hospital performance on the readmission measure. n

Key Findings• The 2018 all-payer readmission rate in Massachusetts is unchanged from 2017.

• The average length of stay for discharges that led to a readmission was 1.5 days longer than those without a

readmission.


0

5

10

15

20

Rea

dmis

sion

Rat

e (%

)

15.9 15.4 14.9 14.9

15.4 15.3

15.4

2011 2012 2013 2014 2015 2016 20182017

Year

15.4

566 555 534

514 527 528 535 537

90 85 80 77 81 81 83 83

0

200

400

600

2011 2012 2013 2014 2015 2016 2017 2018

Year

Cou

nt (t

hous

ands

)

Eligible Discharges

Readmissions

KEY

OVERALL TREND

Trends in Statewide All-Payer Readmission Rate, Discharges, and ReadmissionsSFY 2011-2018

The eight-year trend in all-payer

readmission rates shows that

after a decline from 2011-2013

and an increase from 2013-2015,

readmission rates have stabilized

in recent years. In 2018, the

statewide observed readmission

rate was 15.4%.

The statewide number of eligible

discharges followed a similar

trend, with the total number of

eligible discharges remaining

relatively consistent in the past

few years.

In 2018, there were 536,709

eligible discharges and 82,900

readmissions.

Note: This year’s report matches patient records using a probabilistic patient identifier, instead of Social Security Number. Readmission rates may not match those from earlier reports. Analyses include eligible discharges for adults with any payer, excluding discharges for obstetric or primary psychiatric care. See technical appendix for more information.Data source: Massachusetts Hospital Inpatient Discharge Database, July 2010 to June 2018.



Discharges with Readmission

Discharges with No Readmission

KEY

0

2

4

6

2011 2012 2013 2014 2015 2016 2017 2018

Year

Ave

rage

Len

gth

of S

tay

(Day

s) 4.2

5.6

4.2

5.5

4.3

5.7

4.4

5.8

4.4

5.8

4.4

5.8

4.4 4.5

6.0 5.9

KEY

OVERALL TREND

Trend in Average Length of Stay (ALOS) by Readmission Status SFY 2011-2018

The average length of stay (ALOS)

for discharges with a subsequent

readmission was six days in

2018, 1.5 days longer than

discharges without a readmission.

ALOS for all discharges has

increased since 2012.

Note: The average length of stay (ALOS) was calculated as the difference in the number of days between the discharge date and the admission date. Due to technical changes, readmission rates may not match those from earlier reports. Analyses include eligible discharges for adults with any payer, excluding discharges for obstetric or primary psychiatric care. See technical appendix for more information.Data source: Massachusetts Hospital Inpatient Discharge Database, July 2010 to June 2018.



All-Payer Readmissions by Characteristics of Patients and HospitalizationsThis section presents observed readmission rates by several characteristics of patients and hospitalizations, such as patient

age, expected payer type, primary discharge diagnosis, prior utilization, and discharge setting. n

Key Findings• Medicare and Medicaid beneficiaries have higher readmission rates than patients with commercial insurance (17.8%,

16.4%, and 9.8%, respectively).

• Readmission rates for adults aged 18-64 have remained stable over time, whereas rates for patients aged 65 and over

have decreased.

• Though Medicare patients 65 and over had the highest number of readmissions, Medicare patients under age 65 had the

highest readmission rate in 2018 (22.0%).

• Frequently hospitalized patients, defined as those with four or more hospitalizations within 12 months of their most recent

discharge, represented 6% of the patient population, and accounted for 19% of all discharges and 52% of all readmissions.


0

2

4

6

Perc

ent

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30Days Since Discharge

35% of readmissions occur within one week of initial discharge

STATEWIDE READMISSIONS

All-Payer Readmissions by Days Since DischargeSFY 2018

Any unplanned admission, for

any cause, within 30 days of an

eligible discharge is counted as

a readmission.

Over one-third (35%) of

readmissions occurred within

seven days of the initial

discharge, peaking at two days

post discharge.

Note: Due to technical changes, readmission rates may not match those from earlier reports. Analyses include eligible discharges for adults with any payer, excluding discharges for obstetric or primary psychiatric care. See technical appendix for more information.Data source: Massachusetts Hospital Inpatient Discharge Database, July 2017 to June 2018.



0

5

10

15

20

25

18−24 25−34 35−44 45−54 55−64 65−74 75−84 85+

Age

Rea

dmis

sion

Rat

e (%

)

Size of square is proportional to number of readmissions.

KEY

= 10,000readmissions

Statewide rate=

All-Payer Readmissions by Patient AgeSFY 2018

Both the volume and rate of

readmission increase with patient

age. Patients aged 65 and over

accounted for almost 60% of

all readmissions in the state.

Additionally, patients aged 85 and

over had the highest readmission

rate in 2018 (17.2%), followed by

patients aged 75-84 (17.1%).

Note: The size of the squares is proportional to the number of readmissions. Due to technical changes, readmission rates may not match those from earlier reports. Analyses include eligible discharges for adults with any payer, excluding discharges for obstetric or primary psychiatric care. See technical appendix for more information.Data source: Massachusetts Hospital Inpatient Discharge Database, July 2017 to June 2018.




Trends in All-Payer Readmissions by Patient AgeSFY 2011-2018


10.0 10.2 9.8

10.1 10.1 10.1 10.3 10.2

15.0 14.7

14.0 14.5 14.7 14.6 14.9 14.8

13.2 13.0 12.8 13.1 13.6

13.3 13.6

13.2

16.3

15.5 15.2 15.1

15.6 15.3 15.5 15.6

13.5 13.6 13.4 13.5 14.1 14.1

13.7 13.6

18.3

17.4

16.6 16.5 17.1 17.1 16.8 17.1

14.0 14.0 14.0 14.1 14.6 14.6 14.8

14.4

18.9

17.7 17.0

16.5 17.0 17.0 17.2 17.2

11 12 13 14 15 16 17 18 11 12 13 14 15 16 17 18 11 12 13 14 15 16 17 18 11 12 13 14 15 16 17 18

10

12

14

16

18

20

10

12

14

16

18

20

State Fiscal Year, 2011 to 2018

Rea

dmis

sion

Rat

e (%

)

65-74 75-84 85+55-64

18−24 25−34 35−44 45−54


The trend in readmission rates

varies by patient age. For

patients aged 18-64, the eight-

year trend is relatively stable,

whereas for patients aged 65

and over, readmission rates have

decreased.



All-Payer Readmissions by Payer TypeSFY 2011-2018

Medicare beneficiaries had

the highest number and rate

of readmission in 2018, as in

previous years. The rates for

Medicare and Medicaid patients,

17.8% and 16.4%, respectively,

were much higher than that

of patients with commercial

coverage (9.8%).

The trend in readmission rates

for both Medicare and Medicaid

patients shows a decline

from 2011 to 2015, followed

by a plateau in recent years.

Readmission rates for patients

with commercial insurance

have remained consistently low

over time.

Note: The size of the squares in the top figure is proportional to the number of readmissions. Self-pay and other payer type categories were not included due to small number of discharges. Due to technical changes, readmission rates may not match those from earlier reports. Analyses include eligible discharges for adults with any payer, excluding discharges for obstetric or primary psychiatric care. See technical appendix for more information.Data source: Massachusetts Hospital Inpatient Discharge Database, July 2010 to June 2018.


SFY 2018

Eight-Year Trend

0

5

10

15

20

25

Rea

dmis

sion

Rat

e (%

)

Statewide rate


=

=

10,000readmissions

KEY

Medicare Medicaid Commercial


10

12

14

16

18

20

Rea

dmis

sion

Rat

e (%

)

Medicare Commercial

0

Medicaid

18.9 18.1

17.4 17.3 17.8 17.7 17.8 17.8 17.6

17.1 16.8 16.6 16.5 16.5 16.4 16.4

10.2 10.0 9.7 9.8 10.0 9.7 9.8 9.8

11 12 13 14 15 16 17 18 11 12 13 14 15 16 17 18 11 12 13 14 15 16 17 18

0

5

10

15

20

25

Rea

dmis

sion

Rat

e (%

)

Statewide rate


=

=

10,000readmissions

KEY

Medicare Medicaid CommercialPayer Type



All-Payer Readmissions by Payer Type and Patient AgeSFY 2018

Medicare beneficiaries aged 65

and over had the highest number

of readmissions. However,

Medicare beneficiaries aged 18-

64 had the highest readmission

rate, at 22.0%. Medicare

beneficiaries under age 65 are

most likely dually eligible for both

Medicare and Medicaid.

Note: The size of the squares is proportional to the number of readmissions. Self-pay and other payer type categories were not included due to small number of discharges. Due to technical changes, readmission rates may not match those from earlier reports. Analyses include eligible discharges for adults with any payer, excluding discharges for obstetric or primary psychiatric care. See technical appendix for more information.Data source: Massachusetts Hospital Inpatient Discharge Database, July 2017 to June 2018.


Medicare18-64

Medicare65+

Medicaid18-64

Medicaid65+

Commercial18-64

Commercial65+

Payer Type/Age

0

5

10

20

25

15R

eadm

issi

on R

ate

(%)


KEY


Statewide rate=

Medicare18-64

Medicare65+

Medicaid18-64

Medicaid65+

Commercial18-64

Commercial65+

Payer Type/Age

0

5

10

20

25

15

Rea

dmis

sion

Rat

e (%

)


KEY


Statewide rate=



Trends in All-Payer Readmissions by Payer Type and Patient AgeSFY 2011-2018

The eight-year trends for

readmission rates by payer type

and patient age have remained

relatively stable over time.

Note: Self-pay and other payer type categories were not included due to small number of discharges. Due to technical changes, readmission rates may not match those from earlier reports. Analyses include eligible discharges for adults with any payer, excluding discharges for obstetric or primary psychiatric care. See technical appendix for more information.Data source: Massachusetts Hospital Inpatient Discharge Database, July 2010 to June 2018.


Medicaid


10

15

20

25

Rea

dmis

sion

Rat

e (%

)

Commercial (18-64) Commercial (65+)

12.4 12.6

11 12 13 14 15 16 17 18 11 12 13 14 15 16 17 18

13.1 12.9 12.8 12.8 13.0

9.6 9.5 9.2 9.4 9.4 9.1 9.3 9.1

14.0

Medicaid

10

15

20

25

Medicaid (18-64)

10

15

20

25

Medicaid (65+)

17.7 17.3 16.9 16.8 16.6 16.6 16.5 16.5

Medicaid (18-64)

14.4 14.8 14.8 14.6 13.6 13.6 14.0 15.7

10

15

20

25

10

15

20

25

Medicare (65+)Medicare (18-64)

18.1 17.2 16.6 16.3 16.8 16.7 16.8 16.9

23.1 22.5 21.4 21.6 22.2 22.3 22.6 22.0



0

5

10

15

20

25

Rea

dmis

sion

Rat

e (%

)

Statewide rate


=

=

10,000readmissions

KEY

Home HHA SNF Rehab

Discharge Setting

11.8 11.9 11.7 11.8 12.2 12.2 12.2 12.1

19.9 19.1

18.1 17.7 17.6 17.3 17.2 17.2

20.7

18.5 18.4

19.9 19.9 20.0 20.3

18.5 18.0 18.1 17.7

19.5 19.8

11 12 13 14 15 16 17 18 11 12 13 14 15 16 17 18 11 12 13 14 15 16 17 18 11 12 13 14 15 16 17 18

RehabHome HHA SNF


Rea

dmis

sion

Rat

e (%

)

10

12

14

16

18

20 19.0 19.4 18.9

All-Payer Readmissions by Discharge SettingSFY 2011-2018

Patients discharged to home had

the lowest rate of readmission

(12.1%) in 2018. Patients

discharged to post-acute care

settings had much higher

readmission rates: 17.2% for

home health agencies (HHAs),

20.0% for skilled nursing

facilities (SNFs), and 19.8% for

rehabilitation.

Though readmission rates

have been relatively stable over

time for patients discharged

to home, rates for patients

discharged to HHA markedly

decreased. Readmission rates for

patients discharged to SNF and

rehabilitation increased over the

past few years.

Note: The size of the squares in the top figure is proportional to the number of readmissions. HHA = home with home health agency care, SNF = skilled nursing facility. Hospice discharges were not included due to its small number of discharges. Due to technical changes, readmission rates may not match those from earlier reports. Analyses include eligible discharges for adults with any payer, excluding discharges for obstetric or primary psychiatric care. See technical appendix for more information.Data source: Massachusetts Hospital Inpatient Discharge Database, July 2010 to June 2018.


SFY 2018

Eight-Year Trend



Discharge Diagnoses with the Highest Numbers of ReadmissionsSFY 2018

The 10 discharge diagnoses

associated with the highest

numbers of readmissions have

been consistent for the past

few years.

These top 10 discharge

diagnoses cumulatively

accounted for approximately

one-third of all readmissions.

While it may be important to

focus readmission reduction

efforts on these high volume

conditions, exclusively focusing

on the top 10 diagnoses would

miss a substantial portion of all

readmissions.

Note: The discharge diagnosis is based on APR DRG version 30.0. Some discontinuity in trend by diagnosis may be attributed to the change in diagnostic coding from ICD-9-CM to ICD-10-CM in October 2015. Due to technical changes, readmission rates may not match those from earlier reports. Analyses include eligible discharges for adults with any payer, excluding discharges for obstetric or primary psychiatric care. See technical appendix for more information.Data source: Massachusetts Hospital Inpatient Discharge Database, July 2017 to June 2018.


Discharges=Readmissions=

KEY

0 30,000 60,000 90,000

Top 10 Diagnoses

28,266 (34%)Other Diagnoses

54,634 (66%)

Statewide Number of Readmissions (%)

Number of Discharges and Readmissions

0 5,000 10,000 15,000 20,000 25,000 30,000

Cellulitis & OtherBacterial Skin Infections

Pulmonary Edema &Respiratory Failure

Cardiac Arrhythmia &Conduction Disorders

Kidney & Urinary TractInfections

Alcohol Abuse & Dependence

Renal Failure

Other Pneumonia

Chronic ObstructivePulmonary Disease

Septicemia & DisseminatedInfections

Heart Failure

13%

24%

14%

17%

21%

21%

15%

23%

18%

25% (readmission rate)



Trends in Discharge Diagnoses with the Highest Numbers of ReadmissionsSFY 2011-2018

Readmission rates for

several, but not all, of the

diagnoses leading to the

most readmissions decreased

over the first few years of the

eight-year study period. In

recent years, many have either

remained relatively stable or

slightly decreased.

After several years of increasing

readmission rates for chronic

obstructive pulmonary disease,

rates decreased in 2018.

Note: The discharge diagnosis is based on APR DRG version 30.0. Some discontinuity in trend by diagnosis may be attributed to the change in diagnostic coding from ICD-9-CM to ICD-10-CM in October 2015. Due to technical changes, readmission rates may not match those from earlier reports. Analyses include eligible discharges for adults with any payer, excluding discharges for obstetric or primary psychiatric care. See technical appendix for more information.Data source: Massachusetts Hospital Inpatient Discharge Database, July 2010 to June 2018.


25.4 24.5

23.7 22.5

24.2 23.8 24.1 24.6

21.7 21.8 21.0

22.0 22.1 22.0 21.7 21.3

21.2 20.0

18.4 18.5 18.9 18.4 18.1 17.9

18.8

17.1 17.0 16.5 17.4

16.6 16.7 17.0

24.1 22.9

21.4 21.6 22.3 22.5 23.1

22.5

16.4 15.6 15.1 15.3

14.6 15.0 15.5 14.5

17.0 16.1

15.3 16.2 15.8 16.3

15.4 15.4

25.6 25.9

24.1

22.5

24.9 24.8 24.4 24.1

22.9 21.5

20.3

21.9 21.3 21.3 21.0 21.1

13.6 13.4 12.7 12.6

13.4 13.2 12.4

13.2

11 12 13 14 15 16 17 18 11 12 13 14 15 16 17 18 11 12 13 14 15 16 17 18 11 12 13 14 15 16 17 18 11 12 13 14 15 16 17 18

10

15

20

25

10

15

20

25

Trends in Readmission Rate by Diagnosis, SFY 2011 to 2018

Alcohol Abuse & Dependence

Kidney & UrinaryTract Infections

Cardiac Arrhythmia &Conduction Disorders

Pulmonary Edema &Respiratory Failure

Cellulitis & Other BacterialSkin Infections

Heart Failure Septicemia &Disseminated Infections

Chronic ObstructivePulmonary Disease Other Pneuomina Renal Failure




Discharge Diagnoses with the Highest Rates of ReadmissionsSFY 2018

As in previous years, sickle cell

anemia, transplants, and liver

disease are among the discharge

diagnoses with the highest

readmission rates.

While the overall number of

readmissions attributed to

these diagnoses is relatively

small—about three percent of

all readmissions—patients with

these diagnoses have a very high

risk of readmission.

* Number of readmissions.Note: The discharge diagnosis is based on APR DRG version 30.0. Some discontinuity in trend by diagnosis may be attributed to the change in diagnostic coding from ICD-9-CM to ICD-10-CM in October 2015. Due to technical changes, readmission rates may not match those from earlier reports. Analyses include eligible discharges for adults with any payer, excluding discharges for obstetric or primary psychiatric care. See technical appendix for more information.Data source: Massachusetts Hospital Inpatient Discharge Database, July 2017 to June 2018.

40%

38%

36%

34%

32%

30%

30%

27%

27%

27%HIV W Multiple Major HIV RelatedConditions (89)

Respiratory System Diagnosis WVentilator Support 96+ Hours (141)

Other Circulatory SystemProcedures (104)

Heart &/or Lung Transplant (58)

Kidney Transplant (125)

Hepatic Coma & Other Major Acute Liver Disorders (543)

Alcoholic Liver Disease (651)

Other Hepatobiliary, Pancreas &Abdominal Procedures (476)

Liver Transplant &/or IntestinalTransplant (97)

Sickle Cell Anemia Crisis (436*)

0 10 20 30 40

Statewide rate=KEY

Readmission Rate (%)




All-Payer Readmissions Among Frequently Hospitalized PatientsSFY 2018

Frequently hospitalized patients

are defined as those with four

or more hospitalizations within

12 months of their most recent

discharge. For example, a patient

whose most recent discharge

occurred in April 2018 and was

hospitalized three other times

between April 2017 and April

2018 would be classified as a

frequently hospitalized patient.

In 2018, six percent of patients

were hospitalized four or more

times in the previous 12 months.

This group of patients accounted

for 19% of discharges and over

half (52%) of readmissions.

The readmission rate for

frequently hospitalized patients

was 43%, substantially higher

than the rate of 9% for

patients who were not

frequently hospitalized.Note: Due to technical changes, readmission rates may not match those from earlier reports. Analyses include eligible discharges for adults with any payer, excluding discharges for obstetric or primary psychiatric care. See technical appendix for more information.Data source: Massachusetts Hospital Inpatient Discharge Database, July 2017 to June 2018.

6%

94%

19%

81%

52%

48%

Patients withFrequent (4+)Hospitalizations

Patients withoutFrequentHospitalizations

Patients Discharges Readmissions0

20

40

60

80

100

Perc

ent



Frequently Hospitalized Patients by Payer Type and AgeSFY 2018

Almost 12% of Medicare

beneficiaries aged 18-64 were


in 2018. In contrast, only 2.5%

of patients aged 18-64 with

commercial insurance were

frequently hospitalized patients.

The proportion of patients aged

65 and over who were frequently

hospitalized varied much less by

payer type (4.1%-6.8%).

Among frequently hospitalized

patients, the majority were

Medicare beneficiaries (71%).

Furthermore, patients with either

Medicare or Medicaid coverage

made up 86% of all frequently

hospitalized patients.

Note: Self-pay and other payer type categories were not included due to small number of discharges. Percentages may not add up to 100% due to rounding. Due to technical changes, readmission rates may not match those from earlier reports. Analyses include eligible discharges for adults with any payer, excluding discharges for obstetric or primary psychiatric care. See technical appendix for more information

Data source: Massachusetts Hospital Inpatient Discharge Database, July 2017 to June 2018.


3,595 3,187 Number of FrequentlyHospitalized Patients

Percent of All Frequently Hospitalized Patients

30,935 48,576Number of All Patients

11,763

172,650

151

2,808

1,976

79,993

657

16,161

Medicaid,18-64

15%

0% 100%

Medicare,65+

54% Medicare,

18-64

17% Commercial,

18-64

9%

Medicaid,65+

<1% Commercial,

65+

3%

18-64 18-64

Age Group

65+ 18-64 65+65+Medicare Medicaid Commercial

2.5%4.1%

6.6%5.4%

11.6%

6.8%

0

5

10

15

Perc

ent



Percentage of Frequently Hospitalized Patients by Patient Region SFY 2018

Almost eight percent of

patients in Fall River were


in 2018. The lowest proportion

of frequently hospitalized

patients were in the Cape and

Islands region (4.7%).

Note: Due to technical changes, readmission rates may not match those from earlier reports. Analyses include eligible discharges for adults with any payer, excluding discharges for obstetric or primary psychiatric care. See technical appendix for more information.



Berkshires

Cape and Islands

Central MA

E. Merrimack

Fall River

Metro Boston

Metro South

Metro West

New Bedford

Norwood/Attleboro

Pioneer Valley /Franklin

South Shore

Upper N. Shore

W. Merrimack / Middlesex

Lower N. Shore

Percent of FrequentlyHospitalized Patients

7−7.9%

6−6.9%

5−5.9%

4−4.9%

KEY



All-Payer Readmissions by HospitalThis section contains analyses of both observed (raw) and risk-standardized readmission rates (RSRRs) for individual

hospitals and for groups of hospitals. RSRRs account for differences across hospitals in patient age, patient comorbidities

and the profile of conditions that each hospital treats. Thus, RSRRs allow for a more accurate comparison of hospitals than

observed readmission rates. For details about how RSRRs are calculated, see the technical appendix. n

Key Findings• RSRRs for acute care hospitals ranged widely from 12.9% to 19.8% in 2018.

• There was very little difference in RSRRs by hospital type.



READMISSIONS BY HOSPITAL

All-Payer Risk-Standardized Readmission Rates of Acute Care HospitalsSFY 2018

Hospital RSRRs ranged from

a low of 12.9% at Falmouth

Hospital to a high of 19.8% at

Martha’s Vineyard Hospital.

The range of RSRRs between

hospitals in Massachusetts varied

by 6.9 percentage points.

* Readmission rate calculations for these hospitals, and potentially other hospitals, may include swing bed discharges. CHIA will examine approaches to appropriately account for these discharges in future reporting.

Note: The risk-standardized readmission rates (RSRRs) shown in this figure account for patient case mix and hospital service mix. This figure excludes specialty hospitals (New England Baptist and the Massachusetts Eye and Ear Infirmary). Due to technical changes, readmission rates may not match those from earlier reports. Analyses include eligible discharges for adults with any payer, excluding discharges for obstetric or primary psychiatric care. See technical appendix for more information.


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Statewide rate=KEY

●

●●● ●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●

●● ●●●●●●

●




Hospitals Consistently in Highest and Lowest Risk-Standardized Readmission Rate QuartilesSFY 2014-2018

Hospitals were grouped into

quartiles based on their RSRRs

for each of the last five years

(2014 to 2018). Those in the

highest quartile had the highest

readmission rates, while those

in the lowest quartile had the

lowest readmission rates of

all Massachusetts acute care

hospitals in the last five years.

Three hospitals had consistently

high RSRRs in each of the last

five years, while five hospitals had

consistently low rates.

* Readmission rate calculations for these hospitals, and potentially other hospitals, may include swing bed discharges. CHIA will examine approaches to appropriately account for these discharges in future reporting.

Note: Due to technical changes, readmission rates may not match those from earlier reports. Analyses include eligible discharges for adults with any payer, excluding discharges for obstetric or primary psychiatric care. See technical appendix for more information.


RSRR Quartile HospitalsMedian Risk-Standardized

Readmission Rate in SFY 2018

Highest RSRRs (worse readmission

rates) in each of the last five years

Martha’s Vineyard Hospital*

Steward Good Samaritan Medical Center

Steward St. Elizabeth’s Medical Center

16.9%

Lowest RSRRs (better readmission

rates) in each of the last five years

Beth Israel Deaconess Hospital – Plymouth

Cape Cod Hospital

Emerson Hospital

HealthAlliance Hospital

Newton-Wellesley Hospital

14.4%




All-Payer Risk-Standardized Readmission Rates by Hospital TypeSFY 2018

RSRRs are presented by types

of similar hospitals: Academic

Medical Centers, teaching

hospitals, community hospitals,

and community-High Public

Payer (HPP) hospitals.

There was very little difference in

RSRRs by hospital type. Rates

ranged from 15.2%-15.6%.


Academic Medical Center(6)

Community Hospital(12)

Community−High Public Payer Hospital

(30)

Teaching Hospital(7)

Statewide rate



KEY

10

12

14

16

18

20

Ris

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)




All-Payer Risk-Standardized Readmission Rates by Hospital SystemSFY 2018

RSRRs varied by hospital

system, from a low of 13.6%

for Cape Cod Healthcare to

a high of 16.5% for Steward

Health Care. The largest

hospital system—Partners

HealthCare—had an RSRR

of 15.3% and accounted for

19% of all discharges and

19% of all readmissions.

See the technical appendix

for a list of hospitals with their

system affiliation.


Cape CodHealthcare

(2)

TenetHealthcare

(2)

CareGroup(6)

PartnersHealthCare

(9)

LaheyHealthSystem

(3)

BerkshireHealth

Systems(2)

UMassMemorial

Health Care(3)

BaystateHealth

(4)

HeywoodHealthcare

(2)

Wellforce(3)

StewardHealth Care

(8)

10

12

14

16

18

20

Ris

k−St

anda

rized

Rea

dmis

sion

Rat

e (%

)

Statewide rate



KEY

Cape CodHealthcare

(2)

TenetHealthcare

(2)

CareGroup(6)

PartnersHealthCare

(9)

LaheyHealthSystem

(3)

BerkshireHealth

Systems(2)

UMassMemorial

Health Care(3)

BaystateHealth

(4)

HeywoodHealthcare

(2)

Wellforce(3)

StewardHealth Care

(8)

10

12

14

16

18

20

Ris

k−St

anda

rized

Rea

dmis

sion

Rat

e (%

)

Statewide rate



KEY





All-Payer Observed and Risk-Standardized Readmission Rates by Hospital RegionSFY 2018

The top figure shows geographic

variation in observed

readmission rates, while the

bottom figure shows variation

in RSRRs that account for

differences in hospitals’ patient

populations and services

provided.

The observed rates varied

considerably from a low of

12.7% on the Cape and

Islands to 19.0% in Fall River.

Once differences in patient

populations and hospital service

mix were accounted for by

risk-standardization (bottom

figure), the geographic variation

narrowed, ranging from 14.0% in

the Cape and Islands to 16.6% in

Norwood/Attleboro.


Observed ReadmissionRates

Risk-StandardizedReadmission Rates

Berkshires

Cape and Islands

Central MA

E. Merrimack

Fall River

Metro Boston

Metro South

Metro West

New Bedford

Norwood/Attleboro


South Shore

Upper N. Shore


Lower N. Shore

17−17.9%

16−16.9%

KEYObserved Readmission Rate

18% +

15−15.9%

14−14.9%

<14%

Berkshires

Cape and Islands

Central MA

E. Merrimack

Fall River

Metro Boston

Metro South

Metro West

NewBedford

Norwood/Attleboro


South Shore

Upper N. Shore


Lower N. Shore

Risk−Standardized Readmission Rate

16−16.9%

15−15.9%

14−14.9%

<14%

KEY



CHIA has adapted the Hospital-Wide All-Cause Unplanned 30-day Readmission Measure (NQF #1789) developed

by CMS and the Yale Center for Outcomes Research and Evaluation to report on all-payer readmissions in the

Commonwealth. The measure was applied to CHIA’s Hospital Inpatient Discharge Database, which is collected

from all non-federal acute care hospitals in Massachusetts.10 This year’s report uses the 2019 CMS readmission

measure methodology (version 8.0), which updates the planned readmissions algorithm.11 This year’s report also

matches patient records using a probabilistic patient identifier instead of Social Security Number. Readmission

rates will not match those from earlier reports.

A readmission is defined as an inpatient admission to an acute care facility in Massachusetts occurring within 30

days of an eligible index discharge. All readmissions are counted except for those that are considered planned.

Readmission rates are calculated in four broad steps. First, eligible hospital discharges are defined. Second, from

among this set of eligible discharges, the number of eligible readmissions within 30 days is derived. Then, the

latter is divided by the former and turned into a percentage to calculate the observed readmission rate. In step

four, the risk-standardized readmission rate (RSRR) is derived from the volume-weighted results of five different

statistical models, one for each of the following clinically-defined patient cohorts: surgery/gynecology, general

medicine, cardiorespiratory, cardiovascular, and neurology. These risk-standardized readmission rates account for

differences between hospitals in patient case mix and hospital service mix.

The technical appendix has further details on the readmissions methodology, including the categories of

discharges that are excluded from the readmissions analyses. n

About the Readmissions Methodology



* Eligible discharges are discharges for adults during the study period from non-Federal acute-care hospitals in Massachusetts. Analyses exclude obstetric and primary psychiatric discharges. Nine further exclusions are made. See the technical appendix for further details.

** Eligible readmissions are admissions for any reason that occur within 30 days of an eligible discharge and are not planned.

Count # of eligible readmissions** within 30 days

Count # of eligible discharges*

Observed rate adjusted for:• Patient age• Patient comorbidities• Discharge condition

Risk-Standardized Readmission

Rate

# of eligible readmissions

# of eligible discharges*X 100

Observed Readmission

Rate=

=

1

3

2

4



1 Rau, J. “New Round of Medicare Readmission Penalties Hits 2,583 Hospitals.” Kaiser Health News (October 1, 2019). Accessed 10/17/2019. https://khn.org/news/hospital-readmission-penalties-medicare-2583-hospitals.

2 For the original measure technical report see: Horwitz, L., C. Partovian, Z. Lin, J. Herrin, J. Grady, M. Conover, J. Montague et al. “Hospital-wide all-cause unplanned readmission measure: final technical report.” Centers for Medicare and Medicaid Services (2012).

3 For this report, CHIA used version 8.0 of the readmission measure specification. Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation (YNHHSC/CORE). “2019 Hospital-Wide Readmission Measure Updates and Specifications – Version 8.0” (March 2019). Accessed 10/17/2019. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Measure-Methodology.html.

4 Information on the Massachusetts Hospital Inpatient Discharge Database is available at http://www.chiamass.gov/case-mix-data/. The FY 2018 Hospital Inpatient Discharge Dataset processed by CHIA on September 5, 2018 was used for all analyses published in this year’s annual statewide report. CHIA’s readmission measure is based on inpatient data only. Observation stay data, which is reported by acute care hospitals to CHIA in a separate data file, was not included in the readmission measure.

5 See note 1.

6 See note 2.

7 See note 3.

8 See note 4.

9 See note 3.

10 National Quality Forum, ““Patient Outcomes: All-Cause Readmissions Expedited Review 2011” (July 2012). Accessed 4/5/2018. http://www.qualityforum.org/Projects/Readmissions_Endorsement_Maintenance.aspx.

11 See note 3.

Notes

https://khn.org/news/hospital-readmission-penalties-medicare-2583-hospitals/

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Measure-Methodology

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Measure-Methodology

http://www.chiamass.gov/case-mix-data/

http://www.qualityforum.org/Projects/Readmissions_Endorsement_Maintenance.aspx

http://www.qualityforum.org/Projects/Readmissions_Endorsement_Maintenance.aspx

For more information, please contact:

CENTER FOR HEALTH INFORMATION AND ANALYSIS

501 Boylston Street www.chiamass.govBoston, MA 02116 @Mass_CHIA

(617) 701-8100

Publication Number 19-352-CHIA-01

http://www.chiamass.gov/

https://twitter.com/mass_chia?lang=en

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