30-Day Home Time Performance as a Hospital Quality Metric for Patients With Heart Failure

Following comparison with the 30-day risk-standardized readmission rate (RSRR) and 30-day risk-standardized mortality rate (RSMR) from CMS, 30-day home time was associated with readmission and mortality outcomes among patients discharged with heart failure from the hospital, according to study results published in JAMA Cardiology.

The novel patient-centered performance metric was also associated with 1-year RSMR and reclassification of hospital performance.

For the purpose of this study, home time was defined as “time spent alive and out of a short-term hospital, skilled nursing facility, or intermediate/long-term facility 30 days after discharge,” and it was calculated for each of the 3134 hospitals included in the final analysis and in a manner similar to CMS’ risk-adjusted models.

“Correlations between the 30-day risk-adjusted home time metric and 30-day RSRR, 30-day RSMR, and 1-year RSMR were calculated using the Pearson coefficient test,” the authors noted.

Results show that the median (interquartile range [IQR]) hospital risk-adjusted 30-day home time was 21.77 (8.22-28.41) days, and that the best-performing hospitals were larger, with a mean (SD) bed count of 285 (275), median (IQR) volume of patients with heart failure of 797 (395-1484), and greater participation in bundled payment programs (28.9%). Most (59.9%) of these hospitals were also academic hospitals.

The cohort study used 100% CMS Medicare Provider Analysis and Review data from 2,968,341 patients with Medicare fee-for-service coverage who filed claims between January 1, 2012, and November 30, 2017. Their mean (SD) age was 81.0 (8.3) years, and 53.6% were female.

Analysis also found that close to three-fourths (72%) of home time was attributable to time spent at the following:

• Intermediate- or long-term care facilities, which had a mean (SD) stay of 2.65 (6.44) days
• Skilled nursing facility, which had a mean (SD) stay of 3.96 (9.04) days

Stays at both types of facilities accounted for most days spent away from home during the 30-day follow-up period.

Next was death, to which 15% of home time lost was attributed, or a mean (SD) of 1.37 (6.04) days. Thirteen percent was attributable to short-term readmissions, and these had a mean (SD) stay of 1.25 (3.25) days.

Additionally, there was a significant inverse correlation seen between 30-day home time and the following:

• 30-day RSRR (r = –0.23; P < .001)
• 30-day RSMR (r = –0.31; P < .001)
• 1-year RSRR (r = –0.35; P < .001)

For increasing categories of 30-day home time, statistically significant decreases were seen in both 30-day RSRR (worst-performing, 0.23; best-performing, 0.21; P < .001) and RSMR (worst-performing, 0.09; best-performing, 0.07; P < .001).

The reclassification measure of hospital performance saw lower mortality rates among the hospitals that were up-classified according to 30-day home time vs 30-day RSRR, for both 30-day and 1-year mortality:

• 30-day mean: 0.07 (0.25)
• 1-year mean: 0.24 (0.43)

“Postdischarge home time was readily calculated using administrative claims and was associated with short-term (30-day readmission and mortality) and longer-term (1-year mortality) outcomes,” the authors concluded. “Furthermore, [the] 30-day home time metric was associated with reclassification of the performance status of up to one-third of hospitals compared with the current CMS standard hospital performance metric of 30-day RSRR.”

They believe their assessment of hospital-level risk-adjusted 30-day home time for heart failure was feasible. However, generalization of their results is limited, both toward younger patients because the study population was Medicare fee-for-service beneficiaries and overall because detailed information on heart failure programs at the participating hospitals was not available, which could have influenced 30-day home time.

Reference

Pandey A, Keshvani N, Vaughan-Sarrazin MS, et al. Evaluation of risk-adjusted home time after hospitalization for heart failure as a potential performance metric. JAMA Cardiol. Published online October 28, 2020. doi:10.1001/jamacardio.2020.4928