Association between quality improvement for care transitions in communities and rehospitalizations among Medicare beneficiaries.

IMPORTANCE

Medicare beneficiaries experience errors during transitions among care settings, yielding harms that include unnecessary rehospitalizations.

OBJECTIVE

To evaluate whether implementation of improved care transitions for patients with Medicare fee-for-service (FFS) insurance is associated with reduced rehospitalizations and hospitalizations in geographic communities.

DESIGN, SETTING, AND PARTICIPANTS: Quality improvement initiative for care transitions by health care and social services personnel and Medicare Quality Improvement Organization staff in defined geographic areas, with monitoring by community-specific and aggregate control charts and evaluation with pre-post comparison of performance differences for 14 intervention communities and 50 comparison communities from before (2006-2008) and during (2009-2010) implementation. Intervention communities had between 22,070 and 90,843 Medicare FFS beneficiaries.

INTERVENTION

Quality Improvement Organizations facilitated community-wide quality improvement activities to implement evidence-based improvements in care transitions by community organizing, technical assistance, and monitoring of participation, implementation, effectiveness, and adverse effects.

MAIN OUTCOME MEASURES

The primary outcome measure was all-cause 30-day rehospitalizations per 1000 Medicare FFS beneficiaries; secondary outcome measures were all-cause hospitalizations per 1000 Medicare FFS beneficiaries and all-cause 30-day rehospitalizations as a percentage of hospital discharges.

RESULTS

The mean rate of 30-day all-cause rehospitalizations per 1000 beneficiaries per quarter was 15.21 in 2006-2008 and 14.34 in 2009-2010 in the 14 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 rehospitalizations in intervention communities (by 0.56/1000 per quarter; 95% CI, 0.05-1.07; P = .03). The mean rate of hospitalizations per 1000 beneficiaries per quarter was 82.27 in 2006-2008 and 77.54 in 2009-2010 in intervention communities and was 82.09 in 2006-2008 and 79.48 in 2009-2010 in comparison communities, with the pre-post between-group difference showing larger reductions in hospitalizations in intervention communities (by 2.12/1000 per quarter; 95% CI, 0.47-3.77; P = .01). Mean community-wide rates of rehospitalizations 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 = .14). Process control charts signaled onset of improvement coincident with initiating intervention.

CONCLUSIONS AND RELEVANCE

Among Medicare beneficiaries in intervention communities, compared with those in uninvolved communities, all-cause 30-day rehospitalization and all-cause hospitalization declined. However, there was no change in the rate of all-cause 30-day rehospitalizations as a percentage of hospital discharges.