Elements of the care environment influence coronary artery bypass surgery readmission

BACKGROUND: Coronary artery bypass grafting 30-day unplanned readmission is a focus for the CMS Hospital Readmissions Reduction Program. Awareness of the critical elements of the care delivery environment, including hospital infrastructure and patient clinical profiles that predispose toward readmission, is essential to proactively decrease readmissions. METHODS: The Healthcare Cost and Utilization Project-State Inpatient Database, American Hospital Association Annual Health Survey Database, and Healthcare Information Management Systems Society data sets were merged to create a single data set of patient- and hospital-level data from 8 states. Isolated coronary artery bypass grafting procedures were queried for all-cause 30-day readmission, and backwards stepwise logistic regression was performed. Readmission rate was then used to categorize hospitals into quartiles, and analysis focused on the hospitals with the lowest (Q1) and highest (Q4) readmission rates. Univariate analysis was performed comparing Q1 and Q4 hospitals. RESULTS: A total of 150,215 patients underwent isolated coronary artery bypass grafting with 23,244 (15.5%) readmitted patients among 903 hospitals. Model area under the curve was 0.709 (95% confidence interval, 0.702–0.716), with the top 3 readmission determinants related to discharge disposition. Compared to Q1, Q4 patients more often were female, were > 70 years of age, and had Medicare as a primary payor (P < .001). Low readmission rate hospitals were characterized by higher costs; not-for-profit status; having Joint Commission accreditation; and higher total admissions, operative volume, hospital/ICU beds, full-time physicians, nurses, and ancillary personnel (P < .001). CONCLUSION: Readmission after coronary artery bypass grafting is strongly influenced by discharge disposition. However, hospital factors such as scale, personnel, and ownership structure are significant contributors to readmission. Focus beyond patient factors to include the entire continuum of care is required to enhance outcomes, of which readmission is one surrogate measure.