Potential of community-based risk estimates for improving hospital performance measures and discharge planning.

Background: Risk-adjusted rates of hospital readmission are a common indicator of hospital performance. There are concerns that current risk-adjustment methods do not account for the many factors outside the hospital setting that can affect readmission rates. Not accounting for these external factors could result in hospitals being unfairly penalized when they discharge patients to communities that are less able to support care transitions and disease management. While incorporating adjustments for the myriad of social and economic factors outside of the hospital setting could improve the accuracy of readmission rates as a performance measure, doing so has limited feasibility due to the number of potential variables and the paucity of data to measure them. This paper assesses a practical approach to addressing this problem: using mixed-effect regression models to estimate case-mix adjusted risk of readmission by community of patients' residence (community risk of readmission) as a complementary performance indicator to hospital readmission rates.

Methods: Using hospital discharge data and mixed-effect regression models with a random intercept for community, we assess if case-mix adjusted community risk of readmission can be useful as a quality indicator for community-based care. Our outcome of interest was an unplanned repeat hospitalisation. Our primary exposure was community of residence.

Results: Community of residence is associated with case-mix adjusted risk of unplanned repeat hospitalisation. Community risk of readmission can be estimated and mapped as indicators of the ability of communities to support both care transitions and long-term disease management.

Conclusion: Contextualising readmission rates through a community lens has the potential to help hospitals and policymakers improve discharge planning, reduce penalties to hospitals, and most importantly, provide higher quality care to the people that they serve.