Readmissions and Mortality After "Before Medically Advised" Hospital Discharges Among Medicare Beneficiaries with Opioid Use Disorder.

Background: "Before medically advised" (BMA) discharges are rising among hospitalized people with opioid use disorder (OUD) and associated with worse outcomes. However, little is known about BMA discharge among the growing share of U.S. Medicare beneficiaries with OUD.

Objective: To examine patterns of hospital readmissions and mortality by discharge type among Medicare beneficiaries with OUD.

Design: Retrospective cohort study using 100% national inpatient Medicare data from 2016 to 2019.

Participants: Fee-for-service Medicare beneficiaries age 18 + with an OUD diagnosis during an inpatient hospitalization. Discharge types were classified as BMA, home, skilled nursing facilities (SNFs), or non-SNF institutional settings.

Main Measures: Using linear probability models adjusted for demographic, clinical, and hospital covariates, we examined 30-day unplanned all-cause readmission and mortality probabilities across discharge types. Secondarily, we assessed time until readmission and mortality, repeated readmissions or BMA discharges, readmission to different hospitals, and primary readmission diagnoses.

Key Results: Among 339,712 hospitalized Medicare beneficiaries with OUD, 13,997 (4.1%) were discharged BMA. Within 30 days, 25.5% of patients discharged BMA were readmitted and 2.5% died. Compared to other discharges, readmissions after BMA discharge occurred sooner (9.9 vs. 12.8-13.3 days), and were more likely to happen repeatedly (23.4% vs. 13.1-18.3%), end in another BMA discharge (20.9% vs. 0.8-3.5%), and take place at different hospitals (50.8% vs. 29.8-37.6%). Adjusted readmission probabilities for BMA discharges were 7.1 percentage points (pp) higher than home discharges and 6.0-8.9 pp higher than SNF and non-SNF discharges (all p < 0.001). Adjusted mortality probabilities for BMA discharges were 0.7 pp higher than home discharges, but 0.8-1.9 pp lower than SNF and non-SNF discharges (all p < 0.001).

Conclusions: BMA discharge among Medicare beneficiaries with OUD is associated with fragmented patterns of post-discharge care, and increased readmissions and deaths relative to home discharges. Efforts are needed to address the drivers and consequences of BMA discharge among individuals with OUD in Medicare.