Outcomes and Costs of Post-Hospitalization Transitions in Urban and Rural Settings

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  • March 19, 2019
Creator
  • Toth, Matthew
    • Affiliation: Gillings School of Global Public Health, Department of Health Policy and Management
Abstract
  • Introduction. The Patient Protection and Affordable care Act introduced new incentives and reforms to improve hospital 30-day readmission rates and reduce unnecessary expenditures during a post-discharge period. Early follow-up care and home health utilization are key elements to improving these outcomes and costs. Little is known on how rural Medicare beneficiaries fare during a post-discharge period. This project will determine whether rural beneficiaries experience poorer quality of post-discharge care compared to urban beneficiaries (Aim 1), and assess whether the effect of early follow-up care and home health care on outcomes and costs are modified by rural residency (Aim 2 and Aim 3). Methods. We use the Medicare Current Beneficiary Survey, Cost and Use files, 2000-2010. Key independent variables include rural residency, follow-up care (7-day/14-day), and use of home health care within 14 days. Key dependent variables included: Aim 1) time to first readmission, emergency department use (ED), and follow-up care; Aim 2) 30- and 60-day readmission, ED use, and mortality; and Aim 3) 30-, 60-, and 180-day Medicare expenditures. The analytical approach included a Cox Proportional Hazard model (Aim 1), a logistic regression with a two-stage residual inclusion (Aim 2), and a quantile regression with a two-stage residual inclusion (Aim 3). Results. Rural beneficiaries had fewer follow-up visits and a greater probability of ED use over 60-days post-discharge. There were no rural-urban differences in the effect of follow-up care and home health on readmission and mortality; however we found that rural beneficiaries experienced a greater benefit of 14-day follow-up care on reducing 30-day ED use. Early follow-up care increased expenditures for low-cost beneficiaries, and decreased expenditures for high-cost beneficiaries. High-cost rural beneficiaries who received a follow-up visit expended more Medicare expenditures compared to high-cost urban beneficiaries. Implications. These findings support the role of early-follow-up care on reducing readmission, ED use, mortality, and expenditures. Efforts to improve access to early follow-up care for rural beneficiaries, and targeting high-cost beneficiaries for early follow-up care, may be advantageous for rural providers working within bundled payment models, ACOs, or other shared-risk arrangements.
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  • In Copyright
Advisor
  • Toles, Mark
  • Weinberger, Morris
  • Van Houtven, Courtney
  • Holmes, George M.
  • Silberman, Pam
Degree
  • Doctor of Philosophy
Degree granting institution
  • University of North Carolina at Chapel Hill Graduate School
Graduation year
  • 2015
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  • Chapel Hill, NC
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