Predictors Associated With 30-Day Readmission Among a Cohort of Adult Congenital Heart Disease Patients, Medicaid Claims Data 2010-2013 Público

Abstract

Purpose: Advancements in medical technology and treatment of CHD has led to improved survival. Adults with CHD (ACHD) have been largely understudied, especially with respect to hospital readmissions - a quality indicator commonly used to assess healthcare utilization. This study aims to identify common diagnoses at index admission associated with readmissions within 30-days of a cardiac-related hospital admission among ACHD patients. We also analyze socio-contextual factors associated with 30-day readmission including race, sex, and distance from patient zip code to a facility providing specialized cardiology care.

Methods: This study is a retrospective cohort design analyzing Georgia Medicaid claims data, 2010-2013. The sample consists of ACHD patients aged 20-64 years, covered under Medicaid and with at least one of 55 ICD-9-CM CHD diagnostic codes on their encounter claim (n=1,697). To assess travel distance to specialized healthcare facilities, we conducted adjusted Cox-proportional models and reported hazard ratios with corresponding 95% CI’s.

Results: Of the 1,697 patients included in the analysis, about 22% had a 30-day hospital readmission. The remaining 78% had no recorded hospital readmissions within 30 days. Readmission was higher for those at initial admission with comorbid congestive heart failure (CHF) non-hypertensive (13% higher in readmitted patients compared to non-readmitted patients), fluid and electrolyte disease (15% higher), and diabetes mellitus (DM) with complications (~7% higher). Readmission was also higher for black patients compared to white (~6% higher). After adjustment for potential confounding variables, there was no significant increase in hazard found for greater distance between patient’s resident zip code and healthcare facilities providing cardiology care.

Conclusion: Specific comorbid diagnoses at index admission and black race identify subpopulations at increased risk for 30-day hospital readmission. Increased attention to comorbid diagnoses during initial hospital stay may reduce 30-day hospital readmission rates and improve health outcomes for the ACHD population.

Table of Contents

CHAPTER I: BACKGROUND          1

Congenital Heart Defect (CHD)  1

30-Day Hospital Readmission    2

Congenital Heart Defects and 30-Day Readmission         4

Travel Distance 6

Medicaid Claims             7

Georgia Medicaid           9

CHAPTER II. METHODS  11

Hypotheses      11

Study Design    11

Population        12

Data Management and IRB        12

Inclusion and Exclusion Criteria 12

Outcome Variables        13

Predictor Variables        14

Directed Acyclic Graph (DAG)    16

Statistical Analysis         16

CHAPTER III: MANUSCRIPT        18

Introduction     19

Methods            20

Study Design    20

Population        20

Exclusion Criteria           21

Predictor Variables        21

Statistical Analysis         22

Results 23

Discussion         25

Strengths and Limitations           26

Conclusion        27

REFERENCES     28

TABLES 33

FIGURES            35

Supplimentary Tables and Figures (1-6) 36

CHAPTER IV: EXTENDED ANALYSIS         42

Characteristics of the Cohort     42

Diagnosis Categories at Readmission     42

Proportional Hazards Assumptiom         42

Distance Analyses          43

Kaplan Meier Curves     44

CHAPTER V: PUBLIC HEALTH IMPICATIONS AND FUTURE DIRECTIONS      46

APPENDICIES    48

APPENDIX A: CHD Severity Classification Based on a Modified Marelli Scheme             48

APPENDIX B: List of Adult Congenital Heart Defect Clinics in Georgia       51

APPENDIX C: Supplimentary Tabes and Figures (7-19).    51

APPENDIX D: ICD-9-CM Codes and Corresponding CCS Multilevel Classification (Level 7).           65

APPENDIX E: ICD-9-CM Codes and Corresponding CCS Multilevel Classification (All Levels)        69

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Subfield / Discipline	Epidemiology - MPH & MSPH
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Epidemiology
Palabra Clave	race congenital heart defect 30-day readmission adult congenital heart defect travel distance medicaid
Committee Chair / Thesis Advisor	Hogue, Carol, Emory University
Committee Members	Hoffman, Trenton, Emory University Raskind-Hood, Cheryl, Emory University
Partnering Agencies	Emory University schools, faculty or affiliated programs

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