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Effect of Clinical and Social Risk Factors on Hospital Profiling for Stroke Readmission: A Cohort StudyHospital Profiling for Stroke Readmission

Salomeh Keyhani, MD, MPH; Laura J. Myers, PhD; Eric Cheng, MD; Paul Hebert, PhD; Linda S. Williams, MD; and Dawn M. Bravata, MD
[+] Article, Author, and Disclosure Information

From the San Francisco Veterans Affairs Medical Center and University of California, San Francisco, San Francisco, California; Veterans Health Administration Health Services Research and Development Stroke Quality Enhancement Research Initiative Program and Center of Excellence on Implementing Evidence-Based Practice, Richard L. Roudebush Veterans Affairs Medical Center, Indiana University School of Medicine, and Regenstrief Institute, Indianapolis, Indiana; Veterans Affairs Greater Los Angeles Healthcare System and University of California, Los Angeles, Los Angeles, California; and University of Washington and Veterans Affairs Puget Sound Health Care System, Seattle, Washington.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views of the U.S. Department of Veterans Affairs.

Financial Support: By the Veterans Health Administration Office of Quality and Performance and Health Services Research and Development Service Quality Enhancement Research Initiative of the Department of Veterans Affairs (RRP 12-192) and the National Heart, Lung, and Blood Institute, U.S. Department of Health and Human Services (1R01HL116522-01A1).

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-0361.

Reproducible Research Statement:Study protocol and statistical code: Available from Dr. Keyhani (e-mail, salomeh.keyhani@va.gov). Data set: Not available.

Requests for Single Reprints: Salomeh Keyhani, MD, MPH, San Francisco Veterans Affairs Medical Center, 4150 Clement (111A1), San Francisco, CA 94121; e-mail, salomeh.keyhani@va.gov.

Current Author Addresses: Dr. Keyhani: San Francisco Veterans Affairs Medical Center, 4150 Clement (111A1), San Francisco, CA 94121.

Drs. Myers, Williams, and Bravata: Richard L. Roudebush Veterans Affairs Medical Center, 1481 West 10th Street (11H), Indianapolis, IN 46202.

Dr. Cheng: Department of Neurology, ML 127, Veterans Affairs Greater Los Angeles Healthcare System, 11301 Wilshire Boulevard, Los Angeles, CA 90073.

Dr. Hebert: Veterans Affairs Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101.

Author Contributions:Conception and design: S. Keyhani, P. Hebert, D.M. Bravata.

Analysis and interpretation of the data: S. Keyhani, L.J. Myers, E. Cheng, P. Hebert, L.S. Williams, D.M. Bravata.

Drafting of the article: S. Keyhani.

Critical revision of the article for important intellectual content: S. Keyhani, L.J. Myers, E. Cheng, L.S. Williams, D.M. Bravata.

Final approval of the article: S. Keyhani, L.J. Myers, E. Cheng, P. Hebert, L.S. Williams, D.M. Bravata.

Statistical expertise: S. Keyhani, L.J. Myers, P. Hebert.

Obtaining of funding: S. Keyhani, L.S. Williams, D.M. Bravata.

Administrative, technical, or logistic support: S. Keyhani.

Collection and assembly of data: L.J. Myers, L.S. Williams.

Ann Intern Med. 2014;161(11):775-784. doi:10.7326/M14-0361
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Background: The Centers for Medicare & Medicaid Services (CMS) and Veterans Health Administration (VA) will report 30-day stroke readmission rates as a measure of hospital quality. A national debate on whether social risk factors should be included in models developed for hospital profiling is ongoing.

Objective: To compare a CMS-based model of 30-day readmission with a more comprehensive model that includes measures of social risk (such as homelessness) or clinical factors (such as stroke severity and functional status).

Design: Data from a retrospective cohort study were used to develop a CMS-based 30-day readmission model that included age and comorbid conditions based on codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (model 1). This model was then compared with one that included administrative social risk factors (model 2). Finally, the CMS model (model 1) was compared with a model that included social risk and clinical factors from chart review (model 3). These 3 models were used to rank hospitals by 30-day risk-standardized readmission rates and examine facility rankings among the models.

Setting: Hospitals in the VA.

Participants: Patients hospitalized with stroke in 2007.

Measurements: 30-day readmission rates.

Results: The 30-day readmission rate was 12.8%. The c-statistics for the 3 models were 0.636, 0.646, and 0.661, respectively. All hospitals were classified as performing “as expected” using all 3 models (that is, performance did not differ from the VA national average); therefore, the addition of detailed clinical information or social risk factors did not alter assessment of facility performance.

Limitation: A predominantly male veteran cohort limits the generalizability of these findings.

Conclusion: In the VA, more comprehensive models that included social risk and clinical factors did not affect hospital comparisons based on 30-day readmission rates.

Primary Funding Source: U.S. Department of Veterans Affairs.


Grahic Jump Location

Hospital-level RSRRs.

CMS = Centers for Medicare & Medicaid Services; RSRR = risk-standardized readmission rate.

Grahic Jump Location




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