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Impact of vertical integration on the readmission of individuals with chronic conditions
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ABSTRACT - INTRODUCTION: Ageing populations and the increasing prevalence of
multimorbidity are a challenge for healthcare delivery and health system design.
Integrated care has been discussed as a solution to address these challenges. In Portugal,
Local Health Units (LHU) promote vertical integration of healthcare, with one of the
expected effects being a decrease of readmission rates in individuals with chronic
conditions. Readmissions are frequently studied for its negative impacts on individuals,
carers, and providers, with excessive unplanned readmission rates among hospitals being
a sign of frail integrated care. Thus, we assume as the main aim of this study to assess the
impact of vertical integration on the readmission of individuals with chronic conditions.
METHODS: A database including administrative data from 1 679 634 inpatient episodes
from years 2002-14 was considered. We identified readmissions with the hospital-wide
all-cause unplanned readmission measure methodology of Centers for Medicare and
Medicaid Services. The considered outcome was 30-day hospital-wide all-cause
unplanned readmissions (1: readmitted), and risk-standardized readmission ratio. Chronic
conditions were identified from all diagnoses coded with International Classification of
Diseases – 9th version – Clinical Modification codes (1: chronic). In order to assess the
impact of LHU on the readmission of individuals with chronic conditions, we compared
30-day readmissions before and after the creation of each LHU. We used difference-indifferences
technique to address our main aim. In addition, to understand the associations
between individuals’ risk factors and time to readmission, we developed a Cox regression
model for LHU and control group.
RESULTS: Difference-in-differences results suggest that vertical integration promoted
a decrease on risk-standardized readmission ratio in four LHU, but significant only in
LHU 1. In addition, when analysed the individual risk of readmission we observed that it
was reduced for four LHU, but only significantly for LHU 3 and LHU 5. A sensitivity
analysis was performed for annual evolution of odds ratio of risk of readmission, and
initial results were considered stable for most years. Cox regression results suggest that
for LHU and control hospitals, female individuals were less at risk of readmission than
men, the risk increased with increasing age and number of comorbidities. At LHU, we
observed a decreased risk of readmission with increasing number of chronic conditions. CONCLUSIONS: Individuals with chronic conditions faced higher risk of readmission,
despite vertical integration phenomena. In order to promote better healthcare to these
individuals, namely protecting them from readmission, healthcare organizations should
develop integrated care pathways for the most prevalent chronic conditions on their
catchment area, revise discharge processes, continuously evaluate health outcomes, and
share best practices of integration involving community and other levels of care (namely
palliative care).
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Integrated healthcare Vertical integration Chronic conditions Readmissions Difference-in-differences