Improving Patient Care Transitions at Rural and Urban Hospitals Through Risk Stratification

  • Shan Xie
  • Yuehwern Yih
Part of the Women in Engineering and Science book series (WES)


Rural and urban hospitals may face different challenges in care transition and care coordination. This chapter explored important care transition issues pertaining to rural and urban hospitals and demonstrated how data analytics and risk stratification methods could be applied to help identify patients who would be most likely to benefit from care transition interventions and inform decisions regarding resource allocation and intervention design. Two studies are included in this chapter. The first study examined emergency department (ED) utilization in critical access hospitals (CAHs), especially ED transfers to larger hospitals and non-emergent ED visits. The second study assessed hospital and community characteristics associated with 30-day all-cause hospital readmissions for general medicine patients. The findings identify the need to improve care coordination between local CAH, larger urban hospitals as well as primary care physicians to ensure proper follow-up care for patients discharged to their home community. Hospital and community characteristics are significantly associated with 30-day readmission and hence should be considered when adjusting readmission rates and setting financial penalties.



The CAH study was funded, in part, with support from the Indiana Clinical and Translational Sciences Institute funded, in part by National Institutes of Health, National Center for Advancing Translational Sciences, Clinical and Translational Sciences Award. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. This work was also supported in part by Regenstrief Center for Healthcare Engineering and Regenstrief Foundation. We thank Dr. Steve Witz and Dr. Greg Arling for their valuable suggestions.


  1. 2013 National Rural Emergency Department Study (2013.) Accessed 9 Aug 2016
  2. Agresti A (2013) Categorical data analysis, 3rd edn. Wiley, HobokenzbMATHGoogle Scholar
  3. Allaudeen N, Vidyarthi A, Maselli J, Auerbach A (2011) Redefining readmission risk factors for general medicine patients. J Hosp Med 6(2):54–60CrossRefGoogle Scholar
  4. Amarasingham R, Moore BJ, Tabak YP et al (2010) An automated model to identify heart failure patients at risk for 30-day readmission or death using electronic medical record data. Med Care 48(11):981–988CrossRefGoogle Scholar
  5. America’s Health Rankings (n.d.) United Health Foundation. Accessed 7 July 2016
  6. Arbaje AI, Wolff JL, Yu Q, Powe NR, Anderson GF, Boult C (2008) Postdischarge environmental and socioeconomic factors and the likelihood of early hospital readmission among community-dwelling Medicare beneficiaries. Gerontologist 48(4):495–504. CrossRefGoogle Scholar
  7. Axon R, Williams MV (2011) Hospital readmission as an accountability measure. J Am Med Assoc 305(5):504–505. CrossRefGoogle Scholar
  8. Bohannon RW, Maljanian RD (2002) Hospital readmissions of elderly patients hospitalized with pneumonia. Conn Med 67(10):599–603Google Scholar
  9. Brand C, Sundararajan V, Jones C, Hutchinson A, Campbell D (2005) Readmission patterns in patients with chronic obstructive pulmonary disease, chronic heart failure and diabetes mellitus: an administrative dataset analysis. Intern Med J 35(5):296–299. CrossRefGoogle Scholar
  10. Calvillo-King L, Arnold D, Eubank KJ et al (2012) Impact of social factors on risk of readmission or mortality in pneumonia and heart failure: systematic review. J Gen Intern Med 28(2):269–282. CrossRefGoogle Scholar
  11. Casey M, Burlew M (2006) Analysis of CAH inpatient hospitalizations and transfers: implications for National Quality Measurement and Reporting. Flex Monitoring Team Briefing Paper. Accessed 14 Aug 2013
  12. Casey M, Burlew M, Moscovice I (2010) Critical access hospital year 5 hospital compare participation and quality measure results. Flex Monitoring Team Briefing Paper. Accessed 13 Aug 2013
  13. Casey M, Hung P, Barton B, Moscovice I (2012) Hospital compare quality measures: 2010 National and Washington Results for Critical Access Hospitals. Flex Monitoring Team Briefing Paper. Accessed 13 Aug 2013
  14. Casey MM, Moscovice I, Klingner J, Prasad S (2013) Rural relevant quality measures for critical access hospitals. J Rural Health 29(2):159–171CrossRefGoogle Scholar
  15. Clancy CM (2006) Care transitions: a threat and an opportunity for patient safety. Am J Med Qual 21(6):415–417CrossRefGoogle Scholar
  16. Coburn AF, Wakefield M, Casey M, Moscovice I, Payne S, Loux S (2004) Assuring rural hospital patient safety: what should be the priorities? J Rural Health 20(4):314–326CrossRefGoogle Scholar
  17. Coleman EA, Berenson RA (2004) Lost in transition: challenges and opportunities for improving the quality of transitional care. Ann Intern Med 141(7):533–536. CrossRefGoogle Scholar
  18. Coleman EA, Boult C (2003) Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc 51(4):556–557. CrossRefGoogle Scholar
  19. Coleman EA, Min S, Chomiak A, Kramer AM (2004) Posthospital care transitions: patterns, complications, and risk identification. Health Serv Res 39(5):1449–1466CrossRefGoogle Scholar
  20. Coleman EA, Smith JD, Raha D, Min S (2005) Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med 165(16):1842–1847CrossRefGoogle Scholar
  21. Critical Access Hospitals (CAHs) (n.d.) Introduction—rural health information hub. Accessed 11 Aug 2016
  22. De Freitas TL, Spooner GR, Szafran O (1998) Admissions and transfers from a rural emergency department. Can Fam Physician 44:789–795Google Scholar
  23. Donzé J, Aujesky D, Williams D, Schnipper JL (2013) Potentially avoidable 30-day hospital readmissions in medical patients: derivation and validation of a prediction model. JAMA Intern Med 173(8):632–638. CrossRefGoogle Scholar
  24. Elixhauser A, Steiner C, Harris DR, Coffey RM (1998) Comorbidity measures for use with administrative data. Med Care 36(1):8–27CrossRefGoogle Scholar
  25. Elixhauser A, Steiner C, Palmer L (2013) Clinical classifications software (CCS)Google Scholar
  26. Faculty & Research|NYU Wagner (n.d..) Accessed 11 Aug 2016
  27. Fan L, Shah MN, Veazie PJ, Friedman B (2011) Factors associated with emergency department use among the rural elderly. J Rural Health 27(1):39–49. CrossRefGoogle Scholar
  28. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW (2003) The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 138(3):161–167CrossRefGoogle Scholar
  29. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW (2005) Adverse drug events occurring following hospital discharge. J Gen Intern Med 20(4):317–323. CrossRefGoogle Scholar
  30. Gresenz CR, Rogowski J, Escarce JJ (2007) Health care markets, the safety net, and utilization of care among the uninsured. Health Serv Res 42(1p1):239–264. CrossRefGoogle Scholar
  31. Halfon P, Eggli Y, Pretre-Rohrbach I, Meylan D, Marazzi A, Burnand B (2006) Validation of the potentially avoidable hospital readmission rate as a routine indicator of the quality of hospital care. Med Care 44(11):972–981. CrossRefGoogle Scholar
  32. Hasan O, Meltzer DO, Shaykevich SA et al (2009) Hospital readmission in general medicine patients: a prediction model. J Gen Intern Med 25(3):211–219. CrossRefGoogle Scholar
  33. Henriksen M, Walzer N (2012) Illinois critical access hospitals: enhancing quality of care in rural Illinois. Center for Governmental Studies, DeKalb. Accessed 14 Aug 2013
  34. Herrin J, St Andre J, Kenward K, Joshi MS, Audet A-MJ, Hines SC (2015) Community factors and hospital readmission rates. Health Serv Res 50(1):20–39CrossRefGoogle Scholar
  35. Hines A, Fraze T, Stocks C (2011) Emergency department visits in rural and non-rural community hospitals, 2008. Accessed 10 Sept 2013
  36. Horwitz L, Partovian C, Lin Z et al (2012) Hospital-wide all-cause unplanned readmission measure: final technical report. Centers for Medicare and Medicaid Services, BaltimoreGoogle Scholar
  37. Hu J, Gonsahn MD, Nerenz DR (2014) Socioeconomic status and readmissions: evidence from an urban teaching hospital. Health Aff 33(5):778–785. CrossRefGoogle Scholar
  38. Jencks SF, Williams MV, Coleman EA (2009) Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 360(14):1418–1428CrossRefGoogle Scholar
  39. Jiang HJ, Andrews R, Stryer D, Friedman B (2005) Racial/ethnic disparities in potentially preventable readmissions: the case of diabetes. Am J Public Health 95(9):1561–1567. CrossRefGoogle Scholar
  40. Joynt KE, Jha AK (2013a) Characteristics of hospitals receiving penalties under the hospital readmissions reduction program. J Am Med Assoc 309(4):342–343. CrossRefGoogle Scholar
  41. Joynt KE, Jha AK (2013b) A path forward on Medicare readmissions. N Engl J Med 368(13):1175–1177. CrossRefGoogle Scholar
  42. Joynt KE, Harris Y, Orav EJ, Jha AK (2011a) Quality of care and patient outcomes in critical access rural hospitals. J Am Med Assoc 306(1):45–52CrossRefGoogle Scholar
  43. Joynt KE, Orav E, Jha AK (2011b) Thirty-day readmission rates for Medicare beneficiaries by race and site of care. J Am Med Assoc 305(7):675–681. CrossRefGoogle Scholar
  44. Kansagara D, Englander H, Salanitro A et al (2011) Risk prediction models for hospital readmission: a systematic review. J Am Med Assoc 306(15):1688–1698. CrossRefGoogle Scholar
  45. Kripalani S, Jackson AT, Schnipper JL, Coleman EA (2007) Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med 2(5):314–323CrossRefGoogle Scholar
  46. Krumholz HM, Parent EM, Tu N et al (1997) Readmission after hospitalization for congestive heart failure among Medicare beneficiaries. Arch Intern Med 157(1):99–104CrossRefGoogle Scholar
  47. Lindenauer PK, Lagu T, Rothberg MB et al (2013) Income inequality and 30 day outcomes after acute myocardial infarction, heart failure, and pneumonia: retrospective cohort study. BMJ 346:f521. CrossRefGoogle Scholar
  48. Medicare Hospital Quality Chartbook 2012: Performance Report on Outcome Measures (2012) Prepared by Yale New Haven Health Services Corporation Center for Outcomes Research and Evaluation. Accessed 7 July 2016
  49. Michelle Casey MS (2014) Which Medicare patients are transferred from rural emergency departments?. Accessed 11 Aug 2016
  50. Moore C, Wisnivesky J, Williams S, McGinn T (2003) Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med 18(8):646–651CrossRefGoogle Scholar
  51. Philbin EF, DiSalvo TG (1999) Prediction of hospital readmission for heart failure: development of a simple risk score based on administrative data. J Am Coll Cardiol 33(6):1560–1566. CrossRefGoogle Scholar
  52. Prasad S, Klingner JM, Moscovice I (2011) Care transitions: “time to come home”. Accessed 23 Sept 2013
  53. Quan H, Sundararajan V, Halfon P et al (2005) Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care 43:1130–1139CrossRefGoogle Scholar
  54. Quan H, Li B, Couris CM et al (2011) Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol 173(6):676–682. CrossRefGoogle Scholar
  55. State HMO Penetration Rate. Kaiser Family Foundation (n.d..) Accessed 2 Aug 2016
  56. Van Walraven C, Dhalla IA, Bell C et al (2010) Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community. Can Med Assoc J 182(6):551–557CrossRefGoogle Scholar
  57. Weissman JS, Stern RS, Epstein AM (1994) The impact of patient socioeconomic status and other social factors on readmission: a prospective study in four Massachusetts hospitals. Inquiry 31(2):163–172Google Scholar
  58. Xie S (2018) Risk stratification and prediction for tailored population health management interventions. Dissertation, Purdue UniversityGoogle Scholar
  59. Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation (YNHHSC/CORE) (2014) 2014 Measure Updates and Specifications Report: Hospital-Wide All-Cause Unplanned Readmission—Version 3.0Google Scholar
  60. Yazdany J, Marafino BJ, Dean ML et al (2014) Thirty-day hospital readmissions in systemic lupus erythematosus: predictors and hospital and state-level variation. Arthritis Rheumatol 66(10):2828–2836. CrossRefGoogle Scholar
  61. Zhan C, Miller MR, Wong H, Meyer GS (2004) The effects of HMO penetration on preventable hospitalizations. Health Serv Res 39(2):345–361. j.1475-6773.2004.00231.x

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Shan Xie
    • 1
    • 2
    • 3
  • Yuehwern Yih
    • 4
  1. 1.LASER PULSE ConsortiumWest LafayetteUSA
  2. 2.Regenstrief Center for Healthcare EngineeringWest LafayetteUSA
  3. 3.Purdue UniversityWest LafayetteUSA
  4. 4.School of Industrial EngineeringPurdue UniversityWest LafayetteUSA

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