OBJECTIVES To determine whether patients discharged after hospital admissions for conditions covered by national readmission programs who received care in emergency departments or observation units but were not readmitted within 30 days had an increased risk of death and to evaluate temporal trends in post-discharge acute care utilization in inpatient units, emergency departments, and observation units for these patients. DESIGN Retrospective cohort study. SETTING Medicare claims data for 2008-16 in the United States. PARTICIPANTS Patients aged 65 or older admitted to hospital with heart failure, acute myocardial infarction, or pneumonia-conditions included in the US Hospital Readmissions Reduction Program. MAIN OUTCOME MEASURES Post-discharge 30 day mortality according to patients' 30 day acute care utilization; acute care utilization in inpatient and observation units and the emergency department during the 30 day and 31-90 day post-discharge period. RESULTS 3 772 924 hospital admissions for heart failure, 1 570 113 for acute myocardial infarction, and 3 131 162 for pneumonia occurred. The overall post-discharge 30 day mortality was 8.7% for heart failure, 7.3% for acute myocardial infarction, and 8.4% for pneumonia. Risk adjusted mortality increased annually by 0.05% (95% confidence interval 0.02% to 0.08%) for heart failure, decreased by 0.06% (-0.09% to -0.04%) for acute myocardial infarction, and did not significantly change for pneumonia. Specifically, mortality increased for patients with heart failure who did not utilize any post-discharge acute care, increasing at a rate of 0.08% (0.05% to 0.12%) per year, exceeding the overall absolute annual increase in post-discharge mortality in heart failure, without an increase in mortality in observation units or the emergency department. Concurrent with a reduction in 30 day readmission rates, stays for observation and visits to the emergency department increased across all three conditions during and beyond the 30 day post-discharge period. Overall 30 day post-acute care utilization did not change significantly. CONCLUSIONS The only condition with increasing mortality through the study period was heart failure; the increase preceded the policy and was not present among patients who received emergency department or observation unit care without admission to hospital. During this period, the overall acute care utilization in the 30 days after discharge significantly decreased for heart failure and pneumonia, but not for acute myocardial infarction.

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减少再入院倡议后的出院后急性护理和预后：美国医疗保险受益人的全国回顾性队列研究。

目的确定住院后因国家再入院计划覆盖的病情出院并在急诊科或观察室接受护理但未在30天内再次入院的患者是否有增加的死亡风险，并评估出院后急性护理利用的时间趋势在这些病人的住院单元，急诊科和观察单元中。设计回顾性队列研究。设置美国2008-16年的Medicare索赔数据。参与者65岁以上的患者因美国医院再入院减少计划中包含的心力衰竭，急性心肌梗塞或肺炎而入院。主要观察指标出院后30天死亡率，取决于患者30天的急诊护理使用率；出院后30天和出院后31-90天，住院和观察单位以及急诊科的急性护理利用率。结果发生了3 772 924例因心力衰竭入院，1 570 113例急性心肌梗塞和3 131 162例肺炎。出院后30天的总死亡率为：心衰8.7％，急性心肌梗塞7.3％，肺炎8.4％。对于心力衰竭，风险调整后的死亡率每年增加0.05％（95％置信区间0.02％至0.08％），对于急性心肌梗塞，风险调整的死亡率每年降低0.06％（-0.09％至-0.04％），而对于肺炎没有明显改变。具体来说，没有使用出院后急性护理的心力衰竭患者的死亡率以每年0.08％（0.05％至0.12％）的速度增长，超过心力衰竭出院后死亡率的绝对绝对年度增长，而观察单位或急诊科的死亡率没有增加。在30天再入院率降低的同时，在出院后30天及以后的所有这三种情况下，用于观察和前往急诊室的住院时间均增加了。急性后30天的总体使用情况没有明显变化。结论在整个研究期间唯一增加死亡率的疾病是心力衰竭。在政策出台之前，这种增加并不存在于没有住院的情况下接受急诊科或观察单位护理的患者中。在此期间，因心力衰竭和肺炎，出院后30天内的整体急性护理利用率显着下降，