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1 Supplementary Online Content Dharmarajan K, Wang Y, Lin Z, et al. Association of changing hospital readmission rates with mortality rates after hospital discharge. JAMA. doi: /jama etable 1. ICD-9-CM Codes Used to Define Heart Failure, Acute Myocardial Infarction, and Pneumonia Cohorts etable 2. Comorbidities Among Medicare FFS Beneficiaries Discharged After Hospitalization for Heart Failure, Acute Myocardial Infarction, or Pneumonia, etable 3. Hospital Number and Hospitalization by Month for Calculating Trends in Hospital 30-Day Risk-Adjusted Readmission Rates and Hospital 30-Day Risk-Adjusted Mortality Rates After Discharge, etable 4. Hospital Number and Hospitalization by Month for Calculating the Correlation of Paired Monthly Trends in Hospital 30-Day Risk-Adjusted Readmission Rates With Hospital 30-Day and 90-Day Risk-Adjusted Mortality Rates After Discharge, etable 5. Hospital Number and Hospitalization by Month for Calculating the Correlation of Paired Monthly Trends in Hospital 30-Day Risk-Adjusted Readmission Rates and Hospital 30-Day Risk-Adjusted Mortality Rates After Discharge, April 2010 September 2012 etable 6. Hospital Number and Hospitalization by Month for Calculating the Correlation of Paired Monthly Trends in Hospital 30-Day Risk-Adjusted Readmission Rates and Hospital 90-Day Risk-Adjusted Mortality Rates After the Admission Date, etable 7. Hospital Number and Hospitalization by Month for Calculating Trends in Hospital 30-Day Risk-Adjusted Readmission Rates and Hospital 90-Day Risk-Adjusted Mortality Rates After the Admission Date for Heart Failure, efigure 1. Flow Diagrams Describing Study Population Selection in Heart Failure, Acute Myocardial Infarction, and Pneumonia Cohorts efigure 2. Correlation of Paired Trends in Hospital 30-Day Risk-Adjusted Readmission Rates and Hospital 30-Day Risk-Adjusted Mortality Rates After Discharge, April 2010 September 2012 efigure 3. Correlation of Paired Trends in Hospital 30-Day Risk-Adjusted Readmission Rates and Hospital 90-Day Risk-Adjusted Mortality Rates After Discharge, efigure 4. Correlation of Paired Trends in Hospital 30-Day Risk-Adjusted Readmission Rates and Hospital 90-Day Risk-Adjusted Mortality Rates After the Admission Date, efigure 5. Trends in Hospital 30-Day Risk-Adjusted Readmission Rates and Hospital 90- Day Risk-Adjusted Mortality Rates After the Admission Date for Heart Failure, This supplementary material has been provided by the authors to give readers additional information about their work.

2 etable 1. ICD-9-CM Codes Used to Define Heart Failure, Acute Myocardial Infarction, and Pneumonia Cohorts Cohort Name Constituent ICD-9-CM Codes Heart failure , , , , , , , , , 428.xx Acute myocardial infarction 410.xx excluding those with 410.x2 (acute myocardial infarction, subsequent episode of care) Pneumonia 480.x, 481, 482.xx, 483.x, 485, 486, 487.0, and ICD-9-CM: International Classification of Diseases, Ninth Revision, Clinical Modification.

3 etable 2. Comorbidities Among Medicare FFS Beneficiaries Discharged After Hospitalization for Heart Failure, Acute Myocardial Infarction, or Pneumonia, Comorbidity Heart Failure Cohort (n) 449, , , , , , ,222 Coronary Artery Bypass Graft Surgery (%) Congestive Heart failure (%) Acute coronary syndrome (%) Arrhythmias (%) Cardio-respiratory failure and shock (%) Valvular or Rheumatic Heart Disease (%) Vascular or Circulatory Disease (%) Chronic atherosclerosis (%) Other and unspecified heart disease (%) Hemiplegia, Paralysis, Functional Disability (%) Stroke (%) Renal Failure (%) Chronic Obstructive Pulmonary Disease (%) Diabetes and DM Complications (%) Disorders of fluid/electrolyte/acid-base (%) Other urinary tract disorders (%) Decubitus ulcer or chronic skin ulcer (%) Other gastrointestinal disorder (%) Peptic ulcer, hemorrhage, other specified gastrointestinal disorders (%) Severe hematological disorders (%) Nephritis (%) Dementia and Senility (%) Metastatic Cancer and Acute Leukemia (%) Cancer (%) Liver and biliary disease (%) End-stage renal disease or dialysis Asthma (%) Iron deficiency and other/unspecified anemias and blood disease (%) Pneumonia (%) Drug/alcohol abuse/dependence/psychosis (%) Major psychiatric disorders (%)

4 etable 2. Comorbidities Among Medicare FFS Beneficiaries Discharged After Hospitalization for Heart Failure, Acute Myocardial Infarction, or Pneumonia, (continued) Comorbidity Heart Failure Cohort (n) 449, , , , , , ,222 Depression (%) Other psychiatric disorders (%) Fibrosis of lung and other chronic lung disorders (%) Protein-Calorie Malnutrition (%) Acute Myocardial Infarction Cohort (n) 189, , , , , , ,618 Percutaneous Transluminal Coronary Angioplasty (%) Coronary Artery Bypass Graft Surgery (%) Congestive Heart failure (%) Acute coronary syndrome (%) Anterior Myocardial Infarction (%) Other Location of Myocardial Infarction (%) Angina pectoris/old myocardial infarction (%) Coronary atherosclerosis/other chronic ischemic heart disease (%) Valvular or Rheumatic Heart Disease (%) Arrhythmias (%) Cerebrovascular Disease (%) Stroke (%) Vascular or Circulatory Disease (%) Hemiplegia, Paralysis, Functional Disability (%) Diabetes and DM Complications (%) Renal Failure (%) End-stage renal disease or dialysis (%) Other urinary tract disorders (%) Chronic Obstructive Pulmonary Disease (%) Pneumonia (%) Asthma (%) Disorders of fluid/electrolyte/acid-base (%) History of infection (%) Metastatic Cancer and Acute Leukemia (%) Cancer (%)

5 etable 2. Comorbidities Among Medicare FFS Beneficiaries Discharged After Hospitalization for Heart Failure, Acute Myocardial Infarction, or Pneumonia, (continued) Comorbidity Acute Myocardial Infarction Cohort (n) 189, , , , , , ,618 Iron deficiency and other/unspecified anemias and blood disease (%) Decubitus ulcer or chronic skin ulcer (%) Dementia and Senility (%) Protein-Calorie Malnutrition (%) Pneumonia Cohort (n) 405, , , , , , ,563 Coronary Artery Bypass Graft Surgery (%) History of infection (%) Septicemia/shock (%) Metastatic Cancer and Acute Leukemia (%) Lung cancer (%) Lymphatic, head and neck, brain, and other major cancers; breast, prostate, colorectal and other cancers and tumors (%) Diabetes and DM Complications (%) Protein-Calorie Malnutrition (%) Disorders of fluid/electrolyte/acid-base (%) Other gastrointestinal disorders (%) Severe hematological disorders (%) Iron deficiency and other/unspecified anemias and blood disease (%) Dementia and Senility (%) Drug/alcohol abuse/dependence/psychosis (%) Major psychiatric disorders (%) Other psychiatric disorders (%) Hemiplegia, Paralysis, Functional Disability (%) Cardio-respiratory failure and shock (%) Congestive Heart failure (%) Acute coronary syndrome (%) Chronic atherosclerosis (%) Valvular or Rheumatic Heart Disease (%) Arrhythmias (%) Stroke (%)

6 etable 2. Comorbidities Among Medicare FFS Beneficiaries Discharged After Hospitalization for Heart Failure, Acute Myocardial Infarction, or Pneumonia, (continued) Comorbidity Pneumonia Cohort (n) 405, , , , , , ,563 Vascular or Circulatory Disease (%) Chronic Obstructive Pulmonary Disease (%) Fibrosis of lung and other chronic lung disorders (%) Asthma (%) Pneumonia (%) Pleural effusion/pneumothorax (%) Other lung disorders (%) End-stage renal disease or dialysis (%) Renal Failure (%) Urinary tract infection (%) Other urinary tract disorders (%) Decubitus ulcer or chronic skin ulcer (%) Vertebral fractures (%) Other injuries (%) FFS: fee-for-service.

7 etable 3. Hospital Number and Hospitalization by Month for Calculating Trends in Hospital 30-Day Risk- Adjusted Readmission Rates and Hospital 30-Day Risk-Adjusted Mortality Rates After Discharge, a Month Hospital Number Mean Heart Failure Cohort Acute Myocardial Infarction Cohort Pneumonia Cohort Median Min Max Hospital Mean Median Min Max Hospital Mean Median Number Number Min Max

8 etable 3. Hospital Number and Hospitalization by Month for Calculating Trends in Hospital 30-Day Risk- Adjusted Readmission Rates and Hospital 30-Day Risk-Adjusted Mortality Rates After Discharge, (continued) a Month Hospital Number Heart Failure Cohort Acute Myocardial Infarction Cohort Pneumonia Cohort Mean Median Min Max Hospital Mean Median Min Max Hospital Mean Median Number Number Min Max

9 etable 3. Hospital Number and Hospitalization by Month for Calculating Trends in Hospital 30-Day Risk- Adjusted Readmission Rates and Hospital 30-Day Risk-Adjusted Mortality Rates After Discharge, (continued) a Month Hospital Number Heart Failure Cohort Acute Myocardial Infarction Cohort Pneumonia Cohort Mean Median Min Max Hospital Mean Median Min Max Hospital Mean Median Number Number Min Max a Figure 1 data. Study month 1 was January 2008 and study month 84 was December 2014.

10 etable 4. Hospital Number and Hospitalization by Month for Calculating the Correlation of Paired Monthly Trends in Hospital 30-Day Risk-Adjusted Readmission Rates With Hospital 30-Day and 90-Day Risk-Adjusted Mortality Rates After Discharge, a Month Hospital Number Heart Failure Cohort Acute Myocardial Infarction Cohort Pneumonia Cohort Mean Median Min Max Hospital Mean Median Min Max Hospital Mean Median Number Number Min Max

11 etable 4. Hospital Number and Hospitalization by Month for Calculating the Correlation of Paired Monthly Trends in Hospital 30-Day Risk-Adjusted Readmission Rates With Hospital 30-Day and 90-Day Risk-Adjusted Mortality Rates After Discharge, (continued) a Month Hospital Number Heart Failure Cohort Acute Myocardial Infarction Cohort Pneumonia Cohort Mean Median Min Max Hospital Mean Median Min Max Hospital Mean Median Number Number Min Max

12 etable 4. Hospital Number and Hospitalization by Month for Calculating the Correlation of Paired Monthly Trends in Hospital 30-Day Risk-Adjusted Readmission Rates With Hospital 30-Day and 90-Day Risk-Adjusted Mortality Rates After Discharge, (continued) a Month Hospital Number Heart Failure Cohort Acute Myocardial Infarction Cohort Pneumonia Cohort Mean Median Min Max Hospital Mean Median Min Max Hospital Mean Median Number Number Min Max a Figure 2 and efigure 3 data. Study month 1 was January 2008 and study month 84 was December 2014.

13 etable 5. Hospital Number and Hospitalization by Month for Calculating the Correlation of Paired Monthly Trends in Hospital 30-Day Risk-Adjusted Readmission Rates and Hospital 30-Day Risk-Adjusted Mortality Rates After Discharge, April 2010 September 2012 a Month Hospital Number Heart Failure Cohort Acute Myocardial Infarction Cohort Pneumonia Cohort Mean Median Min Max Hospital Mean Median Min Max Hospital Mean Median Number Number Min Max

14 etable 5. Hospital Number and Hospitalization by Month for Calculating the Correlation of Paired Monthly Trends in Hospital 30-Day Risk-Adjusted Readmission Rates and Hospital 30-Day Risk-Adjusted Mortality Rates After Discharge, April 2010 September 2012 (continued) a Month Hospital Number Heart Failure Cohort Acute Myocardial Infarction Cohort Pneumonia Cohort Mean Median Min Max Hospital Mean Median Min Max Hospital Mean Median Number Number Min Max a efigure 2 data. Study month 1 was April 2010 and study month 30 was September 2012.

15 etable 6. Hospital Number and Hospitalization by Month for Calculating the Correlation of Paired Monthly Trends in Hospital 30-Day Risk-Adjusted Readmission Rates and Hospital 90-Day Risk-Adjusted Mortality Rates After the Admission Date, a Month Hospital Number Heart Failure Cohort Acute Myocardial Infarction Cohort Pneumonia Cohort Mean Median Min Max Hospital Mean Median Min Max Hospital Mean Median Number Number Min Max

16 etable 6. Hospital Number and Hospitalization by Month for Calculating the Correlation of Paired Monthly Trends in Hospital 30-Day Risk-Adjusted Readmission Rates and Hospital 90-Day Risk-Adjusted Mortality Rates After the Admission Date, (continued) a Month Hospital Number Heart Failure Cohort Acute Myocardial Infarction Cohort Pneumonia Cohort Mean Median Min Max Hospital Mean Median Min Max Hospital Mean Median Number Number Min Max

17 etable 6. Hospital Number and Hospitalization by Month for Calculating the Correlation of Paired Monthly Trends in Hospital 30-Day Risk-Adjusted Readmission Rates and Hospital 90-Day Risk-Adjusted Mortality Rates After the Admission Date, (continued) a Month Hospital Number Heart Failure Cohort Acute Myocardial Infarction Cohort Pneumonia Cohort Mean Median Min Max Hospital Mean Median Min Max Hospital Mean Median Number Number Min Max a efigure 4 data. Study month 1 was January 2008 and study month 84 was December 2014.

18 etable 7. Hospital Number and Hospitalization by Month for Calculating Trends in Hospital 30-Day Risk-Adjusted Readmission Rates and Hospital 90-Day Risk-Adjusted Mortality Rates After the Admission Date for Heart Failure, a Month Heart Failure Cohort Hospital Number Mean Median Min Max

19 etable 7. Hospital Number and Hospitalization by Month for Calculating Trends in Hospital 30-Day Risk-Adjusted Readmission Rates and Hospital 90-Day Risk-Adjusted Mortality Rates After the Admission Date for Heart Failure, (continued) a Month Heart Failure Cohort Hospital Number Mean Median Min Max

20 etable 7. Hospital Number and Hospitalization by Month for Calculating Trends in Hospital 30-Day Risk-Adjusted Readmission Rates and Hospital 90-Day Risk-Adjusted Mortality Rates After the Admission Date for Heart Failure, (continued) a Month Heart Failure Cohort Hospital Number Mean Median Min Max a efigure 5 data. Study month 1 was January 2008 and study month 84 was December 2014.

21 efigure 1. Flow Diagrams Describing Study Population Selection in Heart Failure, Acute Myocardial Infarction, and Pneumonia Cohorts Composite data are presented for all study years. Data for heart failure, acute myocardial infarction, and pneumonia are presented in panels A, B, and C, respectively. We did not double count 30-day readmissions as index hospitalizations. Cohort exclusions are not mutually exclusive. efigure 1A. Heart Failure Total heart failure admissions, N=3,603,586 Less than 65 years of age (12.4%, N=452,370) In-hospital death (3.7%, N=132,883) <30 days post-discharge enrollment in Medicare FFS in the absence of death (0.6%, N=20,351) Transfer to another acute care facility (1.1%, N=39,494) Discharge against medical advice (0.7%, N=25,259) Final cohort N=2,962,554 heart failure admissions surviving hospitalization (1,972,172 unique patients)

22 efigure 1B. Acute Myocardial Infarction Total acute myocardial infarction admissions, N=1,676,590 Less than 65 years of age (11.5%, N=193,021) In-hospital death (7.7%, N=128,825) <30 days post-discharge enrollment in Medicare FFS in the absence of death (0.6%, N=10,763) Transfer to another acute care facility (6.1%, N=103,861) Discharge against medical advice (0.6%, N=10,181) Final cohort N=1,229,940 AMI admissions surviving hospitalization (1,116,618 unique patients)

23 efigure 1C. Pneumonia Total pneumonia admissions, N=3,189,535 Less than 65 years of age (14.6%, N=468,285) In-hospital death (4.5%, N=143,186) <30 days post-discharge enrollment in Medicare FFS in the absence of death (0.5%, N=17,420) Transfer to another acute care facility (0.8%, N=25,303) Discharge against medical advice (0.6%, N=17,812) Final cohort N=2,544,530 pneumonia admissions surviving hospitalization (2,096,035 unique patients)

24 efigure 2. Correlation of Paired Trends in Hospital 30-Day Risk-Adjusted Readmission Rates and Hospital 30-Day Risk-Adjusted Mortality Rates After Discharge, April 2010 September 2012 Risk adjustment was made for patient age, sex, comorbidities, season, and hospital length of stay. Data for heart failure (4,231 hospitals), acute myocardial infarction (2,523 hospitals), and pneumonia (4,475 hospitals) are presented in panels A, B, and C, respectively. Data on hospital number and volume by month are presented in etable 5. efigure 2A. Heart Failure Monthly Change in Hospital 30-Day Risk Adjusted Readmission Rate (%), 04/ / Heart Failure Monthly Change in Hospital 30-Day Risk Adjusted Mortality Rate After Discharge (%), 04/ /2012

25 efigure 2B. Acute Myocardial Infarction Monthly Change in Hospital 30-Day Risk Adjusted Readmission Rate (%), 04/ / Myocardial Infarction Monthly Change in Hospital 30-Day Risk Adjusted Mortality Rate After Discharge (%), 04/ /2012

26 efigure 2C. Pneumonia Monthly Change in Hospital 30-Day Risk Adjusted Readmission Rate (%), 04/ / Pneumonia Monthly Change in Hospital 30-Day Risk Adjusted Mortality Rate After Discharge (%), 04/ /2012

27 efigure 3. Correlation of Paired Trends in Hospital 30-Day Risk-Adjusted Readmission Rates and Hospital 90-Day Risk-Adjusted Mortality Rates After Discharge, Risk adjustment was made for patient age, sex, comorbidities, season, and hospital length of stay. Data for heart failure (4,221 hospitals), acute myocardial infarction (2,469 hospitals), and pneumonia (4,483 hospitals) are presented in panels A, B, and C, respectively. Data on hospital number and volume by month are presented in etable 4. efigure 3A. Heart Failure Heart Failure Monthly Change in Hospital 30-Day Risk Adjusted Readmission Rate (%), Monthly Change in Hospital 90-Day Risk Adjusted Mortality Rate After Discharge (%),

28 efigure 3B. Acute Myocardial Infarction Acute Myocardial Infarction Monthly Change in Hospital 30-Day Risk Adjusted Readmission Rate (%), Monthly Change in Hospital 90-Day Risk Adjusted Mortality Rate After Discharge (%),

29 efigure 3C. Pneumonia Pneumonia Monthly Change in Hospital 30-Day Risk Adjusted Readmission Rate (%), Monthly Change in Hospital 90-Day Risk Adjusted Mortality Rate After Discharge (%),

30 efigure 4. Correlation of Paired Trends in Hospital 30-Day Risk-Adjusted Readmission Rates and Hospital 90-Day Risk-Adjusted Mortality Rates After the Admission Date, Risk adjustment was made for patient age, sex, comorbidities, season, and hospital length of stay. Data for heart failure (4,038 hospitals), acute myocardial infarction (2,385 hospitals), and pneumonia (4,419 hospitals) are presented in panels A, B, and C, respectively. Data on hospital number and volume by month for this analysis are presented in etable 6. efigure 4A. Heart Failure Heart Failure Monthly Change in Hospital 30-Day Risk Adjusted Readmission Rate (%), Monthly Change in Hospital 90-Day Risk Adjusted Mortality Rate After Admission (%),

31 efigure 4B. Acute Myocardial Infarction Acute Myocardial Infarction Monthly Change in Hospital 30-Day Risk Adjusted Readmission Rate (%), Monthly Change in Hospital 90-Day Risk Adjusted Mortality Rate After Admission (%),

32 efigure 4C. Pneumonia Pneumonia Monthly Change in Hospital 30-Day Risk Adjusted Readmission Rate (%), Monthly Change in Hospital 90-Day Risk Adjusted Mortality Rate After Admission (%),

33 efigure 5. Trends in Hospital 30-Day Risk-Adjusted Readmission Rates and Hospital 90-Day Risk-Adjusted Mortality Rates After the Admission Date for Heart Failure, Linear trends in mean monthly 30-day risk-adjusted readmission rates and 90-day risk-adjusted mortality rates after the admission date are shown for time periods: (1) January 2008 through March 2010, (2) April 2010 through September 2012, and (3) October 2012 through December The vertical lines correspond to dates proximate to when the Affordable Care Act was passed (April 2010) and the Hospital Readmissions Reduction Program began (October 2012). Risk adjustment was made for patient age, sex, comorbidities, season, and hospital length of stay. Data on hospital number and volume by month for this analysis are presented in etable 7.

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