Hu J, Gonsahn MD, Nerenz DR. Socioeconomic status and readmissions: evidence from an urban teaching hospital. Health Aff (Millwood). 2014;33(5).

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1 Appendix Definitions of Index Admission and Readmission Definitions of index admission and readmission follow CMS hospital-wide all-cause unplanned readmission (HWR) measure as far as data are available. Index admission: any eligible admission to an acute care hospital, according to the following inclusion/exclusion criteria. Inclusion criteria: a. Patient is 65 or older b. Patient survives hospitalization Exclusion criteria: a. Patients discharged against medical advice (AMA) are excluded b. Admissions for medical treatment of cancer are excluded Table Cancer discharge condition categories excluded from the measure AHRQ CCS Description 42 Secondary malignancies 19 Cancer of bronchus; lung 45 Maintenance chemotherapy; radiotherapy 44 Neoplasms of unspecified nature or uncertain behavior 17 Cancer of pancreas 38 Non-Hodgkin`s lymphoma 39 Leukemias 14 Cancer of colon 40 Multiple myeloma 35 Cancer of brain and nervous system 16 Cancer of liver and intrahepatic bile duct 13 Cancer of stomach 29 Cancer of prostate 15 Cancer of rectum and anus 18 Cancer of other GI organs; peritoneum 12 Cancer of esophagus 11 Cancer of head and neck 27 Cancer of ovary 33 Cancer of kidney and renal pelvis 32 Cancer of bladder 24 Cancer of breast 43 Malignant neoplasm without specification of site 25 Cancer of uterus 36 Cancer of thyroid 21 Cancer of bone and connective tissue 41 Cancer; other and unspecified primary 20 Cancer; other respiratory and intrathoracic

2 23 Other non-epithelial cancer of skin 26 Cancer of cervix 28 Cancer of other female genital organs 34 Cancer of other urinary organs 37 Hodgkin`s disease 22 Melanomas of skin 31 Cancer of other male genital organs 30 Cancer of testis c. Admissions for primary psychiatric disease are excluded Table Psychiatric discharge condition categories excluded from the measure AHRQ CCS Description 657 Mood disorders 659 Schizophrenia and other psychotic disorders 651 Anxiety disorders 670 Miscellaneous disorders 654 Developmental disorders 650 Adjustment disorders 658 Personality disorders 652 Attention-deficit, conduct, and disruptive behavior disorders 656 Impulse control disorders, NEC 655 Disorders usually diagnosed in infancy, childhood, or adolescence 662 Suicide and intentional self-inflicted injury d. Admissions for rehabilitation care; fitting of prostheses and adjustment devices (CCS 254) are excluded Readmission: a subsequent inpatient admission to any acute care facility which occurs within 30 days of the discharge date of an eligible index admission. Note that a readmission within 30-days will also be eligible as an index admission, if it meets all other eligibility criteria. This allows our measure to capture repeated readmissions for the same patient, whether at the same hospital or another. We defined the outcome as all-cause unplanned readmissions rather than readmissions related to the previous hospitalization.

3 Risk Adjustment Methods To account for differences in patient clinical characteristics that might be related to the readmission outcome, we took a similar approach developed by Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation (YNHHSC/CORE) for the hospital-wide all-cause unplanned readmission (HWR) measure. We adjusted both for case mix differences (clinical status of the patient, or comorbidities that were not due to complications) and service mix differences (the types of conditions cared for by the hospital, or the discharge condition category). Comorbidities were assessed using diagnosis data from the index admission and any admissions in the prior year. Specifically, we used secondary and comorbidity ICD-9 discharge diagnosis codes from the index admission, and all discharge diagnosis codes (primary, secondary, and comorbidity) from admissions in the 12 months prior to the index admission. To exclude potential complications occurring during hospitalization from comorbidities used for risk adjustment, we further excluded diagnoses if they appeared only on the index admission (but not in any historic admission). We then grouped these diagnoses into 31 comorbid risk factors using the CMS Condition Category (CMS-CC) Classification (crosswalk between ICD-9 codes and CMS-CCs can be found at The condition categories were defined using the principal discharge diagnosis of the index admission. These were grouped into 285 mutually-exclusive diagnosis condition categories using the Agency for Healthcare Research and Quality (AHRQ) Clinical Classification Software (AHRQ-CCS). For each of the top 10 frequent condition categories we created a conditionspecific indicator in the model; all other conditions were grouped together into an other category.

4 Crosswalk between CMS-CCs and Risk Variable (RV) Groups Risk Variable CMS-CC Description rv1 1, 3-5 Severe infection rv2 6, Other infectious disease & pneumonias rv3 7 Metastatic cancer/acute leukemia rv4 8, 9 Severe cancer rv6 10, 11, 12 Other major cancers rv , 119, 120 Diabetes mellitus rv10 21 Protein-calorie malnutrition rv11 25, 26 End-Stage liver disease rv12 44 Other hematologoical disorders rv14 51, 52 Drug and Alcohol disorders rv , 58, 60 Psychiatric comorbidity rv , , 177, 178 Hemiplegia, paraplegia, paralysis, functional disability rv19 74 Seizure disorders and convulsions rv20 80 CHF rv , 89, 98, 99, Coronary atherosclerosis or angina, cerebrovascular disease rv24 92, 93 Specified arrhythmias rv Chronic obstructive pulmonary disease rv Fibrosis of lung or other chronic lung disorders rv Dialysis Status rv30 148, 149 Ulcers rv31 2 Septicemia/shock rv32 22, 23 Disorders of fluid, electrolyte, acid-base rv33 47 Iron deficiency rv34 79 Cardio-respiratory failure or cardio-respiratory shock rv Acute Renal failure rv40 32 Pancreatic disease rv41 38 Rheumatoid arthritis and inflammatory connective tissue disease rv42 77 Respirator dependence/tracheostomy status rv43 128, 174 Transplants rv44 46 Coagulation defects and other specified hematological disorders rv Hip fracture/dislocation

5 Crosswalk between ICD-9 Codes and AHRQ-CCS Categories AHRQ-CCS Description ICD Congestive heart failure; nonhypertensive Septicemia (except in labor) Acute myocardial infarction Acute cerebrovascular disease 237 Complication of device; implant or graft Chronic obstructive pulmonary disease and bronchiectasis Urinary tract infections Cardiac dysrhythmias Pneumonia (except that caused by tuberculosis or sexually transmitted disease) Fluid and electrolyte disorders

6 Selection of Study Cohort: Inclusion/Exclusion Criteria Medicare FFS Admissions of Patients >=65, Discharged 2010 (N=7,845) Admissions with an in- hospital death (N=309) Starting Cohort (N=7,536) Exclusions Discharged against medical advice (N=34) Medical treatment for cancer (N=670) Primary psychiatric (N=35) Hospitalizations with rehabilitation CCS 254 (N=35) Study Cohort before Reconciliation (N=6,762) Additions Adjustment for minor discrepancies between CMS and CDS files * (N=70 ) Final Study Cohort (N=6,832) Note: * Minor discrepancies between CMS and CDS files included slightly different admission/discharge dates and main insurance types. Adjustments were made to be consistent with CMS records.

7 Prevalence of Clinical Risk Factors among Patients with and without Any Readmission Followed By A Readmission Clinical Risk Factor All No Yes p-value N 6,832 5,525 1,307 Frequent discharge conditions congestive heart failure; non-hypertensive (CCS 108) 7.2% 6.6% 9.6% <.001 septicemia (except in labor) (CCS 2) 3.9% 3.7% 4.8% acute myocardial infarction (CCS 100) 3.8% 3.7% 4.5% acute cerebrovascular disease (CCS 109) 3.8% 4.1% 2.8% complication of device; implant or graft (CCS 237) 3.6% 3.5% 3.8% chronic obstructive pulmonary disease and bronchiectasis (CCS 127) 3.4% 3.3% 3.8% urinary tract infections (CCS 159) 3.4% 3.4% 3.8% cardiac dysrhythmias (CCS 106) 3.1% 3.2% 2.5% pneumonia (CCS 122) 2.8% 2.7% 3.4% fluid and electrolyte disorders (CCS 55) 2.8% 2.8% 3.1% Comorbid risk factors severe Infection (RV1) 1.2% 1.1% 1.6% other infectious disease & pneumonias (RV2) 1.8% 1.5% 3.3% <.001 metastatic cancer/acute leukemia (RV3) 3.3% 2.9% 5.0% <.001 severe cancer (RV4) 5.5% 5.1% 7.0% other major cancers (RV6) 5.0% 4.7% 6.7% diabetes mellitus (RV9) 37.2% 36.6% 39.6% protein-calorie malnutrition (RV10) 4.2% 3.6% 6.6% <.001 end-stage liver disease (RV11) 2.1% 1.9% 3.1% other hematological disorders (RV12) 1.7% 1.4% 3.1% <.001 drug and alcohol disorders (RV14) 2.2% 2.1% 2.5% psychiatric comorbidity (RV15) 11.2% 11.1% 11.5% hemiplegia, paraplegia, paralysis, functional disability (RV18) 8.5% 8.2% 9.6% seizure disorders and convulsions (RV19) 4.7% 4.5% 5.7% CHF (RV20) 10.3% 9.0% 15.8% <.001 coronary atherosclerosis or angina, cerebrovascular disease (RV21) 47.7% 46.9% 51.2% specified arrhythmias (RV24) 24.4% 23.7% 27.1% coronary obstructive pulmonary disease (RV26) 15.4% 14.7% 18.4% fibrosis of lung or other chronic lung disorders (RV27) 1.4% 1.3% 2.0% dialysis status (RV29) 3.3% 2.7% 6.0% <.001 ulcers (RV30) 3.7% 3.3% 5.4% <.001 septicemia/shock (RV31) 0.3% 0.3% 0.5% disorders of fluid, electrolyte, acid-base (RV32) 6.6% 5.8% 10.2% <.001 iron deficiency (RV33) 7.4% 6.3% 12.1% <.001 cardiorespiratory failure or cardiorespiratory shock (RV34) 0.6% 0.4% 1.1% acute renal failure (RV39) 13.7% 11.7% 21.7% <.001 pancreatic disease (RV40) 1.2% 1.1% 1.5% rheumatoid arthritis and inflammatory connective tissue (RV41) 3.2% 3.3% 2.6% respirator dependence/tracheostomy status (RV42) 0.7% 0.7% 0.9% transplants (RV43) 2.4% 2.5% 2.0% coagulation defects/other specified hematological disorders (RV44) 6.0% 5.9% 6.4% hip fracture/dislocation (RV45) 0.4% 0.3% 0.5% Note: Differences between readmission groups are tested by chi-square test.

8 Associations of Clinical Risk Factors with 30-Day Readmission (Study Unit: Admission) Base (N=6,832) Poverty (N=6,732) Education (N=6,733) Household Income (N=6,735) All-In (N=6,732) Clinical Risk Factor OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI Condition Indicator congestive heart failure; non-hypertensive (CCS 108) septicemia (except in labor) (CCS 2) acute myocardial infarction (CCS 100) acute cerebrovascular disease (CCS 109) complication of device; implant or graft (CCS 237) chronic obstructive pulmonary disease and bronchiectasis (CCS 127) urinary tract infections (CCS 159) cardiac dysrhythmias (CCS 106) pneumonia (CCS 122) fluid and electrolyte disorders (CCS 55) Comorbid Risk Variable severe Infection (RV1) other infectious disease & pneumonias (RV2) metastatic cancer/acute leukemia (RV3) severe cancer (RV4) 1.26# # # # # other major cancers (RV6) diabetes mellitus (RV9) protein-calorie malnutrition (RV10) end-stage liver disease (RV11) other hematological disorders (RV12) drug and alcohol disorders (RV14) psychiatric comorbidity (RV15) hemiplegia, paraplegia, paralysis, functional disability (RV18) seizure disorders and convulsions (RV19) CHF (RV20) coronary atherosclerosis or angina, cerebrovascular disease (RV21) specified arrhythmias (RV24) coronary obstructive pulmonary disease (RV26) 1.18# # # # fibrosis of lung or other chronic lung disorders (RV27) dialysis status (RV29) ulcers (RV30) 1.30# # septicemia/shock (RV31) disorders of fluid, electrolyte, acid-base (RV32) iron deficiency (RV33) cardiorespiratory failure or cardiorespiratory shock (RV34) acute renal failure (RV39) pancreatic disease (RV40) rheumatoid arthritis and inflammatory connective tissue disease (RV41) respirator dependence/tracheostomy status (RV42) transplants (RV43) coagulation defects and other specified hematological disorders (RV44) hip fracture/dislocation (RV45)

9 Associations of Clinical Risk Factors with 30-Day Readmission (Study Unit: Patient) 0 vs. >0 readmission (N=4,574) 0, 1, >1 readmission (N=4,574) Clinical Risk Factor OR 95% CI OR 95% CI Condition Indicator congestive heart failure; non-hypertensive (CCS 108) septicemia (except in labor) (CCS 2) acute myocardial infarction (CCS 100) acute cerebrovascular disease (CCS 109) complication of device; implant or graft (CCS 237) COPD and bronchiectasis (CCS 127) urinary tract infections (CCS 159) cardiac dysrhythmias (CCS 106) pneumonia (CCS 122) fluid and electrolyte disorders (CCS 55) Comorbid Risk Variable severe Infection (RV1) other infectious disease & pneumonias (RV2) metastatic cancer/acute leukemia (RV3) severe cancer (RV4) other major cancers (RV6) diabetes mellitus (RV9) protein-calorie malnutrition (RV10) end-stage liver disease (RV11) other hematological disorders (RV12) drug and alcohol disorders (RV14) psychiatric comorbidity (RV15) hemiplegia, paraplegia, paralysis, functional disability (RV18) seizure disorders and convulsions (RV19) CHF (RV20) coronary atherosclerosis/angina, cerebrovascular disease (RV21) specified arrhythmias (RV24) coronary obstructive pulmonary disease (RV26) fibrosis of lung or other chronic lung disorders (RV27) dialysis status (RV29) ulcers (RV30) septicemia/shock (RV31) disorders of fluid, electrolyte, acid-base (RV32) # iron deficiency (RV33) cardiorespiratory failure or cardiorespiratory shock (RV34) acute renal failure (RV39) pancreatic disease (RV40) rheumatoid arthritis and inflammatory connective tissue (RV41) respirator dependence/tracheostomy status (RV42) transplants (RV43) coagulation defects/other specified hematological disorders (RV44) # hip fracture/dislocation (RV45) Note: Highlighted numbers indicate associations statistically significant at p < 0.05; # indicates p < 0.10