• Harlan Krumholz on hospital readmissions

    Harlan M. Krumholz, MD, SM, is a cardiologist and the Harold H. Hines, Jr. Professor of Medicine and Epidemiology and Public Health at Yale University School of Medicine. He is the Director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation (CORE) and Director of the Robert Wood Johnson Clinical Scholars Program at Yale. His research has directly led to improvements in the use of guideline-based medications, the timeliness of care for acute myocardial infarction, public reporting of outcomes measures, and the current national focus on reducing the risk of readmission. He led the work that underlies the risk adjustment model for Medicare’s Hospital Readmission Reduction Program (HRRP). We (Aaron and Austin) asked him some questions about the HRRP via email. Our exchange is below.

    Note: Karen Joynt offers a different perspective in response to a similar set of questions.

    1. Based on our reading of the literature, it seems like the purpose and motivation of Medicare’s Hospital Readmissions Reduction Program (HRRP) is to use financial penalties and rewards to motivate hospitals to improve discharge planning and transitions of care. Readmissions would not be the first metric for this purpose I would think of. How did the idea to use them arise? In what ways are they well and not so well designed for this role?

    First, it is important to know that we focused on readmission as an important marker of quality of care, knowing that there were many deficiencies in the care of patients in the transition from inpatient to outpatient. Anyone who has been in the hospital or had a family member or friend in the hospital has experienced the lack of communication and coordination that occurs – and the stressors in the hospital – that make it difficult to have a successful recovery.

    We have studied readmissions and interventions to reduce risk after discharge for two decades. We did not develop the measures for a particular policy – but to highlight our performance in this area. We felt this was a very patient-centered measure that focused on a neglected area of care. The HRRP seized on these measures so there would be an incentive for hospitals and health care systems to invest in improving care for patients. Before this policy readmissions were simply more revenue for a hospital and there was no reason to invest in reducing the risk of these individuals who were entering a very hazardous period.

    For patients, readmissions are often a marker of a catastrophic adverse health event that has occurred within a short period after hospitalization. I have described the period of generalized risk that patients seem to have after a hospitalization as “Post-Hospital Syndrome” – to focus our attention on the fact that after leaving the hospital people appear susceptible to a wide range of ailments, the majority of which are different than what brought them in the hospital in the first place. It is a dangerous period for them as they are vulnerable to all sorts of health problems. These events are unwelcome, disruptive and often life threatening. Interestingly, we never learned in medical schools about the risks that patients face soon after leaving the hospital. Our textbooks lack chapters on this topic. Most of us learned about inpatient and outpatient care – but somehow the transition from inpatient to outpatient was lost.

    In our work with CMS [Centers for Medicare & Medicaid Services] we have tried to bring this period into bright relief, a period of great vulnerability for patients. Patient do not experience the hospitalization as a singular event, they experience an episode of illness that spans physical locations. If we reflect on our care processes we see so many deficiencies in our transitional care – errors in communication, collaboration, cooperation among health care providers. We do not recognize the disabilities that a patient acquires as a result of their illness and the hospitalization. We spend little time seeking to mitigate the stressors of the hospitalization (physical, psychological, social). And until recently there was no financial incentive to do so – in fact, readmissions generated revenue. A sad chapter in medicine is that many grant-funded programs that showed reductions in readmissions were discontinued when the funding ended likely because the health care system did not see a sustainable business model for them.

    We selected readmission because success in reducing rates holds the possibility of improving patient outcomes and decreasing costs. We chose it because there seemed so little attention on ensuring that patients did well in the transition from inpatient to outpatient, that there would be ample opportunities for improvement. We have pushed readmissions because for too long the medical profession has ignored this extraordinary dangerous time for patients – in part, we believe, because health care professionals were unaware of how high the rates were. In a patient-centered health care system, we would be looking out for patients at the time that they are at greatest risk – and generate strategies that can lower their risk and help them be safe in this period.

    I also want to be clear, I did not write the law. Our group sought to focus attention on readmission, developed the measure in collaboration with experts at CMS, and encouraged the public reporting of it. I like the idea that there is now an incentive for hospitals to work on this problem, though I might have had a different approach to the policy.

    2. It’s not likely that we want all readmissions to be avoided. Some are probably appropriate and unavoidable. How will the HRPP account for these, or differentiate them from bad readmissions?

    This effort should be about reducing the risk of unplanned readmissions. We are improving the measures by removing readmissions that seem likely to be planned. But this measure is not about a single readmission, but about a pattern of performance. The idea is that we should be able to reduce risk in the post-hospitalization period and have the need for fewer readmissions. In any effort we need to watch other measures to be sure that there are no unintended adverse consequences for patients as a result of actions that are not in their best interests. We need to track mortality, for example. But it would be a mistake to try to assess the need for each readmission – whether it was truly preventable or not. If we lower the risk generally then the rate will drop. And the goal of a health care system and the clinicians should be to prevent a patient from getting to the point of needing to be readmitted. We do not expect the rate to ever be zero – but do people really think that 20% rate of return in 30 days is the best we can do for our patients, especially given the evidence of the gaps in care.

    3. Is there a realistic danger that the HRRP could encourage hospitals to resist readmissions, even if that practice is to the detriment of patients? Might hospitals dump patients to alternate facilities instead of readmitting them? Are there mechanisms in place to monitor or prevent such practice?

    I would hope that health care professionals would not seek to excel on a measure at the expense of a patient. I do not believe that the vast majority of individuals or institutions would ever consider such an act. It is impossible to develop measures that are resistant to those who would disregard the best interests of patient. What I hope will occur is a realization that our current practices are not serving patients well and that care can be improved – better coordinated – and that we can recognize in our patient populations what most conspires against their success in this dangerous period – and help them through it. As I said, it will be important to monitor other outcomes, such as mortality, to ensure that the policy is not resulting in harm.

    4. You’ve argued that hospital readmission rates aren’t very sensitive to socioeconomic status. What’s the evidence for this?

    Overall, the effects have tended to be small at the patient level. Race seems to be stronger than SES. We have a series of articles that we are preparing that will put this in better perspective. I am not saying that SES and race do not have some effect – patients with fewer resources often face greater challenges in our health care system. But I am saying that it is not the dominant factor. Look at the variation in readmission rates – the risk for all types of patients with all types of demographic characteristics is not that different. And if we adjust for SES in the models, it does little to the result, the SES variable is significant but the effect is small.

    5. Even if readmissions are related to socioeconomic status, you’ve written that it would be problematic to risk adjust the HRRP model to reflect that. Why is this so?

    Well, if it were the dominant factor, then we would need to determine how best to proceed because it would be a principal cause of the patient risk. However, we lack evidence that is true. But even if it were true, to adjust for that factor would be to hide differences in our population – and I think it is best to confront the differences and then determine the best policy response to reduce or eliminate the disparity. Social determinants of health are real – and important – and deserve our attention so we do not want to hide them. But as I said, I do not believe that they have a strong influence on an institution’s readmission rates.

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    • Dr Krumholz–thanks for the interview. A few comments:

      1) I believe CMS must separate out the outcome of interest–readmit %–and the contributing factors associated with the metric. In some instances, process may not be subservient to outcomes. The hospital as nidus of responsibility–and I know the justifications well–may be premature given what we dont know and all the contributing factors related to return trips.

      As you state, the risk of readmission facing patients concerns as much as what happens after discharge, and much of what we do during the hospitalization, as the transition itself. With many unknowns, I believe as we accrue more data, we will learn the rush to utilize readmit % as the penultimate measurement will translate to wasted resources.

      Hospitals will misapply interventions to correct problems they weren’t meant to solve. The dissonance will produce a one step forward, two step back mindset and will contribute to hospital and front line worker cynicism. We need evidence and an openness to evolve. The latter, as I can attest, is not present in the hospital environment currently.

      2) I must disagree on your answer to the last question. For most hospitals, race and SES dont play a strong influence. But for 10-20% of fragile hospitals–resource poor and struggling–they do. Without adjustment, the action needed to assist them by leveling the analytic playing field–we will pummel them. As the program progresses, I am certain we will learn hard lessons. No data to support, just my opinion and the crude early findings from year one.

      I should add, I endorse measurement and transparency.and feel our hospitals need scrutiny. But morale and signaling–especially from CM–must be a priority to garner a productive response from institutions. We hold the hot potato, like it or not; I just wish the metric (crude readmit %) fit the task (use it to identify your problems).

      Brad

    • First, while we wait for perfect information about contributing factors to readmission, people are suffering because of obvious flaws in our current system. For example, discharge summaries are often not done in a timely way, often lack critical information, and often do not get sent to the right place, or are made easily available to other health care providers. Medication errors are common. Patient disabilities are often not appreciated and instructions are not aligned with patient capability. At least for me, I have evidence that our system is not working well for patients and have a strong belief that these flaws are contributing to the risk of adverse outcomes after discharge. The hospital as the center of gravity of the care for these patients can make a difference. Do we really need more evidence that our broken systems are a problem? I spoke to representatives of 600 hospitals recently and there was a clear consensus that there is much that hospitals can do to improve their transitional care – and in ways that are likely to make a difference for patients. I prefer to move now rather than wait for more studies when the gaps in quality are so obvious.

      Second, again, you can debate the responsibility – but from the patient perspective the entire episode of the illness is important and they depend on us to work together on solutions, not debate who is responsible. We are all responsible. And the hospital is the logical actor to pull everyone together.

      Third, I have more faith in hospitals than you do. I think there is so much to improve that their attention to this care is likely to make things better for patients.

      Fourth, at the hospital level, the percentage of low SES patients has only a weak effect on the risk-standardized mortality rates – and many safety net hospitals excel (see Health Aff (Millwood). 2012 Aug;31(8):1739-48). I would like to see policies that help them improve. The Partnership for Patients, with a $500m investment, is an example. I am sure that suggestions about how policies may help these resource poor hospitals would be welcome.