• Hospital readmissions summary comments

    Though I am sure to blog more on hospital readmissions in the future, I’ve reached a pause, with no papers on the subject in my queue to read. Since it’s likely many readers weren’t following my posts on this in detail, below is a summary. You can follow the links back to posts in the series to date. All of them are tagged with “hospital readmissions.”

    The proportion of hospitalizations leading to rapid readmissions is shocking. Whatever you think of Medicare’s Hospital Readmissions Reduction Program (HRRP), which penalizes or rewards hospitals based on their readmission rates, there is no reason to be satisfied with this. But what causes readmissions? In particular, what causes those that are potentially preventable? Many point to inadequate discharge planning, poor transitions of care, and insufficient outpatient follow up. Post-hospitalization is a vulnerable time, requiring more than the normal level of support. It is not implausible that many patients just don’t get what they need.

    Is this the fault of hospitals? Evidence about the extent to which hospital readmissions are related to quality of care during the index admission is mixed. Readmissions may be related to some notions of hospital quality or safety but not others. They are also related to many other factors that are not amenable to modification by hospitals. Joynt and Jha offer the most compelling and complete case that variation in socioeconomic status and hospital resources play large roles in variation in readmission rates. Hospitals that lose resources due to high readmission rates may be the very ones that can least afford it. Quality may suffer for the most vulnerable populations, which is the opposite of the policy’s goal.

    Whatever “potentially preventable” means (definitions vary), the proportion of readmissions that are such is likely fairly small, though varies by region. The ability to predict hospital readmissions is modest, and little work has been done on predicting potentially preventable hospitalizations. MedPAC’s estimate that 79% of readmissions are avoidable is almost surely way too high. Here’s an evidence-based rule of thumb: 20% of Medicare hospitalizations lead to readmissions, and 20% of those are avoidable So, of all Medicare hospitalizations, perhaps about 4% lead to avoidable readmissions. That’s not nothing, but I’ll bet you thought it was higher.

    It is not evident how hospitals can reliably reduce readmissions. One recent study suggests that increasing nursing staff or improving their work environment can help, but I have some methodological concerns about it. Some interventions that reduce hospitalizations may not reduce the rate of readmissions, suggesting the HRRP is inadequate. More primary care may increase readmissions.

    Researchers have observed a negative correlation between rates of mortality and readmissions. There’s a simple explanation for this: Dead people can’t be readmitted, a type of immortal time bias. Readmission rate estimates do vary depending on how mortality is handled in analysis.

    I have concerns about how the HRRP computes readmission rates. Socioeconomic status is not among the risk adjusters. Medicare Advantage enrollment is not considered. All in all, it’s very hard to be excited about the program. It’s unclear it is targeting the right thing and measuring it in the right way.

    Still, it is possible readmission rates — perhaps more thoroughly risk adjusted — provide a more valuable signal for certain sub-populations. Perhaps, in concert with other measures, they reveal something of import about health systems in general or hospitals in particular. I don’t really know. I don’t want to say they’re useless. Right now, all I’m saying is that the way they are currently used by Medicare has been severely challenged in the literature. There’s a lot on the “con” side. Where’s the “pro”? I’m still seeking the counterpoint to Joynt and Jha. Who has offered the case for the HRRP? For all my looking, I haven’t found it.

    @afrakt

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    • You have done a yeoman job on this issue, thank you.

      If readmission rates are higher today than they were 50 years ago, I would advance the following causes:

      - 50 years ago, some patients never left the hospital. President Eisenhower was hospitalized for over 20 days after his heart attack in 1955. I had the same kind of heart attack in 2007 and went home after 4 days.

      If alcohol treatment centers started sending patients home after 7 days instead of after 28 days, we would see the same trends.

      - 50 years ago, we had far fewer persons over age 85 who were hanging onto life by a thread, fragile hearts and fragile kidneys etc.

      Once again, the success of Medicare in terms of longer life expectancy is going to make us poorer, not richer, I continue my private crusade against the assumption that longer lives are a mark of prosperity.

    • Twenty-five years ago, I spent 2 years as Medical Director for a small ( <100,000 lives ) gate-keeper, risk-sharing HMO. Looking at <30 day re-admissions then, it seemed that two factors related to Primary Health Care might be reliably associated with these readmissions: 1) the health supervision process during the 6 months prior to a hospital admission and 2) delays in accessing health care prior to a hospitalization. Have either of these two possible factors been studied?

    • “But what causes readmissions?”

      I vote for medical malpractice.

      (And not just anecdotally: my understanding is that malpractice kills more Americans than cars and workplace accidents combined.)

      My father fainted at home. Woke up, called an ambulance, was admitted through the ER at “the best hospital in Boson”. They never diagnosed or treated or even considered the fainting. They did carve up his gut looking for cancer and kick him out to rehab as soon as they could. Where he fainted trying to get to the bathroom. He was readmitted to a different hospital, where the hospital acquired infections killed him (on the phone, he was clearly losing it (confused, in pain), so I talked to the MD in charge “He’s doing fine. Once we’ve got the pneumonia and urinary tract infections under control, he’ll be discharged.” He was dead 8 hours later.). One of the side effects of a medication he had been taking (prescribed by an MD at said “best hospital in Boston”, who never even came by to see my father during his week or so stay) is, according to Wiki, fainting.

      But that’s two (one actual, one planned) discharges that were way too early, and clearly count as genuine malpractice (i.e. discharging without even thinking about the condition that brought the patient to the hospital in the first place).

      FWIW, I do think that the goal of reducing lengths of hospital stays is a good idea. But only if you actually treat the problem.

    • Very interesting and timely topic. Your summary however, disregards your previously-cited study(‘s) that indicate that increased access to PCP post-discharge positively correlates with increased readmission rates. This indicates (IMO) that: 1) suboptimal discharge planning and/or 2) clinically premature discharge are the principal indicators….

      • You may be right, but I’d like you to be more specific. Please include the URL of the post in which I cited that study. Thanks.

        • Your 01/19 post discusses the Oddone & Weinberger commentary regarding increased readmission rates (albeit concomitant with greater paient. satisfaction). I recall another recent post (on another blog..) that dealt with this topic in more detail. I’ll post a reference here if I can find it..).

    • Follow the money goes the famous aphorism, which applies to health care at least as much as any other sector of activity. Once Medicare turned to DRG-based payments for hospital stays, hospitals became determined to reduce length of stay in order to protect/increase margins. Part of their “strategy” was to buy or pressure home health agencies, to raise home care’s skill levels and technology adoption to meet the needs of quickly discharged patients at home. Naturally, spending on home care increased, so Medicare pushed prospective payment on to that segment, too; predictably, home care agencies started discharge planning at the same time they began an episode of care.

      One metric I haven’t seen cited: the patient/discharge planner ratio, either for hospitals or for home care (or even for nursing homes, which are also pressured to keep rehabbing patients no more than 3 weeks.) And make sure supervisors don’t get counted.

      Meanwhile, don’t get me started about how hospitals transfer brink-of-death patients to hospice, both to protect their mortality stats and to find another payment source for a few more days in a bed.