A grab-bag of readmissions stuff from JAMA

I have not had time to read the research papers on readmissions in the latest issue of JAMA. But I have read all the shorter items — the editorials, View Points, and relevant letters. Below are some passages I thought worth flagging. I’ll get to the research articles later.

From Recasting Readmissions by Placing the Hospital Role in Community Context, by Douglas McCarthy, Marian Johnson, and Anne-Marie Audet:

Section 3025 of the US Affordable Care Act established the Hospital Readmissions Reduction Program, which requires the Centers for Medicare & Medicaid Services (CMS) to reduce Medicare payments to hospitals with excess readmissions for select conditions, as defined by the CMS. These activities reinforce a conceptual model in which causality is assigned to the admitting hospital, reinforced by a measurement strategy that uses admissions rather than the population in the denominator of the equation. Systems thinking argues for broadening the logic model to understand that patient outcomes are affected by a complex adaptive system that involves multiple individuals and entities including the patient, family caregivers, hospitals, postacute care facilities, home health agencies, physicians, other health care professionals, pharmacies, and public health and social service agencies.[2-3]

Evidence about factors related to hospital readmissions is inconsistent. Typically, a complex interplay of personal, medical, and social factors determines whether patients successfully recover or cope with their condition following a hospital stay or experience deterioration that leads to readmission. To date, successful efforts to reduce hospital readmissions have been mostly limited to small pilot populations, often funded by grants or payers, and without evidence of long-term sustainability. The lack of solid evidence to guide improvement has resulted in hospitals facing difficult challenges in finding effective solutions to address the problem. […]

From a societal perspective, patients benefit from improved care coordination and payers benefit from reduced utilization. For individual hospitals, however, reduced readmissions means that fixed costs must be spread across fewer encounters. The traditional business model, by which one organization designs an innovation to solve a problem expecting to reap the rewards of its investment, fails in this situation.

The Hospital Readmission Reduction Program has raised awareness of readmissions as an indicator of a fragmented health care delivery system. Yet financial penalties alone are not likely to drive change. As the nation moves toward comprehensive payment and delivery system reforms to promote integrated care, the focus should shift toward reducing avoidable hospital use, not just readmission, by strengthening primary and preventive care and chronic disease management for populations of patients at risk of poor health outcomes.

This strikes the right balance. Readmission penalty advocates have a very good point that something related to some readmissions is rotten in our health system: it’s fragmented and transitions are not handled well, etc. Yet readmission penalty critics make good points that the metric is blunt, removed from its intended target, and sensitive to many things outside the control of hospitals. Neither side is entirely wrong.

From Tension Between Quality Measurement, Public Quality Reporting, and Pay for Performance, by Steven Farmer, Bernard Black, and Robert Bonow

Outcome data are often derived from administrative (billing) data rather than clinical patient records because billing data provide readily available information on large numbers of patients. […]

If adverse event minimization is central to profitability, hospitals will be incented to maintain accurate metrics.

It’s particularly problematic that readmission rates upon which Medicare penalizes hospitals are not risk adjusted with socioeconomic variables (PDF). If you follow that link, you’ll find an argument by the authors as to why such socioeconomic adjustment would bias the results. I don’t find it convincing. I’m not alone. (See the quotes below.) Though their argument is not based on the fact that such variables are typically absent in administrative data (and are absent in Medicare claims), it is worth pointing out that one can probably do quite well with small area averages available from Census data.

It will always be the case that payment based on data will affect data collection. Though perhaps some degree of auditing could attenuate the relationship, it is not possible to have zero impact of measurement-based payment on reporting. One hopes there is a larger impact on behavior, but one can’t presume that to be so.

From Thirty-Day Readmissions: The Clock Is Ticking, by Muthiah Vaduganathan, Robert Bonow, and Mihai Gheorghiade:

Limited data support the use of all-cause readmissions as an appropriate performance metric following hospitalization for heart failure. Quality measures including total hospital admissions, length of stay, and in-hospital mortality have significantly improved over the last decade, based on national Medicare data for heart failure.[5] These trends may reflect greater use of evidence-based therapies and higher hospital adherence to national performance measures. Thirty-day readmission remains one of the stand-alone measures that has not demonstrated progress. It is uncertain whether this is attributable to inadequate effort toward postdischarge care or to an intrinsic problem with the quality metric.

Not all readmissions reflect poor hospital quality. Clear competing risks exist between mortality and rehospitalization. Patients who die soon after hospital discharge do not have the chance to be rehospitalized. Hospital centers with higher adjusted mortality rates have apparently lower adjusted readmission rates because of this competing-risk phenomenon.[6] Thus, hospitals that successfully reduce postdischarge mortality rates may be unjustly penalized under the current reimbursement system. This point is especially pertinent given the distinct differences in predictors of postdischarge rehospitalization and mortality in heart failure.

I have nothing to add.

From Characteristics of Hospitals Receiving Penalties Under the Hospital Readmissions Reduction Program, Karen Joynt and Ashish Jha:

We found that large hospitals, teaching hospitals, and SNHs [safety-net hospitals] are more likely to receive payment cuts under the HRRP [Hospital Readmissions Reduction Program]. It is unclear exactly why these hospitals have higher readmission rates than their smaller, nonteaching, non-SNH counterparts, but prior research suggests that differences between hospitals are likely related to both case mix (medical complexity) and socioeconomic mix of the patient population.[2- 3] There is less evidence that differences in readmissions are related to measured hospital quality.[6]

This is the heart of the debate.


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