- Regulators and payers use hospital readmissions as an indicator of quality of care, but the omission of observation stays provides an incomplete picture, according to a paper in this week’s New England Journal of Medicine.
- The authors analyzed eight years of claims data covering more than 5 million emergency department visits a year. Patients who had an initial observation stay or inpatient admission were followed for 30 days post-discharge to identify subsequent stays or admissions.
- In 2015, 14% of ED visits resulted in hospitalizations. Of those, 57% were inpatient admissions and 43% were for observation.
What’s striking is the trajectory of 30-day readmissions for the two groups. Over the nine years, the rate of inpatient readmissions declined from 17.8% to 15.5%, while the rate of readmissions for an observation stay increased from 10.9% to 14.8%, the authors note.
Under the Hospital Readmissions Reduction Program, part of the Affordable Care Act, Medicare docks hospitals up to 3% of normal reimbursement if their 30-day readmission rates are higher than expected for six conditions: heart attack, heart failure, pneumonia, chronic obstructive pulmonary disease, hip/knee replacement and coronary artery bypass graft surgery. Observation stays, which are treated as outpatient stays, are not counted in readmission scores.
Yet those types of stays are increasing on average 0.3% a year, the authors say. “If this trend extends to the 138 million ED visits that occur each year in the United States, excluding observation stays from readmission measures means that information on more than 400,000 additional unscheduled hospitalizations will be omitted from readmission measures each year,” they write.
The authors argue that the need for high-quality care transitions is no less because the stay is deemed observational rather than inpatient.
“All patients with an acute condition require timely and coordinated care. Moreover, there is no reason to think that a repeat observation is any less preventable or less reflective of the quality of car transitions than an inpatient readmission,” they write. “Although repeat observation stays cost payers less than inpatient readmissions, they still represent excess costs for the health care system and are meaningful for patients.”
Given the role readmission rates play in quality scoring, the research in this study could be useful if it compels providers to copy the same procedures that have helped reduce inpatient readmissions.
Still, more research is needed to understand the impact of observation stays on readmission measures, the authors say. Questions to address include whether inpatient and observation stays should be combined in a single measure and what, if any, unintended consequences might occur from including observation stays in readmission measures.