- Hospital re-admissions that occur in the first week after a patient is discharged are more likely to be preventable than those occurring later, according to a new study in the Annals of Internal Medicine that suggests it may be time to rethink the association between hospital quality and 30-day readmission rates.
- Researchers from Beth Israel Deaconess Medical Center analyzed re-admission records for 810 adults treated at 10 U.S. academic medical centers and found early re-admissions were twice as likely to be preventable as late re-admissions.
- Early re-admissions were more often caused by factors within the hospital’s control and were responsive to hospital interventions, while later re-admissions were due to outside factors, such as monitoring or follow-up by a primary care team.
Under the Hospital Readmissions Reduction Program, part of the Affordable Care Act, Medicare docks hospitals up to 3% of normal reimbursement if they have higher than expected 30-day re-admission rates for six conditions: heart attack, heart failure, pneumonia, chronic obstructive pulmonary disease, hip/knee replacement and coronary artery bypass graft surgery. The idea is that high re-admission rates reflect poor quality of care.
And some research has suggested that’s the case. A study published last year in JAMA found that reducing hospital re-admission rates does not increase, and may actually lower deaths following discharge.
But this most recent study suggests a seven-day re-admission window may more accurately reflect hospital quality than the current 30-day time period.
“We believe that a 7-day cutoff would avoid inappropriate penalization while continuing to incentivize hospitals to develop processes of care that reduce re-admissions,” the researchers write. “This idea is supported by our finding that the hospital was identified as the ideal location for an intervention to reduce early re-admissions nearly half of the time, compared with about a quarter for late re-admissions.”
The study suggests that to reduce re-admissions, it is important to coordinate care, including follow-ups and rehabilitation plans. Coordinated care is a key factor for many value-based models that focus on outcomes rather than procedures and emphasize looking at an entire episode of care.
The authors recommend “multifaceted integration” between hospital care teams and primary care, with hospitalists focused on interventions to reduce mistakes that affect diagnosis and treatment planning. Hospitals should also examine whether internal incentives to increase throughput contribute to premature discharge and re-admissions.
On the outpatient side, multidisciplinary care management teams can improve post-discharge monitoring and coordinate follow-up appointments, the study adds.
“Shared accountability over the 30 days, possibly with weighted penalties by readmission timing, would engage outpatient practices in readmission reduction efforts and reduce unfair financial penalties on hospitals, which have negative downstream effects on the patients they serve,” the authors write.
Most hospitals agree on the importance of post-discharge planning. “A lot of re-admissions performance is driven less by what happens in the hospital and more by what’s available in the community to help patients recover once they’ve left the hospital — the availability of pharmacies, or primary care, rehab services,” Akin Demehin, director of policy at the American Hospital Association, told Healthcare Dive last fall.