CMS’ readmissions reduction, or at least nonpayment, program is underway. Hospitals are scrambling to create programs that will help avoid readmissions. A study in the Annals of Internal Medicine, however, finds that the evidence base to guide interventions is insufficient. (Annals Article) The authors looked for all studies related to the topic and came up with 43 articles that were relevant and useful. The authors identified 12 intervention components, many of which were bundled in various interventions. Broadly these fell temporally into pre-discharge, post-discharge and bridges between and across the two time periods.
Pre-discharge patient education and discharge planning were found in 22 studies. Only in one randomized trial was there a showing of significant benefit and that was for discharge planning. Post-discharge interventions included phone calls, visits and coordination with outpatient providers. Again, most of these showed little significant effect on readmissions. The bridging interventions included patient-centered discharge instructions, transition coaches and same-provider continuity. There was not consistent evidence across trials, including randomized trials, of benefit from specific components or even bundles, but there were trials finding a benefit from patient-centered discharge instructions and provider continuity.
The study is not intended to say, and should not be read to say, that various interventions, especially when bundled, won’t work or shouldn’t be tried. What it does reflect is the paucity of consistent, trustworthy evidence that isolated intervention components or bundles of intervention components are successful in reducing readmissions. In many ways this just reflects a need for more and better research. But if hospitals don’t have evidence they can rely on to guide them in their efforts to reduce readmissions, how can they be penalized for not doing so. And even worse, does the lack of evidence for successful interventions suggest that perhaps the causes of most readmissions are not avoidable, which would undermine the rationale for the entire initiative. We continue to believe that if there is going to be a readmissions initiative, the right way to look at this is to do a clinical review of readmissions and use the results of that review to determine if nonpayment is justified.