The fundamental premise of hospital readmission reduction programs is that many, if not most, readmissions are due to factors within the control of the hospital and often represent poor care. The research does little to support this premise. A new study in the New England Journal of Medicine illustrates just how complex this issue is. (NEJM Article) The study looked at admissions and readmissions for congestive heart failure and pneumonia among Medicare beneficiaries in the first half of 2008. The objective was to see what factors might be associated with higher rates of readmissions. Both individual and systematic factors might be at work. At the individual level, obviously health status and sociodemographic characteristics could contribute to variation in readmissions. Systemic issues might include discharge and care coordination capabilities, provider supply and provider or patient care preferences.
Readmission rates for heart failure varied by a factor of almost three across hospital referral regions, and a factor of two for pneumonia. In the regression testing, for heart failure and pneumonia, the single factor most associated with readmission rate was the all cause admission rate in the region. Other supply variables and quality of discharge planning had minor causative evidence. The authors suggest that reducing rates of admission and readmission across the country to those of the lowest regions would result in substantial Medicare savings, but the quality impact is unclear, given the mortality finding noted below.
The fundamental finding is that the strongest single predictor of readmissions was the general rate of hospital admissions in a region, indicating that the decision to readmit may be based on similar factors as the initial decision to admit and may simply be a reflection of regional care preferences. These regional differences may or may not result in inappropriate, inefficient or lower quality care. Please note, for example, that this research indicated that higher readmission rates were associated with lower mortality. Although not discussed in the article, this is a point worth followup, especially given the larger debate about whether more use of medical services might result in better quality outcomes. What the article once again supports is the notion that readmissions are not necessarily a reflection of poor care and that CMS’ current readmissions initiative is deeply flawed.