High hospital readmission rates in different regions of the U.S. may have more to do with the overall high use of hospital services in those regions than with the severity of patients' particular conditions or problems in the quality of care during and after hospital discharges, according to a new study from researchers at Harvard School of Public Health (HSPH).
The study appears in the December 15, 2011 issue of the New England Journal of Medicine.
"This is a very important observation that has been largely unrecognized in the literature or by policy makers," said study lead author Arnold Epstein, John H. Foster Professor of Health Policy and Management and chair of the Department of Health Policy and Management at HSPH. "Hospitals may have limited ability to reduce readmissions. The responsibility for readmissions lies with the entire delivery system. Meaningful progress may require incentives directed at that level and a change in culture."
Rehospitalizing patients after discharge is a costly problem, and hospitals and policymakers have made significant efforts to reduce readmission rates. Most efforts to reduce readmission rates have focused on improving transitional care—what happens to patients at discharge and shortly after they're released from the hospital. This study implies that the problem is much broader than that.
Hospital readmission rates are high—nearly one in four Medicare patients discharged with congestive heart failure is rehospitalized within 30 days, according to the study. Unplanned readmissions are costly and are often associated with poor patient health outcomes. But previous studies have shown that efforts to improve hospital discharge planning have not significantly decreased readmission rates.
Epstein and coauthors Ashish Jha, associate professor at HSPH, and E. John Orav, associate professor at Brigham and Women's Hospital, used national Medicare data from the first six months of 2008 to calculate, for different U.S. regions, the 30-day, 60-day, and 90-day readmission rates among patients discharged with congestive heart failure or pneumonia. They examined overall hospitalization rates as well as differences in patients' coexisting conditions, the quality of discharge planning, and the number of physicians and hospital beds in each region, looking at how each factor affected readmissions.
The results showed that readmission rates among regions ranged from 11% to 32% among patients with congestive heart failure and from 8% to 27% among those with pneumonia. Greater severity of coexisting conditions was associated with higher regional readmission rates. But of all the potential causes for regional differences in readmission rates, overall hospital admission rates were found to play the biggest role; they accounted for 16% to 24% of the variation in cases of congestive heart failure, and 11% to 20% for pneumonia cases. No other factor accounted for more than 6% of the variation.
To effectively reduce readmission rates, the authors recommend that payers use programs that include shared savings with health care providers, such as accountable care organizations, that are able to reduce readmission rates and bring down the overall cost of care.
Support for the study was provided by the Commonwealth Fund.
"The Relationship between Hospital Admission Rates and Rehospitalizations," Arnold M. Epstein, Ashish K. Jha, E. John Orav, New England Journal of Medicine, December 15, 2011, 365:24
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New England Journal of Medicine