Learning About 30-Day Readmissions From Patients With Repeated Hospitalizations
Published Online: June 27, 2014
Jeanne T. Black, PhD, MBA
The finding that nearly 1 in 5 Medicare beneficiaries treated in a hospital is readmitted within 30 days has captured the attention of policy makers concerned with both the cost and quality of health services. Hospital readmissions gained widespread attention with the Medicare Payment Advisory Commission’s June 2007 Report to Congress, which stated that 13.3% of all Medicare 30-day readmissions were potentially preventable and suggested that $12 billion could have been saved in a single year.1 The focus on readmissions intensified with the publication of Steven Jencks’ landmark 2009 paper in the New England Journal of Medicine,2 in which he and his coauthors estimated that unplanned 30-day rehospitalizations cost Medicare $17.4 billion in 2004. Also beginning in 2009, the Hospital Compare website created by CMS began to publish risk-standardized 30-day readmission rates by hospital for Medicare fee-for-service (FFS) patients discharged with a principal diagnosis of heart failure, acute myocardial infarction, or pneumonia. In October 2012, the Medicare Hospital Readmissions Reduction Program (HRRP) began penalizing hospitals for “excessive” readmission rates for these 3 conditions. The National Quality Forum subsequently endorsed a new 30-day readmission metric, the Hospital-Wide All-Cause Readmission Measure, which identifies and excludes specific conditions and procedures for which a hospitalization would be considered planned or expected.3 This measure, added to the Hospital Compare website in 2013, was developed to be applicable to all adult patients, not just those 65 years and older, so it can be used by payers other than Medicare.
National and regional initiatives launched to reduce readmissions to the Society for Hospital Medicine’s Project BOOST (Better Outcomes for Older adults through Safe Transitions),4 State Action on Avoidable Rehospitalizations (STAAR),5 the HHS “Partnership for Patients,”6 and the care transitions project facilitated by the CMS Quality Improvement Organizations (QIOs) in 14 communities.7 Despite all these efforts, between 2007 and 2011, the national Medicare readmission rate remained unchanged, preliminary data for calendar year 2012 show a slight decrease.8
CMS, when finalizing the 3 readmission measures to be used in the HRRP, noted that the 30-day time frame “is a clinically meaningful period for hospitals, in collaboration with their medical communities, to reduce readmission risk. This time period for assessing readmission is an accepted standard in research and measurement.”9 This focus on a single 30-day period has resulted in analyses that assume a patient discharged from the hospital is at risk for a single rehospitalization. It ignores the fact that 25% of Medicare beneficiaries represent 85% of total expenditures.10 Jencks’ analysis was based not on unique patients but on hospital discharges. This traditional encounter-based approach is not patient-centered. It does not reflect the trajectory experienced by some patients who have repeated rehospitalizations. Hospital clinicians are only too aware that certain patients return to their emergency departments (EDs) and nursing units over and over again, but there is a lack of evidence regarding the extent to which these frequently readmitted patients contribute to 30-day readmission rates, whether they differ from other patients, and how those differences may indicate a need for additional or different approaches to prevent their readmissions.
The objective of this descriptive analysis was to understand the population of inpatients with a pattern of repeated hospitalizations at a large urban medical center in order to gain insight into the types of patients who were at the highest risk of readmission and consumed the most inpatient resources. This activity was undertaken as part of a quality improvement initiative and thus was deemed non-reviewable by the medical center’s Institutional Review Board.
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