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How One Extra Day in the Hospital Could Move the Needle on Readmissions

November 7, 2014
by Rajiv Leventhal
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Could keeping patients just one extra day in the hospital lower their risk of readmission and mortality? It might seem inconsequential on the surface, but according to a study by researchers from the Columbia Business School, the answer is yes.

Twenty percent of Medicare patients are readmitted to the hospital within 30 days of discharge, resulting in substantial costs to the U.S. government. As part of the Affordable Care Act, the Hospital Readmissions Reduction Program financially penalizes hospitals with higher than expected readmissions. To that end, last month, Kaiser Health News reported, based on a study of Medicare data,  that 2,610 U.S. hospitals, or fully three-quarters of those subject to the program are being penalized this year for having too many patients return within a month for additional treatments.

For the study, Should Hospitals Keep Their Patients Longer? The Role of Inpatient and Outpatient Care in Reducing Readmissions, the Columbia researchers examined 6.6 million Medicare patients treated between 2008 and 2011. It compared the potential benefits of a one day extended hospital stay to those of outpatient care in terms of reduced readmissions, death rates and costs.

To compare inpatient and outpatient care models, the research included patients covered by traditional Medicare and those covered by Medicare Advantage plans.  Since traditional Medicare plans directly pay hospital costs on a fee-for-service basis, there was little incentive before the enactment of penalties for hospitals to prevent readmissions.  On the other-hand, the payment system for Medicare Advantage plans incentivizes insurers to reduce excess readmissions and therefore they provide better outpatient care to keep patients healthier and out of the hospital.

The researchers found that giving patients one extra day in the hospital—rather than releasing them into outpatient care—resulted in: a 22 percent drop in morality for pneumonia patients; a 7 percent decline in heart attack deaths; and a 7 percent reduction in readmission for heart failure patients. Heart failure and pneumonia are two of the conditions covered under the Hospital Readmissions Reduction Program, along with myocardial infarction.

Additionally, the study showed that one extra day in the hospital would, in many cases, cost less overall than the associated outpatient care required with early discharge.  “Given the stiff penalties imposed under the Affordable Care Act, hospitals are implementing a variety of approaches to aggressively reduce readmission rates, most commonly involving outpatient care,” says Ann P. Bartel, Ph.D., professor of finance & economics at Columbia Business School, and one of the study’s researchers.  “While some types of outpatient interventions can be effective, our study shows that hospitals should consider keeping some of their patients in the hospital longer to better control patient care, reduce readmissions and ensure fewer deaths.”

Why Does One Extra Day Matter?

The big question following the study was, Why does one extra day make such a difference? Bartel has a few suggestions. For one, she says, and this is based on speculation with conversations she had with hospital staff, the patient is in a more stable condition by the time he or she leaves. Another factor could be that the nurses have more time to explain to patients what they should do at home in terms of medications, as well as being able to get them to take the proper steps when they get home to help the chances of not being readmitted.

What’s more, Bartel and her colleagues found that the premature discharges are essentially occurring when the patient’s stay is bumped up against a weekend. For example, take patients who were admitted on Sundays or Mondays and typically require about five days of care for congestive heart failure, for example, as that’s what the protocol calls for, she explains. “We find that there is a big spike of discharges on Fridays because hospitals want to get patients out by the weekend since they are shorter staffed and services are not provided as much on weekends. If a person has been there four days, hospitals won’t keep them until the following Monday, as that becomes too many days. So they send them home a half day or day early.” Premature discharge isn’t in the patient’s interest either, Bartel adds, as no one wants to be readmitted within 30 days.

Bartel thinks that there is no single right way to reduce avoidable readmissions, but a combination “hybrid program” of keeping patients a day longer as well as post-discharge care is the best route to take. “Hospitals are not exactly sure what’s causing the high number of readmissions. The focus has more been on the outpatient management programs—that’s where most of the attention is devoted, and those programs have gotten a lot of press, especially from Medicare advantage programs that will include it as part of their care package for Medicare patients,” she says.

And while it’s good to have these outpatient management programs, you need to think there could be another way, perhaps a more cost effective way, to reduce readmissions, she continues. “We don’t want to disparage the outpatient management programs at all, but there could be something else that hospitals should consider. Maybe there is a more attractive way. That was our hope, that this becomes eye-opening for hospital administrators.”