Is it time to begin to rethink the current orthodoxy on avoidable readmissions? Or is it perhaps simply time to get more granular about the whole concept? The publication of new research on 30-day readmissions this week is providing everyone some food for thought on what elements in hospital readmissions are really significant when it comes to clinical and policy prescriptions. As we reported here, researchers at Beth Israel Deaconess Medical Center (BIDMC) in Boston have published a thought-provoking new study. After reviewing more than 13,000 discharges involving more than 8,000 patients in 2009, 2010, the BIDMC researchers found that most hospital readmissions that occurred between zero and seven days of discharge were caused by factors related to the initial hospitalization, and not related to patients’ existing chronic illnesses. Patients’ chronic illnesses were a factor only in rehospitalizations after eight to 30 days.
In a statement attached to the publication of the research results, Kelly L. Graham, M.D., a physician in the Division of General Medicine and Primary Care at BIDMC, said that “Our research found that risk factors for readmission evolved during the first 30 days following hospital discharge. Readmissions in the first week,” Dr. Graham said, “were more highly associated with factors related to the initial hospitalization than later readmissions. These findings suggest that the standard 30-day metric does not accurately reflect hospitals’ accountability for readmissions.” This is the second study within just a few months to question some of the current thinking—and policy—around readmissions. In February, researchers at the Chicago-based Northwestern Medicine and the American College of Surgeons released a study that found that only 5.7 percent of readmissions following inpatient surgery were triggered by care management issues. In fact, said Karl Y. Bilimoria, M.D., a surgical oncologist and vice chair for quality at Northwestern Memorial Hospital, “Our results… highlighted that many of the complications involved in readmissions, such as surgical-site infections, are already well-known and part of other CMS [Centers for Medicare & Medicaid Services] pay-for-performance programs, which means hospitals are effectively being penalized twice for the same complications.”
So, where do we go from here? As an industry, we are at the beginning, really, of a very, very long journey towards greater accountability and transparency in healthcare. And many of the clinical outcomes we’re using now are very primitive, really; they are proxies for deeper questions and issues. And these two studies point up some of the problems inherent in the early-stage outcomes measures that hospitals are being graded on. Specifically, if, as the BIDMC researchers found, rehospitalizations after a week or less reflect complications related to the initial admission, and therefore should probably not be penalized under the CMS readmissions reduction program, if those researchers’ analysis is correct. Meanwhile, many of the readmissions related to surgery are already being penalized through value-based purchasing programs, so, as the Northwestern Medicine researchers found, readmissions reduction penalties are actually doubly penalizing providers—in other words, over-penalizing them.
Now, it would be very easy to throw the proverbial baby out with the proverbial bathwater here. Do the findings of these two studies mean that CMS’s mandatory avoidable readmissions program is a fundamentally misguided enterprise? I don’t think so. Instead, these study results point to something else: the reality that our first-generation outcomes measures are inevitably going to have to give way to second- and third-generation measures, and beyond, as the U.S. healthcare system finds its way forward in this incredibly complex process of refinement, re-refinement, and re-re-refinement. But honestly, there’s no real way around any of this. Instead, what will help tremendously will be for more thought-leader clinicians, clinical informaticists, data analysts, and others, to wade into the deep end of the pool in this area and help to build better outcomes regimens, with suggestions that will influence policy—and the policymakers at the federal level who will be tasked with refining the avoidable readmissions reduction program over time. The same goes for senior medical management executives at the major private health plans. In the meantime, the more studies like these that are produced and published, frankly, the better. Because the weight of the evidence will be able to help guide healthcare policy. And with insights drawn from the real world of care delivery, those insights will inevitably be helpful to the entire industry, and to patients and communities.