The Same Readmissions Tune Keeps Playing. Not A Pleasant Melody.

Of note, a very nice commentary in today’s NEJM regarding our inability to control 30-day readmissions, and the justifications (or lack thereof) for its continued use as a metric in judging inpatient quality.  I suggest everyone who works on the front lines read it:

[…]Although a focus on readmissions may have good face validity, we believe that policymakers’ emphasis on 30-day readmissions is misguided, for three reasons. First, the metric itself is problematic: only a small proportion of readmissions at 30 days after initial discharge are probably preventable, and much of what drives hospital readmission rates are patient- and community-level factors that are well outside the hospital’s control. Furthermore, it is unclear whether readmissions always reflect poor quality: high readmission rates can be the result of low mortality rates or good access to hospital care. Second, although improving discharge planning and care coordination is a laudable goal, there are better, more targeted policies that are more likely to be effective in achieving it. Finally, because hospitals are expending so much energy on reducing readmissions, they have probably forgone quality-improvement efforts related to more urgent issues, such as patient safety. An evidence-based, holistic approach to quality improvement is far more likely to achieve what policymakers, clinicians, and the public all want: better care at lower cost.

[…] The growing body of evidence suggests that the primary drivers of variability in 30-day readmission rates are the composition of a hospital’s patient population3 and the resources of the community in which it is located — factors that are difficult for hospitals to change. We know that some of the most important drivers of readmissions are mental illness, poor social support, and poverty, which are often deeply ingrained. Therefore, readmission rates have weak signaling value for identifying high-quality hospitals. The current scheme to penalize hospitals with high readmission rates is likely to disproportionately affect institutions that care for poor or minority populations or those with a high burden of mental illness.

The drumbeat does seem to be getting louder, and it’s good to see a well-articulated piece stating what most of us already know, mainly, there are too many readmit elements beyond our province of control.  It’s nice to blame “the system,” or the “other guy” occasionally, but in this instance, I am afraid it is the truth.  The hospital as locus and its “failure” to deliver is not the solitary root cause for ER round trips.

When care is integrated and we repurpose how hospitals function in the community and we shift the resources, then yes.  Until that day, keep yearning, and those who think otherwise need to visit their local community hospital.  They will get an education.

PS–This is not the first well-done commentary piece on the subject.  Here, a link to the recent Annals and JAMA reviews on risks and prevention strategies on readmits.  Both had less than encouraging conclusions.

Brad Flansbaum

Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education.

Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates.

Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University.

He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.

2 Comments

  1. […] Posted 3/28/12 on The Hospitalist Leader […]

  2. Rebecca Coelius on April 3, 2012 at 9:04 pm

    Your point is a good one. I agree that these are flawed quality indicators for a hospital. However if we look beyond the paradigm of hospital as apex of a health system and responsible for solving the problem, it becomes a pretty great indicator for the system as a whole whose goal is to keep people healthy and spend as little as possible doing so.

    I think the real problem is that we measure these sort of inappropriate quality indicators and then slap the wrist of or reward the hospital, versus asking if perhaps the solutions lie elsewhere. (hiring and testing a bunch of home health nurses, telehealth, phone follow up, better access to primary care, self tracking apps, etc as solutions). I think its great that hospitalists have in many ways led in QI work, but it may have unnecessarily narrowed our focus on inpatient improvements.

Leave a Comment