Thirty-Day Readmissions: Truth and Consequences

From NCPA

Reducing hospital readmission rates has captured the imagination of U.S. policymakers because readmissions are common and costly, and at least in theory, a reasonable fraction of readmissions should be preventable, say researchers Karen E. Joynt and Ashish K. Jha.

To harness the potential savings of reducing readmissions, the Patient Protection and Affordable Care Act directed the Centers for Medicare and Medicaid Services to penalize hospitals with "worse than expected" 30-day readmission rates, thereby encouraging them to invest resources in lowering these rates.

However, according to the researchers, this policy focus is damaging and misguided, and unlikely to yield results that Congress is searching for.

• It is unclear whether readmissions always reflect poor quality -- having a low mortality rate or a close relationship with the community can raise readmission rates.
• Also, 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.
• The metric itself is problematic: only a small proportion of readmissions at 30 days after initial discharge are probably preventable, as the primary drivers of readmission rates are outside the control of the hospital.

This last point is perhaps the most crucial, as studies have consistently shown that much of the efforts that are put into reducing readmissions will prove unfruitful.

• A recent systematic review reported that on average just 27 percent of readmissions were preventable.
• Moreover, only 12 percent were deemed preventable in studies that used clinical data.
• Another study showed that although the total number of readmissions varied substantially among hospitals, the rate of preventable readmissions did not, suggesting that it was cause by factors beyond the hospitals' control.

Indeed, 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 population and the resources of the community in which it is located. Some of the most important drivers of readmissions are mental illness, poor social support and poverty, and these are factors most hospitals cannot change.

Source: Karen E. Joynt and Ashish K. Jha, "Thirty-Day Readmissions -- Truth and Consequences," New England Journal of Medicine, March 28, 2012.