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Hospital readmission rates under the microscope
Although hospital readmission rates cost the health care system as much as $1.8 billion per year, there's no need for Canada to follow the United States' lead and impose penalties on facilities for failing to implement measures to reduce readmissions, Canadian experts say.
The incidence and causes of preventable readmissions are so unclear that measures to reduce readmission rates are premature, if not unwarranted, argues Dr. Carl van Walraven, senior scientist in the Clinical Epidemiology Program at the Ottawa Health Research Institute and associate professor in the Department of Epidemiology and Community Medicine at the University of Ottawa in Ontario.
"Before we start focusing on trying to address a statistic, we need to first truly understand the meaning of the statistic. If my hunch is correct that the vast, vast majority of readmissions are unavoidable, then coming up with policies and procedures to influence a statistic that has a very marginal association with quality of care is not in our best interest," he says.
The Canadian Institute for Health Information recently estimated that roughly 8.5% of patients are readmitted to hospital within 30 days (https://secure.cihi.ca/free_products/Readmission_to_acutecare_en.pdf). An estimated 9%–59% of those readmissions could be avoided by better identifying those most likely to return to hospital within short periods and improving the care they receive before and after discharge (www.cmaj.ca/lookup/doi/10.1503/cmaj.109-4248).
By contrast, an estimated 20% of Medicare (which provides health services to the elderly) patients in the United States are readmitted within 30 days, at a cost of US$12 billion per year, prompting American legislators to implement penalties on facilities if patients are readmitted to a hospital for heart failure, acute myocardial infarction or pneumonia within that 30-day period.
Under the Hospital Readmissions Reduction Program, which takes effect in October 2012, hospitals stand to lose up to 1% of their net inpatient Medicare payments if their readmissions are above an established baseline rate. The penalty cap will rise to 2% in 2014 and 3% in 2015.
If you see this sign twice in one month, you may be among the estimated 8.5% of Canadian patients who are readmitted to a hospital within 30 days of being discharged.
The level of penalty will be determined using a formula that calculates each hospital's "excess readmission ratio" relative to national average readmission rates from the period July 2008 to June 2011 (http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html/). Discharging hospitals will be penalized even if the patient is admitted to a different facility, but the formula does include an adjustment for demographic considerations, "comorbidities, and patient frailty."
The aim was to nudge hospitals into improving the quality of their care. To that end, the US Agency for Healthcare Research and Quality was asked to develop "readmission reduction practice recommendations."
Those included improving transitional care by following up with patients post-discharge and providing them with "comprehensive post-discharge instructions on medications, self-care, and symptom recognition and management," as well as the use of a hospital discharge program that "re-engineers the workflow process" (www.ahrq.gov/news/kt/red/readmissionslides/readslides-contents.htm).
But using readmission rates as an indicator of quality of care is a dubious proposition, van Walraven says in arguing against the need for similar measures in Canada.
"The key question is how strongly does a readmission to hospital reflect quality of care and how strongly does it just reflect a sick person," adds van Walraven, who concluded in a systematic review of 34 studies that measured the proportion of hospital readmissions classified as avoidable that there is "a lack of consensus regarding the methods necessary to judge whether readmissions are avoidable" (www.cmaj.ca/lookup/doi/10.1503/cmaj.101860). "All but three of the studies used subjective criteria to determine whether readmissions were avoidable," states the study, which concluded that "the true proportion of hospital readmissions that are potentially avoidable remains unclear."
Others argue that the solution to the problem of high hospital readmission rates lies in systemic reform.
Preventable readmissions are more likely a systems issue than the result of errors, says Dr. Irfan Dhalla, assistant professor in the Department of Medicine and Health Policy, Management and Evaluation at the University of Toronto in Ontario and scientist in the Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital. "If you had an integrated health system where primary care, home care, pharmacy and the hospital were all integrated, it probably would make sense to hold that integrated health system accountable in some manner for its readmission rates … but we don't have an integrated health care system; we have a fragmented health care system."
Canada's unintegrated system is poorly suited for treating patients with complex issues, Dhalla says. "We each operate in our own little silos and we do a very good job completing our own charts, but we don't share our information as readily as we might with all of the other people who are helping take care of an individual patient."
For its part, the Canadian Healthcare Association says the best course of action will only emerge from further research. "We really do need to continue to improve our data collection so we really can tell what the situation is," says Pamela Fralick, president and CEO of the association. "Can we eventually tease out what percentage of the readmissions are avoidable? That's the key question."
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