Is the hospital readmission rate a measure of quality?

Unplanned readmissions to the hospital have been the focus of much attention in recent years for obvious reasons. First, they are relatively easy to measure using administrative claims data. Second, like all inpatient hospitalizations, they cost a lot of money–and are therefore a target for reducing spending. Third, they are a proxy for quality of care, as at least some portion of them are likely avoidable if the hospital does its job well. On this last point, many disagree, citing the lack of continuity of care that exists post-discharge as a major source of readmissions. According to the folks in this camp, the patients themselves and their primary care physicians–not the hospital–are to blame for many of the unexpected returns to the hospital.

While this debate rages on, however, the federal government is taking action. Since 2009 they have published data on hospital quality using the Hospital Compare website, so that the public can be better informed. Then, starting last October, readmission rates for three conditions (heart attack, congestive heart failure, and pneumonia) were tracked, and hospitals with higher than expected rates were subjected to a reduction in Medicare reimbursement.

But a recent study from Matthew Press and colleagues in the June issue of Health Affairs finds that hospital readmission rates may not be such a good indicator of hospital quality after all. First, they found that across all hospitals, readmission rates for heart attack ranged from a low of 15.3% to a high of 25.6%. When they divided the hospitals up into quartiles, they found that only 1.7 percentage points separated the bottom 25% from the top 25%. Then, not surprisingly given the limited distance between the groups, they found that in just two years, many of those in the best performing group moved into the worst performing group and vice versa. Part of the explanation is what statisticians and econometricians call “regression to the mean.” In short, if you’re at the top of the pack, it is statistically more likely that you will move down than move up, just because you’ve got much more room to move in one direction than the other. The same is true in the reverse for the low performers. The investigators also found that, with few exceptions (e.g., teaching status), risk-standardized readmission rates were not correlated with other measures of hospital quality.

So what does this mean? Well, the authors suggest, there could be quite a few problems with policies that rely heavily on readmission rates alone as an indicator of hospital quality. Instead, they argue that other measures should be considered in addition to readmission rates when comparing hospital quality and that it is important to take regression to the mean into account by adjusting accordingly. In short, when it comes to measuring hospital quality, the more ways in which it is measured, the better.

Brad Wright is an assistant professor of health management and policy who blogs at Wright on Health.

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  • Guest

    This is why the hospitals that cherry pick its patients and avoid the sickest/least educated/least affluent patients have better quality scores. The government is way too stupid and slow to realize that their measures of quality will worsen the quality of health care for most Americans. Who cares though? Government officials will always have fine health care and are insulated from the problems that might face the rest of us peons.

    Don’t get sick. If you get sick, do it in another country where people are actually valued more than profit margins.

    • usvietnamvet

      Great points. So how do we change things?

      • Guest

        In my opinion, a 2 tier system. Something for everyone regardless of ability to pay. Better quality and speed for those who can.

        Keep very basic governmental standards. Move away from these private organizations like JCAHO that collect huge sums of money to give their stamp of approval. We need to weed out private enterprises that are profiting from health care. This includes insurance companies, pharmaceutical companies, etc. The only profits in health care should go to actual practitioners, not nameless faceless corporations that are doing nothing but driving up cost.

        Government set prices for everything.

        Take the massive profit and bureaucracy out of health care. Respect that patients are humans and not “clients.”

  • usvietnamvet

    It misses the fact that many patients are discharged too early and the medical records are doctored with lies. This happened to my MIL after her hip replacement. she was sick with diarrhea and hadn’t left the bed yet they said she had walked the length of the corridor several times. She was transferred to a rehab facility when she should have still been in the hospital.

  • Steven Reznick

    Elderly people with chronic multi- system disease who are on multiple medicines from multiple doctors and who can change the care plan despite the best efforts of the doctors, home health or SNF nurses , therapists and concerned family members are hard to keep out of the ER and hospital. Many who follow the care plan perfectly are frail with limited health reserve bounce back and forth between outpatient care and inpatient care despite chronic care outpatient programs and the best of care. If we add to that the premature discharges by hospitalists who do not know the patient and aggressive case managers looking to buff the hospitals bottom line and scorecard and you set up a large number of readmissions. Many are very hard to prevent. The government can look and punish all it wants. The fact is that as the elderly survive and move towards their last few years of life their disabilities increase and the chance of ending back up at the hospital increases. Readmission rate is one more attempt to quantify something that is tough to identify and define , quality

    • usvietnamvet

      Totally correct.

  • Medical Revolt

    In my experience many of the re-admissions are due to over worked and over extended nursing home physicians who do not have the time to see patient’s with a complaint so they send them to the ER for that evaluation. Then you have a elderly patient with many medical problems being seen by an overwhelmed ER physician who recommends admission. I feel if we went to a system where a physician was assigned to a nursing home to care for all the patients that physician would know them better and would be MUCH more likely to be onsite to do an in person evaluation. However, no doubt some re admissions are the fault of the hospital and the physicians who cared for them there.

    • heartdoc345

      In many cases the ER physician is not overwhelmed. He sees an elderly complicated patient, and sees nothing but the downside of possible malpractice if he doesn’t admit, with really minimal incentive to send the patient home

    • T H

      As one of the overwhelmed, the Nursing Home doc NEVER actually sees the patient before they are sent in. When I do send them back to the NH, they just get sent right back with a different but related complaint. And you’re right, HeartDoc, there is minimal incentive: the Nursing Home doc has no problem at all not going in to see their patient. Just like your answering machine at your practice probably says, “If you feel this is an emergency, call 911 or proceed to the nearest Emergency Room.”

      • heartdoc345

        Very true. I hate to admit it, but my practice is to blame as well.

        More effective phone triage would save a lot of ER visits and hospitalizations. But unless someone pays for better phone triage… I’m fortunate to have a very good triage nurse who can appropriately field many calls a day, but there are only so many hours she can work. And it’s hard finding a nurse that good.

        Probably the most frustrating thing is when a patient (already known not to have coronary disease) is being driven to an appointment with my clinic, has chest pain on the way, so ends up in the ER – and through a variety of system problems (in no way do I mean this is the emergency dept’s fault) “misses” their outpatient appointment for an echo or other testing we had arranged months ago, gets admitted, usually triaged to a different cardiologist, and then gets the testing I had ordered several days later (musculoskeletal pain in an Amish guy with valve disease who just needed chronic surveillance and acute reassurance).

        I know I don’t have all the right answers. But when the path of least resistance is for the nursing home, pcp, or cardiologist to send pts to the ED, and for the ED to admit, combined with the pressure to keep hospital stays as short as possible, it’s no wonder re-admission occurs so frequently.

        I work hard to keep my patients out of the ED and to communicate with the ED when patients (often very chronically ill) are at their baseline but I’m only one person. For example, an end-stage patient with severe pulmonary hypertension, already maxed out on Flolan and a large baseline oxygen requirement is unlikely to ever be sent home from the ED – even if they were just in the hospital with no real benefit of hospitalization with rate exceptions.

        • T H

          The safety net is thin and stretched… and I (for one) appreciate any Primary Care or Specialist Physicians who work hard to keep patients out of the ED.

  • Thomas Pane

    Using readmission rates as a metric is tricky. A lot of factors affect readmissions, including the patient’s support network, age and co-morbidities. All of these and more would have to be factored in to make fair and useful conclusions. Without that analysis, its a blunt tool that isn’t likely to achieve the desired results.

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