Reducing hospital readmissions from the emergency department

All of the focus that CMS is putting on hospital readmissions via the Readmissions Reduction Program, and the financial penalties that readmissions can generate, is causing hospital administrators to look to the emergency department and emergency physicians to intervene and resolve the issues that interrupt recovery for post-hospitalization patients.

In today’s world of budget-constrained financing of government health care programs and narrow hospital margins, the question of how best to mitigate the need for readmission is as uncertain as it is important. Some recent studies cast a bit of light on the question, and bloggers like Jordan Rao in the Incidental Economist have taken note. In this post, Rao notes that “readmissions are down … to what extent can that be explained by an increase in ED visits that don’t result in an admission?”

Reducing hospital readmissions from the emergency department

In the same blog, Austin Frakt questions whether the trend is really a reflection of better care or of gaming the measure, or both. Certainly, aggressive ED intervention or observation care can fend-off the need for inpatient readmission; but I can tell you from the experience of a family member who bounced from hospital to ED to SNF to ED to SNF to ED until definitive surgical care was finally provided, that preventing readmissions in this way does not necessarily imply better care.

A recent study of 15,519 inpatient discharges from a large safety net hospital published in the Annals of Emergency Medicine concluded that, “Excluding a return to the ED misses more than 50% of all returns to the acute level of care after discharge.”

What happens if Medicare decides, as seems inevitable, to count and ding hospitals for ED visits within 30 or 60 days of hospital discharge (presumably for issues related to or precipitated by the inpatient stay)?  Will this new accounting measure suddenly cause hospital administrators to shift the role of readmission-blocker from the ED to other services, and likewise reallocate resources like care coordinators and social services staff that may have been moved into the ED to assist in this role? It seems like the regulatory tail may be wagging the health care best-practice dog; and the evidence base for the economic value of these incentive/penalty based regulatory initiatives is very lean.

In fact, the cost-effectiveness of all sorts of care management tools that are being employed to curtail readmissions is still uncertain. There is even a question as to the effectiveness of community health worker intervention on health outcomes and resource utilization, as related in a 2013 report by the New England Comparative Effectiveness Public Advisory Council on Community Health Workers in New England and shown in the following graphic.

Reducing hospital readmissions from the emergency department

Given that the rate of readmissions seems to be significantly dependent on the socio-economic status of the patient, is it fair to disproportionately penalize safety-net hospitals for circumstances that may be beyond the control of these hospitals, even when they invest in community care resources and close post-discharge follow-up? I suspect that the most cost-effective approaches to preventing readmissions are those that are executed during the hospitalization, and are tailored to the specifics of the patient’s health care and social services needs, and to the nature of care provided.

I would argue that trying to prevent readmissions post hoc may or may not lead to better inpatient care and post-operative outcomes, even though it seems intuitive that such a reduction should save health care expenditures (given the costs of hospital care).

However, if by enhancing recognition of the role of EDs and emergency physicians and staff in circumventing readmissions, the Readmission Reduction Program has encouraged hospitals to add discharge planning, social services, and care coordination staff and resources into the emergency department, I am all for it. These resources have, for far too long, been limited or absent from most EDs, to the detriment of many of the patients treated there.

Myles Riner is an emergency physician who blogs at The Fickle Finger.

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