Lat­est read­mis­sion study shows progress has stalled

With rates static, some won­der if fo­cus helps qual­ity

Modern Healthcare - - MODERN HEALTHCARE - Jes­sica Zig­mond

Af­ter a national re­port last week showed stag­nant progress in hos­pi­tal read­mis­sion rates, some providers ques­tioned if the cur­rent national fo­cus on this mea­sure­ment will ac­tu­ally yield the bet­ter qual­ity that pol­i­cy­mak­ers ex­pect.

For the study— Af­ter Hos­pi­tal­iza­tion: A Dart­mouth At­las Re­port on Post-acute Care for Medi­care Ben­e­fi­cia­ries— re­searchers ex­am­ined the records of more than 10.7 mil­lion hos­pi­tal dis­charges for two pe­ri­ods: July 2003 through June 2004, and July 2008 through June 2009. The find­ings showed lit­tle change in U.S. 30day read­mis­sion rates, re­gard­less of the cause of the ini­tial hos­pi­tal­iza­tion. Sur­gi­cal read­mis­sion rates were 12.7% in both 2004 and 2009, while med­i­cal read­mis­sion rates in­creased slightly to a rate of 16.1% in 2009, ver­sus 15.9% in 2004. (For more on read­mis­sion rates, see p. 32.)

The study comes at a time when providers are ready­ing for 2013, when they face a pay­ment penalty for ex­ces­sive read­mis­sions (em­bed­ded in last year’s Pa­tient Pro­tec­tion and Af­ford­able Care Act) of as much as 1% of their to­tal Medi­care billing, ac­cord­ing to Nancy Foster, vice pres­i­dent for qual­ity and pa­tient safety pol­icy at the Amer­i­can Hos­pi­tal As­so­ci­a­tion. That num­ber will climb to 2% in 2014 and 3% in 2015.

“Gen­er­ally, dur­ing this time pe­riod, this is re­ally a static prob­lem,” Dr. David Good­man, the study’s lead author and co-prin­ci­pal in­ves­ti­ga­tor for the Dart­mouth At­las Project, said dur­ing a call with re­porters last week. “Although there was a vari­a­tion by re­gion in read­mis­sion rates, there is no place that stands out as hav­ing low read­mis­sion rates.”

De­spite the over­all slow im­prove­ment rate, some hos­pi­tals showed no­table ad­vances, such as the Univer­sity of Michi­gan Hos­pi­tals and Health Cen­ters in Ann Ar­bor, where the rate de­clined to 17.4% in 2009 from 20% in 2004.

The leader of the 859-bed Michi­gan hos­pi­tal ac­knowl­edged that read­mis­sion rates are one piece of a broader qual­ity spec­trum and may not be the be-all-and-end-all that some in­dus­try lead­ers an­tic­i­pate. “First of all, it’s hard work and we’re prob­a­bly just scratch­ing the sur­face, as is ev­ery­one else,” said CEO Doug Strong. “It may prove that read­mis­sions is not the golden nugget ev­ery­one is af­ter.”

As providers work to im­prove qual­ity and ef­fi­ciency si­mul­ta­ne­ously, Strong said, the con­cept of read­mis­sions is seen as a “proxy” for both. “Our or­ga­ni­za­tion treats very sick pa­tients, many of whom need to be read­mit­ted. It’s not nec­es­sar­ily a med­i­cal er­ror,” he said. “That’s why I call it a proxy. Time will tell. The mea­sure­ment of what is ‘qual­ity’ and what is ‘ef­fi­ciency’ is an ever-chang­ing game right now.”

Strong cited a strong con­nec­tion be­tween in­pa­tient and out­pa­tient care as a pri­mary rea­son for the Univer­sity of Michi­gan Hos­pi­tals’ bet­ter rates, and he high­lighted ex­am­ples of suc­cess­ful pro­grams. One in­cludes hav­ing a solid dis­charge strat­egy that en­sures pa­tients have a clinic ap­point­ment sched­uled when they leave. If a pa­tient is un­able to sched­ule an

ap­point­ment with his or her reg­u­lar doc­tor, then the Univer­sity of Michi­gan will work to sched­ule a clinic ap­point­ment.

“Hav­ing a clinic ap­point­ment af­ter dis­charge ap­pears to be one of the most im­por­tant el­e­ments of suc­cess,” Strong said. He also said some of the im­prove­ment can be at­trib­uted to bet­ter “med­i­ca­tion rec­on­cil­i­a­tion” for pa­tients who leave the hos­pi­tal with a va­ri­ety of med­i­ca­tions, as well as a ro­bust health in­for­ma­tion tech­nol­ogy sys­tem, which in­cludes chronic-care reg­istries, that has helped clin­i­cians pro­vid­ing am­bu­la­tory ser­vices. Un­der a suba­cute-care pro­gram, mean­while, Univer­sity of Michi­gan ge­ri­a­tri­cians work full time in sev­eral un­af­fil­i­ated nurs­ing homes.

Wil­liam Van Slyke, vice pres­i­dent of com­mu­ni­ca­tions and pub­lic re­la­tions at the Health­care As­so­ci­a­tion of New York State, echoed Strong’s com­ments that time will judge if hos­pi­tal read­mis­sion rates will be as im­por­tant a pre­dic­tor of qual­ity as some think it will be.

“There is a huge el­e­ment of ex­per­i­men­ta­tion here,” Van Slyke said. “I think in some broad ways it par­al­lels pre­ven­tive care,” he said, re­fer­ring to the idea that pre­ven­tive-care pro­grams can re­duce health­care costs. “There have been stud­ies that say pre­ven­tive care doesn’t re­duce long-term ex­pen­di­tures,” he added. “A lot of this is like a jack-in-the-box. Ev­ery­one is work­ing hard to turn that crank, and we’re not sure what’s go­ing to pop out.”

Roughly 273,600 pa­tients landed back in New York hos­pi­tals within 30 days af­ter leav­ing, for a to­tal cost of $3.7 bil­lion, ac­cord­ing to a study of 2008 fig­ures pub­lished re­cently by the New York State Health Foun­da­tion, a pri­vate not-for-profit or­ga­ni­za­tion. Com­pli­ca­tions from in­fec­tions ac­counted for 26.5% of the read­mis­sions and 35% of the cost, or $1.3 bil­lion, the study said.

And a strained re­im­burse­ment environment just adds to the prob­lem, Van Slyke said, adding that the state of New York has seen hos­pi­tal in­pa­tient rates cut by bil­lions—in­clud­ing about $15 bil­lion over 10 years as part of the health­care re­form law, and nearly $6 bil­lion in cuts to Med­i­caid in the last 3½ years. “The in­fra­struc­ture and re­sources for post-dis­charge ser­vices is vir­tu­ally un­der as­sault.”

Mean­while, the AHA’s Foster said the Dart­mouth re­port’s study pe­riod came just as the in­dus­try be­gan to take a se­ri­ous in­ter­est in hos­pi­tal read­mis­sion rates. The start­ing point was Au­gust 2008, when data on read­mis­sions first ap­peared on HHS’ Hos­pi­tal Com­pare web­site. “Be­cause these are com­plex prob­lems, I would not have ex­pected to see much im­prove­ment in 2009,” Foster said. “We need the data to catch up with what we’ve been en­gaged in.”

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