QUAL­ITY: Ex­perts say ini­tia­tives not yet re­flected in read­mis­sion-rates study

Lat­est ini­tia­tives not yet re­flected in read­mis­sion-rate study: ex­perts

Modern Healthcare - - NEWS - Mau­reen Mckinney

It’s all about lo­ca­tion. A Medi­care pa­tient dis­charged af­ter surgery in Bend, Ore., has a 7.6% chance of end­ing up back in the hospi­tal within 30 days. But if that pa­tient calls the Bronx in New York City home, the like­li­hood that he or she will be read­mit­ted more than dou­bles, jump­ing to 18.3%.

De­spite ramped up fed­eral over­sight, greater aware­ness of the prob­lem and a host of not-for-profit- and provider-led ini­tia­tives aimed at smooth­ing care tran­si­tions and im­prov­ing ac­cess to post-acute and pri­mary care, read­mis­sion rates still vary widely from one re­gion of the coun­try to an­other.

That’s ac­cord­ing to a report from the Washington-based Robert Wood John­son Foun­da­tion, con­tain­ing the most re­cent anal­y­sis on the topic from the Dart­mouth Atlas of Health Care, a long-run­ning project that uses Medi­care data to ex­am­ine vari­a­tions in the way that health­care is pro­vided across the coun­try. The lat­est data, which echo other re­cent re­ports point­ing to stag­nant read­mis­sion rates, are prompt­ing con­cern among providers who won­der whether their preven­tion ef­forts will pay off or if the prob­lem of read­mis­sions is an in­tractable one.

Some clin­i­cians and ex­perts, how­ever, are ar­gu­ing that the report doesn’t show the fruits of re­cently launched ef­forts to pre­vent read­mis­sions. They ad­vo­cate stay­ing the course on cur­rent im­prove­ment ini­tia­tives, and they con­tend that fu­ture data will show bet­ter tran­si­tions and fewer pre­ventable re­hos­pi­tal­iza­tions.

The pat­terns re­vealed in ear­lier Dart­mouth Atlas re­ports per­sisted in this lat­est anal­y­sis. Com­mu­ni­ties such as Detroit and Chicago had high 30-day read­mis­sion rates fol­low­ing med­i­cal dis­charge—17.8% and 17.7%—while the read­mis­sion rate in Og­den, Utah, was a rel­a­tively low 11.4%. The spread be­tween high and low per­form­ers was even greater fol­low­ing sur­gi­cal dis­charges, with read­mis­sion rates as low as 8.4% and 9% in Boise, Idaho, and Santa Bar­bara, Calif., and as high as 17.4% in White Plains, N.Y.

The report also showed lit­tle trac­tion in im­prov­ing the over­all na­tional read­mis­sion rate, which re­mained vir­tu­ally the same in 2010, at 15.9%, as it was in 2004, when the Dart­mouth Atlas be­gan an­a­lyz­ing the data.

The find­ings come just months af­ter the fed­eral government launched its read­mis­sions re­duc­tion pro­gram, which im­poses fi­nan­cial penal­ties rang­ing from 0.01% to 1% on hos­pi­tals with higher-than-ex­pected read­mis­sion rates. Those penal­ties are sched­uled to jump to 2% in 2014 and 3% in 2015.

“I think the ma­jor take­away is that for a long-rec­og­nized prob­lem, we haven’t made much progress and we have a very long way to go,” said Dr. David Good­man, pro­fes­sor of pe­di­atrics at Dart­mouth Med­i­cal School, Hanover, N.H., and di­rec­tor of the Cen­ter for Health Pol­icy Re­search at the Dart­mouth In­sti­tute. Good­man, co-prin­ci­pal in­ves­ti­ga­tor of the Dart­mouth Atlas, also co-au­thored the newly re­leased read­mis­sions report.

The fac­tors that cause read­mis­sions are com­plex, Good­man said, but the report did show that re­gions with high hospi­tal uti­liza­tion rates had higher read­mis­sion rates, sug­gest­ing that those ar­eas are more de­pen­dent on hospi­tal-based care.

“A bed built is a bed filled,” Good­man said. “If we want to make sure pa­tients stay out of the hospi­tal, we need to make sure we’re not overde­vel­op­ing hospi­tal and ICU beds. We want to change in­vest­ments to­ward com­mu­nity-based care as much as pos­si­ble.”

The lack of progress de­tailed in the report may ap­pear bleak, but Dr. Eric Cole­man, a ge­ri­a­tri­cian and head of the di­vi­sion of health­care pol­icy and re­search at the Univer­sity of Colorado at Aurora, urges op­ti­mism. Cole­man, who also di­rects the Care Tran­si­tions Pro­gram, ar­gued that 2010, the 12-month pe­riod an­a­lyzed for the report, marked the launch of many of the pro­grams now in place to ad­dress avoid­able read­mis­sions.

“The report did not cap­ture what we have seen in terms of in­no­va­tions over the last few years,” he said. For in­stance, Cole­man said, Medi­care qual­ity im­prove­ment or­ga­ni­za­tions, which con­tract with the CMS to lead statewide im­prove­ment ini­tia­tives, have seen mea­sur­able progress in re­duc­ing read­mis­sions. Ac­cord­ing to a Jan­uary study in the Jour­nal of the Amer­i­can Med­i­cal As­so­ci­a­tion, com­mu­ni­ties with QIO-led care-tran­si­tion pro­grams saw read­mis­sion rates fall 5.1% af­ter im­ple­men­ta­tion, com­pared with a 2.1% drop in 50 com­par­i­son com­mu­ni­ties.

Those QIOs are work­ing with more than 400 com­mu­ni­ties across the coun­try, he said. He also cited the 82 com­mu­ni­ties cur­rently par­tic­i­pat­ing in the CMS’ Com­mu­nity-Based Care Tran­si­tions Pro­gram, which was cre­ated by the health­care re­form law and funded through HHS’ $1 bil­lion Part­ner­ship for Pa­tients. Cole­man’s own pro­gram has part­nered with more than 800 providers and or­ga­ni­za­tions to im­prove tran­si­tions of care, he added.

Cole­man ac­knowl­edged that the CMS’ penalty pro­gram is a hard pill for providers to swal­low, par­tic­u­larly when re­searchers ar­gue that many of the rea­sons for read­mis­sions are out­side of hos­pi­tals’ con­trol. Still, he said he had seen a “quantum leap” in hos­pi­tals’ at­ten­tion to the is­sue since the pro­gram launched in Oc­to­ber 2012—a mo­men­tum he hopes will con­tinue.

“I don’t want this report to take the wind out of our sails,” said Cole­man, whose work em­pha­sizes the im­por­tance of pa­tient and fam­ily en­gage­ment. “I think the mes­sage should be, ‘Stay tuned and don’t get dis­cour­aged.’ The report is just a good re­minder that what we were do­ing from 2004 to 2010—which was not a whole lot—didn’t really work.”

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