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Single 30-Day Hospital Readmission Metric Fails to Reflect Changing Risk Factors
A new study from researchers at Beth Israel Deaconess Medical Center suggests that risk factors for readmission change significantly over the course of the 30 days following hospital discharge. Thirty-day hospital readmission rates have become a federal quality metric intended to reflect inpatient quality of care and unnecessary health-care utilization.
Published June 2 in the Annals of Internal Medicine, the research suggests that two distinct 8-day and 30-day readmission rates would serve as better inpatient quality measurements and would better inform readmission prevention strategies.
A review of more than 13,000 discharges involving more than 8,000 patients in 2009 and 2010 found that early readmissions (0 to 7 days post-discharge) were associated with markers of the acute illness managed during initial hospitalization. A patient’s chronic illness burden was more important in predicting late readmissions (8 to 30 days post-discharge).
“Our research found that risk factors for readmission evolved during the first 30 days following hospital discharge,” said lead author Kelly L. Graham, MD, MPH. “Readmissions in the first week were more highly associated with factors related to the initial hospitalization than later readmissions. These findings suggest that the standard 30-day metric does not accurately reflect hospitals’ accountability for readmissions.”
The authors also noted that other research has shown that hospitals that strictly follow evidence-based care standards do not necessarily have the lowest readmission rates and that readmission rates do not serve as a benchmark for inpatient mortality. Under the Patient Protection and Affordable Care Act, the Centers for Medicare & Medicaid Services may reduce payments to acute-care hospitals deemed to have excess readmissions within 30 days of discharge.
The study also found that discharges between 8 a.m. and 12:59 p.m. were associated with lower odds of an early readmission. The authors noted that discharge in the first part of the day likely gave patients and their families more time to access community resources such as pharmacies and social supports, thereby reducing the likelihood of readmission.
The authors also found that social determinants of health are closely tied to readmissions, as they affect how patients access care. They evaluated the effect of barriers to health literacy on readmissions and found that they were associated with both early and late readmissions. A patient’s insurance status was also relevant among those readmitted in the late period; patients with unsupplemented Medicare or Medicaid were more likely to be readmitted 8 or more days after discharge.
“The growing movement toward accountable-care organizations and patient-centered medical homes may prove beneficial in preventing unnecessary hospital readmissions,” Graham said. “Patients discharged from the hospital need support from and teamwork among hospitalists, primary care physicians, nurse practitioners, visiting nurses, pharmacists, and others.”
The authors stressed that both hospital and outpatient settings need systems of care that closely monitor patients as they transition their medical care from the hospital team back to the primary care team. Post-discharge monitoring would better enable a team to make sure patients adhere to the detailed care plan designed by the hospital team, such as taking medications correctly and keeping follow-up appointments.
Source: Beth Israel Deaconess Medical Center; June 2, 2015.