Slowing the Revolving Door
Some facilities are reporting success with various approaches to curb hospital readmissions.
“t’s hard to embrace a 30-day readmission I window as an appropriate quality measure when the centers at risk are the centers that need the resources the most.”
• Einstein Medical Center in Philadelphia reduced 30-day readmission rate by 50% with a discharge program that focuses on medication compliance.
(Source: MEDCITY News, May 5)
• The American Hospital Association finds facilities participating in the CMS’ Hospital Engagement Network program lowered rates of readmission by 14% over 12 months, generating $100 million in savings. (Source: AHA, April 28) • Advocare, an independent physicians group, cuts readmissions via daily phone calls from care coordinators to patients. Its contract with Horizon Blue Cross Blue Shield of New Jersey contains a financial incentive, and practices in its patient-centered medical home program are spending less than those that do not use the model. (Source: MEDCity
News, May 19)
with outpatient providers. Hospitals have responded to the intense interest. Recently, Bradley et al. reported the results of a survey to describe the practices employed by hospitals enrolled in the Hospital to Home (H2H) quality improvement initiative to reduce readmissions for HF or acute MI.1 The initiative, organized by the ACC and the Institute for Healthcare Improvement (IHI), is a rich resource of information and tools to reduce readmission. In the recent survey, the response rate of 90.4% reflects the strong motivation of the participating hospitals and 87% of responding facilities had a quality improvement team. The hospitals tracked a variety of metrics and employed various approaches for medication reconciliation and discharge planning. Clearly, hospitals are investing significant resources for quality improvement and their practices are diverse.
So, Have We Made Any Progress?
Hospital readmission rates for Medicare fee-forservice beneficiaries significantly declined in 2012. Compared to the 19% rate for 30-day all-cause readmission seen for 2007 to 2011, the monthly readmission rate dropped to a low of 18% in October 2012 and averaged 18.4% for the year.2 An analysis from Dartmouth Atlas revealed similarly stagnant levels of readmission rates in recent years (TABLE 1). With so much effort, both punitive and rewarding, is a change of only a six-tenth of one percentTABLE 1 Change in 30-Day Readmission
age point worth the effort? Said Ashish Jha, MD, MPH, of Harvard School of Public Health: “Either we have no idea how to really improve readmissions, or most of the readmissions are not preventable and the efforts being put on it are not useful.” Put another way, in a commentary in JACC, Drs. Butler and Kalogeropoulos believe in the current environment, policy trumps science.3 Hospitals are being compelled to adopt a variety of strategies to reduce HF readmissions with little evidence to justify the enormous resources being expended on this effort. Well, maybe it’s an issue of guideline adherence. Maybe the best centers do better. Consider recent data from the American Heart Association’s Get With The Guidelines Program for HF (GWTGHF).4 Investigators compared hospitals enrolled in GWTG-HF from 2006 to 2007 with other hospitals using data on four process measures of HF care, five noncardiac process measures, risk-adjusted 30-day mortality, and 30-day all-cause readmission after an HF hospitalization, as reported by CMS. While hospitals enrolled in the GTWG-HF program demonstrated better processes of care than other hospitals, there were few clinically important differences in outcomes. After adjusting for hospital characteristics, 30-day mortality rates were no different (p = 0.45), although 30-day readmission was slightly lower for GWTG hospitals (-0.33%; p = 0.002).
• A collaborative that includes 21 San Francisco Bay Area hospitals has reduced the number of discharged patients readmitted to local hospitals by 11%, which represents about 3,300 hospitalizations and saves an estimated $32 million in medical costs. The effort focuses on “support, information, and a seamless handoff to the next provider as they leave the hospital.” (Source: Gordon and Betty
Moore Foundation, May 23)
Searching for a Better Measure
Former president of the American Heart Association, Clyde W. Yancy, MD, coauthored that paper and is now asking, ??