30-day readmission measure fails to account for changing risk factors

Risk factors for readmissions change significantly over the course of the 30 days following hospital discharge, a new study shows, and therefore the current Medicare measure for readmissions doesn't accurately reflect the hospital's accountability for rehospitalizations.

Under the Affordable Care Act, the Centers for Medicare & Medicaid Services may reduce payments to acute care hospitals that have excess readmissions within 30 days of discharge. Last year it penalized more than 2,600 hospitals.

But the study, conducted by researchers at Boston's Beth Israel Deaconess Medical Center and published today in the Annals of Internal Medicine, indicates the federal measurement isn't fair because a patient's risk factors for readmission change during the 30 days post-discharge and many of them are beyond a hospital's control. The findings support claims by the American Hospital Association that hospitals aren't responsible for many readmission factors--such as socioeconomic status and lack of access to support systems.

Researchers analyzed approximately 13,000 discharges that involved more than 8,000 patients in 2009 and 2010. They found that early readmissions within seven days of discharge were associated with markers of the acute illness managed during the initial hospitalization. However, a patient's chronic illness was more of a factor in predicting later readmissions (eight to 30 days post discharge).

The findings call into question the accuracy of the 30-day federal quality benchmark for readmissions, which doesn't take these changing risk factors into account. The authors suggest two distinct measures--an eight-day and 30-day readmission metric--would serve as better inpatient quality measurements to help hospitals create successful readmission prevention strategies.

They also found that patients who are discharged between 8 a.m. and 12:59 p.m. had lower odds of early readmissions. Researchers said that the earlier discharge allows patients and their families to access community resources, such as pharmacies and social networks, reducing the likelihood of readmission.

Furthermore, the research found that social determinants of health, such as health literacy, were tied to early and late readmissions. Insurance status was most relevant to patients readmitted later in the 30-day cycle as patients with unsupplemented Medicare or Medicaid were more likely to return to the hospital eight or more days after discharge.

But the increase of accountable care organizations and patient-centered medical homes may help prevent unnecessary hospital readmissions, lead author Kelly L. Graham, M.D., a physician in the Division of General Medicine and Primary Care at BIDMC and an instructor in internal medicine at Harvard Medical School, said in the study announcement.

"Patients discharged from the hospital need support from and teamwork among hospitalists, primary care physicians, nurse practitioners, visiting nurses, pharmacists and others," she said.

The authors recommend that both hospital and outpatient settings create systems to closely monitor patients as they transition out of the hospital and back to their primary care providers. Post-discharge monitoring would help ensure that patients follow the hospital's detailed care plan, such as taking medications correctly and keeping follow-up appointments, study authors said.

To learn more:
- here's the study abstract
- read the announcement

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