Why 30-Day Readmissions Are High
Once a month, a "dream team" of community and hospital physicians and nurses meets at the University of Connecticut, Farmington. Their goal: To improve the transition out of the hospital for patients with heart failure. Their progress: Since the group’s first meeting in 2008, the hospital’s 30-day, all-cause readmission rates for heart failure have fallen from 27% to less than 19%, according to figures tracked by the Connecticut Hospital Association.
"That’s a significant drop and puts the hospital below the state average of 25%. "We’re pretty proud of that," said Dr. Jason Ryan, a cardiologist and codirector of the Heart Failure Center at the university.
Dr. Ryan attributes the "dream team’s" successes to intensive patient education in the hospital, a mandatory follow-up visit with a physician at 7 days after discharge, and better communication between clinicians in the hospital and those in the community.
But possibly the biggest factor in their success has been physician commitment to keeping patients with preventable readmissions out of the hospital.
In the UConn program, the cardiologists have made a point of getting patients immediate clinic appointments to evaluate whether they are having a minor issue that can be dealt with in an outpatient setting or if they have a more serious concern that requires readmission to the hospital.
"Some of our patients call us with complaints that I could easily over the phone say, ‘Well, you need to go to the emergency room for that,’ " Dr. Ryan said. "If you’ve got a group of physicians who are not interested in this work, it’s very easy to send people to the emergency room."
The UConn program could end up being a model for other hospitals that are looking to reduce their readmission rates for heart failure and acute myocardial infarction ahead of financial penalties coming down the pike this fall from the Medicare program.
But can hospitals that serve diverse communities meaningfully enact such programs and expect similar successes?
And what will be the impact of the penalties on safety net hospitals that lack the money to undertake a major overhaul of their discharge and care coordination systems?
Even after the data are risk adjusted for their sicker patients, safety net hospitals could still end up with higher than average readmissions. If CMS penalizes them with lower reimbursements due to their excessive readmission rates, they could be left with even fewer resource to care for sicker patients.
Medicare Turns Up the Heat
Starting in October, the Centers for Medicare and Medicaid Services will begin cutting Medicare payments to hospitals whose acute MI and heart failure readmission rates are considered too high.
It’s still unclear exactly what the cutoff point will be. CMS will use readmission data from July 2008 through June 2011 to determine excessive rates and penalties for fiscal year 2013, which begins this October.
CMS is defining all-cause readmission as occurring when a patient is discharged from a hospital and then admitted to the same hospital or another acute care hospital within 30 days.
Recent, risk-adjusted data from CMS offer a glimpse of where the country is in terms of reducing readmission rates.
For acute MI, the national rate for 30-day all-cause readmissions has dropped slightly, going from 19.9% from 2006 through 2009 to 19.8% from 2007 through 2010. During the same time period, readmissions for heart failure rose slightly, creeping up from 24.5% to 24.8%.
The data show the similar trends for mortality during the two reporting periods. The acute MI rates fell from 16.2% to 15.9%, while heart failure mortality rose from 11.2% to 11.3%.
Blaming Length of Stay
A study published earlier this year paints a gloomy picture about how U.S. hospitals stack up against other countries in readmission for ST-elevation MI. The study found that 30-day readmission rates were on average 14.5% in the United States vs. 9.9% among the other countries studied (JAMA 2012;307:66-74). The study included patients in the United States, Canada, Australia, New Zealand, and 13 European countries.
At the same time, the median length of stay was shortest in the United States at 3 days. The longest median length of stay noted in the study was 8 days in Germany.
The study investigators pointed to the shorter length of stay in U.S. hospitals as a possible driver of the country’s higher rate of readmissions. But other experts say there are more complex factors at work, such as gaps in the discharge planning process and a lack of resources for patients once they leave the hospital.
