Preventing hospital readmissions improves health, lowers cost

Hospitals may be able to reduce their rates of readmission by focusing their efforts on those that occur within seven days of discharge, according to a June article in the Annals of Internal Medicine co-authored by Christiana Care Health System Chief Transformational Officer Edmondo J. Robinson, M.D., MBA, FACP.

The study found that 36 percent of these early readmissions were preventable, compared with only 23 percent of the readmissions that occurred between eight and 30 days after discharge. The study provides evidence to suggest that the 30-day post-discharge window often used to assess hospitals’ readmission rates may be too long.

“Early readmissions are more often prevented by adequate treatment of clinical conditions,” said Dr. Robinson, who is also senior vice president, consumerism at Christiana Care and a Christiana Care Value Institute Scholar. “Later readmissions are more about the patient’s overall support system.”

The ability to tie specific hospital-based factors, such as determining the correct admitting diagnosis, to readmission can help hospitals identify the preventable readmissions under their control and prevent them, he said.

The prospective cohort study followed 822 adult patients from 10 American academic medical centers, including Christiana Hospital, between April 2012 and March 2013.

Broadly speaking, hospital readmission is seen as one of the ways to evaluate the quality of care a patient receives; returning to the hospital, this reasoning goes, is likely a consequence of the previous hospitalization.

But the typical 30-day window for defining a readmission — created by the Patient Protection and Affordable Care Act for the purpose of imposing financial penalties on hospitals with excessive readmissions — was not based on scientific evidence.

“It’s very clear that we don’t as hospitalists have control over what happens in the entire 30-day window,” Dr. Robinson said. “We feel confident seven days is much closer to a window of time in which an intervention in the hospital will decrease the likelihood of readmission.”

The study sought to break up that 30-day period into “early” readmissions, those seven days or fewer, and “late” readmission, those between eight and 30 days.

The study defined a readmission as preventable based on a scoring system implemented by adjudicators using a standard approach.

The goal of this designation was to identify as preventable those readmissions that are directly influenced by hospital factors, instead of outpatient care settings, end-of-life management and social determinants of health.

This is not Dr. Robinson’s first effort to study how and why readmissions occur. He was previously involved with research that surveyed physicians whose patients were readmitted within 30 days to ask them about the factors that led to the readmission and potential strategies for prevention. That work led to an article in JAMA in 2016.

Dr. Robinson helped to conceive and design the latest study from its early stages, helped to review and write the journal article and was the principal investigator for the Christiana Care site.

Bringing these findings home

Hospital readmissions are expensive, costing Medicare between $15 billion and $17 billion a year. Each readmission also represents a patient who has been hospitalized twice in a 30-day period, both a disruptive experience and a potential sign of overall declining health.

To a patient, there is little distinction between an early and late readmission.

“If you’re really looking at it from a perspective of what’s best for a patient, you should use hospital-based efforts to decrease early readmissions combined with ambulatory and community-based efforts for late readmissions,” Dr. Robinson said.

Christiana Care has created an award-winning care management program that identifies patients who are at risk and coordinates their care with a team that includes nurses, social workers, pharmacists and support staff.

The latest study findings can help Christiana Care further target its efforts to more precisely identify those readmissions that are preventable and address the factors associated with them.