Study Fills In Gaps about Decline in Hospital Readmissions

New research provides insight for policymakers designing strategies for reduction

Tuesday, December 27 2016

Reducing rates of patient readmissions to hospitals after they have been discharged has been a major healthcare policy focus, because readmissions drive up healthcare system costs and can be a sign of suboptimal patient care. In recent years, readmission rates have fallen nationally, strongly linked to an Affordable Care Act program that penalizes hospitals if they do not reduce readmissions in three target areas for Medicare patients: acute myocardial infarction (heart attack), heart failure, and pneumonia.

However, it hasn’t been clear whether these reductions have happened across the board or whether certain hospitals have been more likely to reduce readmissions rates than others. It is also unknown whether hospitals have focused on making reductions primarily in the three target areas—an important question for understanding why the policy worked.

Now a new study published today in the Journal of the American Medical Association by Leora Horwitz, MD, MHS, associate professor in the Department of Population Health at NYU School of Medicine, and colleagues at Yale University School of Medicine fills in gaps about why hospital readmissions rates declined from 2008-2012. The study finds that hospitals that suspected they would be penalized were likely to reduce readmissions for the program’s target conditions, whereas hospitals that didn’t expect penalties had no statistically significant reduction.

Hospitals were given advance access by the Center for Medicare & Medicaid Services to their performance data.

“Low performing hospitals appear to have proactively responded to the threat of penalties, likely because they were aware of their performance; higher-performing hospitals did not respond the same way, suggesting they felt less urgency to specifically improve for target conditions,” write lead author Dr. Nihar Desai, assistant professor of cardiology at Yale University School of Medicine, Dr. Horwitz, who is also director of the Center for Healthcare Innovation and Delivery Science at NYU School of Medicine, and their colleagues. The authors added that: “Policy makers considering penalty programs should thus consider whether the results on which they are based are available—ideally in advance of implementation—to the relevant stakeholders.” Moreover, hospitals that expected penalties focused efforts on those patients that were likely to generate a penalty rather than implementing a system-wide reduction strategy, suggesting that a policy focused instead on readmissions more broadly rather than three conditions in particular could have had greater impact.

The investigators looked at 48 million hospitalizations of 20 million Medicare beneficiaries with 8 million readmissions. Of the 3,497 hospitals studied, 63 percent or 2,214 hospitals received penalties, 37 percent of hospitals did not receive penalties. Penalized hospitals were larger, more likely to be teaching hospitals, and had a higher proportion of Medicare patients.

Readmissions declined an additional 1.2 percent a year for acute myocardial infarction, 1.3 percent for heart failure and 1.4 percent for pneumonia at penalty hospitals compared to non-penalty hospitals, until 2012. At that point readmission rates plateaued.

Other policies, such as public reporting of hospitals’ readmission numbers, have not led to changes in performance. The plateau in readmissions rates since 2012, regardless of penalty status, raises questions about whether additional reductions are possible, according to the authors.

The study was supported by the Agency for Healthcare Research and Quality, grant R01H5022882.