Study: Hospital Performance Can’t Be Fully Measured by Readmission Rates

By Jennifer Larson, contributor

June 14, 2013 - Everyone wants to find a solution to the problem of hospital readmissions, both for the sake of patients and because they tend to be very costly for hospitals and payers. Approximately 20 percent of Medicare recipients are currently readmitted to the hospital within 30 days of discharge.

But hospital readmissions are a complex problem.

Jan Englert: Measuring and improving hospital performance is a multi-faceted issue.
Jan Englert, RN, said that measuring and improving hospital performance is a multi-faceted issue.

“It’s like solving world peace,” said Jan Englert, RN, principal for member engagement for Premier Performance Partners.

Conflicting information about readmission rates is common. For example, some studies suggest a longer length of stay is related to a higher readmission rate, while other studies suggest a link between shorter lengths of stay and readmission. And one must consider other factors that will put readmission rates in context. For example, safety net and teaching hospitals tend to have higher readmission rates, but they also tend to care for disproportionately more patients with very complex medical problems.

Readmission rates offer part of the picture

In a new study for Health Affairs titled “Limits of Readmission Rates in Measuring Hospital Quality Suggest the Need for Added Metrics,” a team of researchers led by Matthew Press, MD, suggest that risk-standardized readmission rates that are currently used to measure hospital performance may need to be augmented with other measures of hospital performance.

As the authors noted, the Affordable Care Act (ACA) has resulted in increased attention to readmission rates. One provision in the legislation led to the creation of the Hospital Readmissions Reduction Program. Through this program, the Centers for Medicare and Medicaid Services (CMS) instituted penalties to hospitals with “excess readmissions,” starting last October. 

That initiative and other recently implemented policies do control for certain patient characteristics by using risk-standardized readmission rates. But there seems to be a need for additional metrics that would give a fuller picture of a hospital’s quality, according to the researchers.

The existence of a certain degree of “statistical noise” should also be taken into account, Press said. The researchers found that the starting point of a hospital’s readmission rate trajectory depended, in part, by how low or high it was at the beginning due to “regression to the mean” (or average) over time--not necessarily true changes in quality of care.

“And there’s no benchmark for what’s an acceptable amount of statistical noise and what’s not,” Press said. “We’re definitely not saying readmission rates should not be measured or the policies should change because there are major problems with them. We’re saying that this regression to the mean needs to be taken into account.”

“Hospital performance could be judged not just by all-cause readmission rates but by developing and using measures of preventable readmissions,” Press and his co-authors wrote. 

It’s encouraging when studies such as the Health Affairs study acknowledge the multi-faceted nature of improving performance and measuring it, too, said Englert.

“There’s not just one silver bullet to measure hospital quality…all these things are aligned hand in hand,” she said.

Better coordination needed for transitions

It may be time to focus more on the transition from hospital to community-based setting--and how to incorporate that into quality measurement.

“The readmissions issue is part of the bigger challenge of care coordination,” said Press. “The real puzzle that we need to solve is how to coordinate their care. And one of the keys to solving that puzzle will be trying to find out what skills and tools healthcare providers need to best work with each other.”

The researchers noted in the Health Affairs article that, “Another approach would be to augment readmission rates with other measures of hospital quality during care transitions, such as Eric Coleman and colleagues’ patient-centered Care Transitions Measure.”

Coleman’s Care Transitions Measure is a three-item questionnaire that addresses three key areas identified by patients as vital to their experience with coordination out of the hospital. The three areas are “understanding one’s self-care role in the post-hospital setting, medication management, and having one’s preferences incorporated into the care plan.” There has been discussion about adding the measure to CMS’s Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

Coleman is also known for his work creating the Care Transitions Intervention, a training program for patients with complex care needs; it incorporates a transitions coach to help patients during the transition from hospital to home. It focuses on four pillars, or key areas, which include: (1) medication self-management; (2) a dynamic patient-centered record; (3) primary care and specialist follow up; and (4) patient knowledge of red flags. Research has shown that patients who participate in the program are much less likely to require readmission.

Another program that may hold promise: CMS’ Community-based Care Transitions Program, which was launched in 2011 through a provision of the Affordable Care Act. It provides $500 million over five years to support hospitals and their community-based partners to develop and launch collaborative programs that would reduce their readmission rates. There are currently more than 100 participating organizations; some are using Coleman’s model.

Accountable care organizations (ACOs) also hold some promise when it comes to coordinating care and improving communication across various providers, which could have a positive impact on readmission rates.

“It’s still early with ACOs,” said Press. “But it’s one way to go.”

Healthcare systems are also examining their own current processes, reviewing the literature and discussing changes that could improve transitions of care--and perhaps eventually reduce their readmission rates.

For example, Premier, which already has a quality-improvement initiative called QUEST that tracks a range of measures, recently convened a number of its hospitals to participate in a mini-collaborative focused on the discharge process.

“We tried to be practical, practical, practical,” said Jeff Vawter, director of collaborative education and delivery for the Partnership for Patients for the Premier healthcare alliance.

They reviewed discharge summaries and discharge phone call scripts from their members and talked about what was missing and what could be done to improve them--and how that could improve the process of communicating with care providers in the community after a patient gets discharged.

The participants received feedback and recommendations for small changes that they could implement easily.

“But they’re really not that small in the effect they’ve had,” Vawter said.

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