It's all about location. A Medicare patient discharged after surgery in Bend, Ore., has a 7.6% chance of ending up back in the hospital within 30 days. But if that patient calls the Bronx in New York City home, the likelihood that he or she will be readmitted more than doubles, jumping to 18.3%.
Despite ramped up federal oversight, greater awareness of the problem and a host of not-for-profit- and provider-led initiatives aimed at smoothing care transitions and improving access to post-acute and primary care, readmission rates still vary widely from one region of the country to another.
That's according to a report from the Washington-based Robert Wood Johnson Foundation, containing the most recent analysis on the topic from the Dartmouth Atlas of Health Care, a long-running project that uses Medicare data to examine variations in the way that healthcare is provided across the country. The latest data, which echo other recent reports pointing to stagnant readmission rates, are prompting concern among providers who wonder whether their prevention efforts will pay off or if the problem of readmissions is an intractable one.
Some clinicians and experts, however, are arguing that the report doesn't show the fruits of recently launched efforts to prevent readmissions. They advocate staying the course on current improvement initiatives, and they contend that future data will show better transitions and fewer preventable rehospitalizations.
The patterns revealed in earlier Dartmouth Atlas reports persisted in this latest analysis. Communities such as Detroit and Chicago had high 30-day readmission rates following medical discharge—17.8% and 17.7%—while the readmission rate in Ogden, Utah, was a relatively low 11.4%. The spread between high and low performers was even greater following surgical discharges, with readmission rates as low as 8.4% and 9% in Boise, Idaho, and Santa Barbara, Calif., and as high as 17.4% in White Plains, N.Y.
The report also showed little traction in improving the overall national readmission rate, which remained virtually the same in 2010, at 15.9%, as it was in 2004, when the Dartmouth Atlas began analyzing the data.
The findings come just months after the federal government launched its readmissions reduction program, which imposes financial penalties ranging from 0.01% to 1% on hospitals with higher-than-expected readmission rates. Those penalties are scheduled to jump to 2% in 2014 and 3% in 2015.
“I think the major takeaway is that for a long-recognized problem, we haven't made much progress and we have a very long way to go,” said Dr. David Goodman, professor of pediatrics at Dartmouth Medical School, Hanover, N.H., and director of the Center for Health Policy Research at the Dartmouth Institute. Goodman, co-principal investigator of the Dartmouth Atlas, also co-authored the newly released readmissions report.
The factors that cause readmissions are complex, Goodman said, but the report did show that regions with high hospital utilization rates had higher readmission rates, suggesting that those areas are more dependent on hospital-based care.
“A bed built is a bed filled,” Goodman said. “If we want to make sure patients stay out of the hospital, we need to make sure we're not overdeveloping hospital and ICU beds. We want to change investments toward community-based care as much as possible.”
The lack of progress detailed in the report may appear bleak, but Dr. Eric Coleman, a geriatrician and head of the division of healthcare policy and research at the University of Colorado at Aurora, urges optimism. Coleman, who also directs the Care Transitions Program, argued that 2010, the 12-month period analyzed for the report, marked the launch of many of the programs now in place to address avoidable readmissions.
“The report did not capture what we have seen in terms of innovations over the last few years,” he said. For instance, Coleman said, Medicare quality improvement organizations, which contract with the CMS to lead statewide improvement initiatives, have seen measurable progress in reducing readmissions. According to a January study in the Journal of the American Medical Association, communities with QIO-led care-transition programs saw readmission rates fall 5.1% after implementation, compared with a 2.1% drop in 50 comparison communities.
Those QIOs are working with more than 400 communities across the country, he said. He also cited the 82 communities currently participating in the CMS' Community-Based Care Transitions Program, which was created by the healthcare reform law and funded through HHS' $1 billion Partnership for Patients. Coleman's own program has partnered with more than 800 providers and organizations to improve transitions of care, he added.
Coleman acknowledged that the CMS' penalty program is a hard pill for providers to swallow, particularly when researchers argue that many of the reasons for readmissions are outside of hospitals' control. Still, he said he had seen a “quantum leap” in hospitals' attention to the issue since the program launched in October 2012—a momentum he hopes will continue.
“I don't want this report to take the wind out of our sails,” said Coleman, whose work emphasizes the importance of patient and family engagement. “I think the message should be, 'Stay tuned and don't get discouraged.' The report is just a good reminder that what we were doing from 2004 to 2010—which was not a whole lot—didn't really work.”