Not all 30-day readmissions indicate problems, study says

Are all 30-day readmissions really a bad thing? Not necessarily, according to researchers comparing readmission rates among California hospitals. The study found safety net hospitals in the state often had better outcomes on 30-day mortality measures, but were still more likely to face readmission penalties.

The research adds to a growing body of data delving into the penalties' effect on hospitals in economically disadvantaged communities.

When compared to other hospitals, patients treated for acute myocardial infarction, heart failure and pneumonia at California safety net hospitals had lower 30-day risk-adjusted mortality rates, but the hospitals still were more likely to be fined under the value-based purchasing program and the hospital readmissions reduction program, found the study published in the August issue of the journal Health Affairs.

The main finding is consistent with several other recent studies looking at how hospitals in low-income communities may be disproportionally affected by readmissions penalties.

The general assumption that readmissions are inherently bad could be part of the issue, explained lead author Edmund Becker, a health policy professor at Emory University's Rollins School of Public Health.

A readmission could represent a high-quality outcome, especially among patients with advanced or difficult to treat stages of a disease, because it means the patient survived long enough to be readmitted, Becker suggested. Or a readmission could be representative of a low-quality outcome, because the readmission was due to a lower standard of care. It also potentially could be linked to other factors, such as the patient's lack of access to a primary-care physician, the study authors suggest.

“Predicting readmissions is notoriously difficult,” they write. More research is needed to understand if simply allowing the additional readmission to occur might lead to less-costly overall care, they said.

A safety-net hospital was defined in the study as those whose percentage of Medicare disproportionate-share patients fell within the highest quartile, which the authors say indicates the hospital cared for more low-income patients relative to other hospitals in the same geographic region.

Of the 242 hospitals analyzed, 60 were defined as safety net. To make the comparison, researchers used data from the 2013 Medicare Impact File; a CMS list of hospitals that received Medicare payments in March 2013; Hospital Compare data from 2011; the California Office of Statewide Health Planning and Development; and data on hospital referral regions from the Dartmouth Institute.

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Using big data to target preventable readmissions

The fairness of readmission penalties has been a topic of increased interest as hospitals now have Medicare reimbursements docked up to 2% for excess readmissions. That penalty rises to 3% in fiscal 2015. America's Essential Hospitals, a national association that advocates for the nation's safety net hospitals and health systems, links to more than 20 other recent studies looking at the impact of socio-economic factors on health outcomes. These types of studies are catching the attention of policymakers.

In June, a group of six U.S. senators introduced legislation called the Hospital Readmissions Program Accuracy and Accountability Act, which aims to address what the senators called the “unfair penalization and stigmatization of hospitals serving low-income populations.” Last week, the National Quality Forum announced it plans to conduct a trial examining the effects of various socio-economic factors factors on risk-adjustments. Thirty-day readmission measures may potentially be included as a component of the trial, though NQF says specific details have not been established.

The current study, conducted by researchers from Emory University in Atlanta; Brown University in Providence, R.I. and Stanford University School of Medicine in Palo Alto, Calif., was funded by one of the first pilot grants issued through the Patient-Centered Outcomes Research Institute. The not-for-profit organization was established through the Patient Protection and Affordable Care Act to support comparative-effectiveness research.

Becker says the current report is a subset of a larger project. The researchers plan to look at similar data in 13 other states, and will also investigate how the size of the penalties affect hospitals' abilities to improve patient outcomes.

Follow Sabriya Rice on Twitter: @MHsrice