Lowering readmission rates does not harm patient safety

As hospitals continue to lower readmission rates and satisfy new value-based incentives, mortality rates have also dropped, signaling improvement in care quality, a new study found.

Hospitals have successfully reduced readmission rates over the past several years, as new payment incentives penalize providers that have patients return within 30 days after they are discharged. But some worry that may lead to hospitals sending patients who should be admitted home from the emergency department or providers becoming distracted from other quality improvement efforts.

So far, those concerns are unfounded. A new study published in JAMA analyzed about 5 million Medicare fee-for-service hospitalizations between 2008 and 2014 and found that 30-day readmission rates declined for all conditions studied—heart failure, acute myocardial infarction and pneumonia. While 30-day mortality rates slightly increased for heart failure patients over that time, they dropped for acute myocardial patients and remained steady for those with pneumonia.

The data suggest that hospitals that lowered their readmission rates also tended to have small reductions in mortality, said Dr. Karen Joynt, an assistant professor of medicine at Washington University School of Medicine.

"This is certainly good news," she wrote in an accompanying editorial. "There is an emerging literature on strategies that hospitals are using to reduce readmissions, the majority of which relate to improving coordination, communication and cooperation among physicians and other health care professionals and across care settings. These strategies are patient centered and, when successful, should be adopted by all hospitals, regardless of baseline readmission rates."

Hospitals have lowered readmissions through improved transitional and post-acute care by better preparing patients and families for discharge, integrating care across settings and following up in a timely manner, researchers said.

"Thousands and thousands of readmissions are being avoided every year without any evidence of people being harmed. That is a victory of improving the quality of care," study co-author Dr. Harlan Krumholz, a professor of cardiology at Yale University, said in a statement.

Still, it is important to study the potential unintended consequences of various payment incentives, Joynt said.

The Hospital Readmissions Reduction Program implemented under the ACA penalizes providers up to 3% of Medicare inpatient payments for those who return to the hospital within 30 days. On the other hand, the federal Hospital Value-Based Purchasing program levies penalties up to 2% of payments based on mortality measures, patient experience, safety and efficiency. This strikes an imbalance favoring reducing readmissions over care quality, she said.

Readmission rates for the three conditions studied by the researchers declined from 21.5% to 17.8% between 2007 and 2015, the study found. Readmission rates significantly declined after the readmissions reductions program was announced but have flattened since penalties began in 2012, research shows. That could be chalked up to providers already maximizing "low-hanging-fruit" solutions and needing to move the needle further with longer-term investments or providers opting to pay the penalty rather than change, which averaged around $158,000 per hospital in 2015, Joynt said.

Researchers recommended tweaking the readmission program to accommodate larger hospitals that provide high-quality care but are disproportionally penalized because they care for the sickest populations. Also, under the program, hospitals can reduce readmissions and still receive an equal or higher penalty compared with the prior year because providers are graded on a curve, Joynt said, which could disincentive providers to improve.

"As more money is 'at risk' under value-based payment arrangements such as the HRRP, getting risk adjustment right is ever more crucial to ensure that such arrangements are as fair as possible and do not unduly disadvantage hospitals caring for the sickest, most vulnerable populations," she wrote.

An​ edited​ version​ of​ this​ story​ can​ also​ be​ found​ in​ Modern​ Healthcare's​ July​ 24​ print​ edition.