Dartmouth Readmissions Report Shows Scant Progress

Despite widespread acknowledgement of the need to reduce hospital readmissions, only slight progress was made in reducing rates of 30-day readmissions among Medicare patients between 2008 and 2010.

That's according to "The Revolving Door Syndrome," the latest report on hospital readmissions from the Robert Wood Johnson Foundation and the Dartmouth Atlas of Health Care, which again points to the highly variable rates even within types of patients within a hospital, or hospitals within a city or state.

For example, among 92 academic medical centers named, 37 hospitals saw readmission rates for their patients actually increase.

>>>View Dartmouth Readmissions Atlas

"This report is consistent with other data showing that relatively little has changed over the past several years," notes David Goodman, MD, co-principal investigator for the Dartmouth Atlas Project. "Despite awareness of the problem, progress has been slow."

The report divided readmissions into two types, those affecting patients whose first admission was for a surgical procedure and those affecting patients whose first admission as for a medical condition, such as congestive heart failure, pneumonia, or heart attack.

The surgical 30-day readmission rate dropped from 12.7% in 2008 to 12.4% in 2010, while the medical 30-day readmission rate went from 16.2% to 15.9%.

As in most reports featuring data from the Dartmouth study, this report showed wide variation, especially among academic medical centers.

For example, among medical patients, the academic medical centers with the highest readmission rates in 2010 were the Cleveland Clinic, with 21.6%, and the Hospital of the University of Pennsylvania, with 21.4%.

The hospital with the lowest rate was NYU Langone Medical Center, with 14.4%. 

Among surgical patients initially treated at academic medical centers, the highest readmission rate was at the University of Medicine and Dentistry in New Jersey, (UMDNJ), with 20.7%, and the Stony Brook University Medical Center on Long Island, with 20.6%.

The hospital with the lowest readmission rate for surgical patients was at Creighton University Medical Center, 9.4%.

Representatives of the UMDNJ and Cleveland Clinic declined to comment, saying that they needed more time to read the report.

Goodman asserts that it is fair to criticize hospitals for not reducing readmission rates by 2010, the year that the Patient Protection and Affordable Care Act was signed and the first time many hospitals realized that readmissions would be penalized up to 3% of their Medicare DRG payment.

"The interest and concern about higher readmission rates really extends back at least 15 years, both in terms of recognizing that they are too high, as well as the development of care models that are effective at reducing them," Goodman says. "This is quite a long-standing problem that's not news to anyone in the healthcare community."

Goodman adds that a frequently overlooked aspect of this report and others published by Dartmouth is that hospitals with higher readmission rates tend to have higher admission rates in the first place.

"Part of this is explained by the way healthcare systems have invested and the way they've built themselves over the years, like how many intensive care unit beds and hospital beds they have, and how many hospital beds they have, rather than whether the community has built up good community care capacity," he says.

These aspects of healthcare are "distinctive patterns that are often invisible to the hospital and doctors themselves, and certainly to the patient, but they're very powerful."

"It's not just a matter of whether the nurse calls the patient up after they leave the hospital in the first 30 days to make sure they're taking their medication," Goodman continues. "There really needs to be some broader changes, in terms of whether systems are building hospital care or building community care."

"There's no question that our reimbursement systems tend to favor payment for care that occurs in a hospital. Though many would agree that is payment for volume and payment for inpatient care that is irrational today, those are the systems largely still in effect."

The latest report differs significantly from others in that it includes interviews with physicians who are frustrated with the system, and with patients about why they were readmitted and what they think went wrong.

"Some doctors feel they are caught in a squeeze play," the report says. "Hospital administrators carefully monitor length of stay—they are eager to send people home because the longer a patient stays, the less money they make. Thus providers said that the prevailing pressure is to discharge patients as early as possible" even if it's too soon.

"So now [they tell you], 'Doctor, you cannot keep that patient,' "a New York family practice physician explained. " 'Are you having the patient on any IV solutions? No? The patient is drinking, the patient is on pills. The patient has to go home.' So it's a lot of pressure also from the hospital to send him home."

On the patient side, the report criticized hospitals for "not being good learning environments" for many patients interviewed. "The patients tried to absorb all of the information and instruction they received, but found it hard to retain anything. They were tired, ill, and their minds foggy with medications. When they reflected back on the experience, some said they should have asked more questions or pushed for more time with their doctor."

Many patients said they were just too unsure of what to ask.