Dartmouth Atlas researchers are again pointing fingers at hospital quality of care, this time showing wide variation in 30-day readmission rates, which have not gone down and in some cases rose between 2005 and 2009.
Hospitals see "their responsibility as ending when the patient leaves their door and have made minimal efforts in terms of coordinating care or communicating to community physicians," said David Goodman, MD, lead author and co-principal investigator for the Dartmouth Atlas Project's latest report.
"The result is that readmission to a hospital is a fairly common phenomenon," occurring in between one in six and one in five patients discharged, he said. "Probably the most important finding is that for a long-standing and well-recognized problem, not much progress has been made," Goodman said.
Some hospitals argue that they can't be blamed for high readmission rates because they have sicker patients with more co-morbidities, people who are less well educated and hampered by transportation and poverty. That "may be an explanation, but it shouldn't be an excuse," Goodman said.
While "every hospital and market has its own legitimate story in terms of why they are and where they are today – sometimes it truly is because patients are sicker or poorer – often it's because of an accidental evolution" of the way care is delivered, without coordination or community provider partnerships. Transition processes are "deeply flawed," he said.
The report, entitled "After Hospitalization: A Dartmouth Atlas Report on Post-acute Care for Medicare Beneficiaries," compares readmission rates between 2004 and 2009 for six categories of patients: those admitted for medical care, surgery, congestive heart failure, heart attack, pneumonia, and hip fracture.
It further dissects the data to show rates for each of 1,924 hospitals in the country for those two years. One can see 30-day readmission trends for medium-sized and large cities, hospital referral regions, and states.
The report also reveals that fewer than half of discharged patients followed up with visits to clinicians – an aspect of care said to help prevent readmissions – within 14 days of leaving the hospital. That rate "fell short of any reasonable expectation," said Goodman, Goodman, who also directs the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice.
The maps and statistical tables within the document show the percentage of patients for both 2004 and 2009 who were seen by a primary care clinician or went to an ambulatory care center within 14 days of discharge or went to the emergency room within 30 days of discharge.
Also highlighted for scrutiny are 92 academic medical centers, which Goodman and colleagues said have somewhat higher ranges of variation. For example, the University of Connecticut in Farmington went from 13.1% to 17.9% and the University of Medicine and Dentistry Hospital of New Jersey's readmission rates rose from 18.3% to 22.3%.
Hospitals must take action on two fronts, Goodman said. One is to improve discharge planning and care coordination, and the other is to make sure patients have the medications they need and the means to have prescriptions filled and that follow-up appointments are made.
The latest Dartmouth report illuminates the same sort of regional practice variation trends that have distinguished many of its other research projects, for example, on use of palliative care at the end-of-life care and regional and racial variation in primary care.
Goodman said that those parts of the country with high readmission rates tend to have "system factors" or patterns of care that rely on hospitals as the primary site of care. Parts of the country that tend to have more patients hospitalized are generally the same places that also experience high readmission rates."
On Aug. 5, the Centers for Medicare & Medicaid Services released the names of 4,600 hospitals and their readmission rates for a three-year period that includes two of the ones that will be used for the Medicare penalty calculation. Hospitals said to have worse than national average rates in one, two or three disease categories found themselves going into defensive mode and scurrying to make changes to their care processes.
Now, these same hospitals await final determination of whether they will be fined up to 1% of their Medicare reimbursement under provisions of the Affordable Care Act, which evaluated each facilities readmission rates between July 2008- June 2011. Even as Medicare will cut up to $850 million in payments to outlier hospitals, several states such as Massachusetts and New York this year launched their own financial penalties for hospitals with higher rates of readmissions of patients covered by Medicaid.
Nancy Foster, Vice President for Quality and Patient Safety Policy for the American Hospital Association, said the AHA favors sharing good information that helps hospitals improve. But the data in this report, she says, "indicates that the challenges of reducing unnecessary readmissions are complex, and there's not one single solution."
Sometimes, she says, the problem is that the patient doesn't have a primary care physician, or maybe they have multiple physicians. "You can say that oh, the problem would be solved if the hospital makes an appointment for the patient in 14 days. It sounds simple, but it is not easy to do."
Sometimes she adds, the doctors are not accepting new patients, or they're overwhelmed, and it becomes very challenging to make sure it happens."
Reducing readmissions is a prominent goal throughout the healthcare industry, she added. "I can't point to one hospital that isn't working very hard on this," she said.
The Dartmouth report provided some examples of the extreme regional variation in readmission rates:
- Readmission rates after surgeries varied with 28 regions experiencing a decrease, most notably Elyria, Ohio which fell from 19% to 15.2% between 2004 and 2009, and White Plains, NY, where readmissions rose from 13% to 17.4%.
- Among patients who went to a hospital for medical treatment as opposed to surgery, Michigan had the highest rates, with 18.9% in Pontiac, 18% in Dearborn and 17.9% in Detroit while lower rates were in Utah, for example 13% in Provo and 13.6% in Salt Lake City. For surgical patients, rates ranged from 7.5% in Rapid City, SD to 19% in the Bronx, NY.
- High rates for one type of hospitalization, for example medical, surgical, heart attack or pneumonia, also had high readmission rates for the others, indicating "there may be common system-level factors within a region influencing readmission rates, independent of particular illnesses or chronic conditions," the report said.
The research project for the first time includes a companion report for patients with advice on how they should take a more active role in managing their own care to prevent a readmission.