A retrospective analysis of Medicare data finds that an extended length of stay lowers readmission rates for heart failure patients, but the analysis seems to contradict previous findings, says a health policy expert.
A group of business school researchers looked at readmissions through an economist's lens and found that keeping heart failure patients in the hospital for an extra day lowered their chances of being readmitted.
The retrospective analysis of Medicare data, conducted by researchers at the Columbia Business School, also found that the extended length of stay lowers 30-day mortality rates for pneumonia and heart attack patients. The finding suggests another approach for hospitals trying to find ways to avoid readmissions and the Medicare penalties that can come with them.
Looking at Medicare data from between 2008 and 2011, the researchers concluded that an extra day in the hospital decreased readmissions for heart failure patients by 7%. The extra day also translated into a 22% reduction in mortality risk for patients treated for pneumonia and a 7% reduction for heart attack patients.
"While some outpatient programs can be very effective at reducing hospital readmissions, we ?nd that inpatient interventions can be just as, if not more, effective," the report says.
The study was designed to address the complaint that hospital readmissions are driven less by inpatient treatment and more by the quality of post-hospital care, says study co-author Carri W. Chan, an associate professor at Columbia.
"We wanted to see if this was a lever within the hospitals' control that could also impact and reduce admissions," said Chan.
By the researchers' calculation, "a significant impact of inpatient interventions on readmission risk and mortality [were found]. In some cases, the impact of keeping a patient one more day in the hospital is more beneficial than what could be achieved via switching all patients to MA (Medicare Advantage) and providing them with the various outpatient programs and primary care included in such plans."
They also determined that one extra day in the hospital would, in many cases, cost less overall than the associated outpatient care required with early discharge.
Cost Considerations
But Chan noted that it is not clear whether it would be cost effective for hospitals to try the approach under current Medicare payment policies. The cost of the extra day of care would likely be more than the penalty for a readmission, she said.
To measure the impact of inpatient versus outpatient care on readmissions, the researchers compared outcomes for Medicare patients insured under a traditional fee for-service model plan with those insured through capitated Medicare Advantage coverage.
Under the FFS model, the reports says, providers have an incentive to provide more care and to perform more tests. For instance, hospital readmissions are "not necessarily bad because hospitals are paid twice for each patient that comes back to the hospital."
The report notes that capitated plans have an incentive to reduce readmissions, so they are under more pressure to provide better outpatient care. Patients are more likely to be readmitted if they are covered under fee-for-service instead of Medicare Advantage.
The readmission risk for high-severity heart failure patients decreases by 7% on average if they are covered under Medicare Advantage instead of fee-for-service. That is comparable to keeping of patients in the hospital for one more day, the found.
The Center for Medicare & Medicaid Services estimates 2,225 hospitals will be penalized $227 million because of excess readmissions in the current fiscal year. About 34% of hospitals will receive no penalty, according to a study from the Robert Wood Johnson Foundation.
The RWJF report, published in Health Affairs, notes that reducing readmissions "has proved to be difficult and not straightforward. Strategies cited include "reducing the risk of infection; paying more careful attention to patient medications; discharge planning and improved communication with patients and caregivers regarding follow-up care; and improving care transition through better communication and collaboration with other community providers."
Contradictory Findings
The report goes on to note, however, that "interventions like these have shown mixed results, with limited evidence of success."
Researchers at Dartmouth have also been monitoring readmissions. Jeremiah R. Brown, assistant professor of health policy at The Dartmouth Institute, said the Columbia analysis seems to contradict previous findings.
"We often see longer length [of stay] associated higher risk patients, higher mortality and higher readmissions," he says.
The Columbia study offers some good ideas based on "high quality" analysis, but the findings are based on retrospective data that need to be tested in practice in the pay-for-performance era, Brown says.
Peter Kaboli of the Iowa City Veterans Affairs Medical Center found that shorter length of stays at his facility did not lead to more readmissions. He noted via email that the Columbia research is flawed in part because none of the researchers "is a physician who understands inpatient care… There is abundant literature that very clearly shows that longer LOS is associated with higher readmission rates," he wrote. "That is a very simple relationship: the sicker you are, the longer you need to be in the hospital, thus the more chance you have of being readmitted."
Columbia Findings 'Not Surprising'
Amanda Brewster of the Global Health Leadership Institute at Yale University co-authored a study looking at hospital strategies designed to lower 30-day mortality rate for heart attack patients. She says the Columbia findings are not surprising. Anecdotally, she is aware of hospitals deciding to keep heart failure patients for an extra day to monitor the efficacy of medications
At the same time, she questions the comparison of patients' coverage under the fee-for-service model with those in Medicare Advantage, who tend to be healthier.
"When you see they are less likely to be readmitted, it's hard to chalk that up to a difference in length of stay or a difference in outpatient management," she says.
Either way, length of stay is on the table as a possible factor in readmission.
Brewster says that the penalties in place for excess readmissions "provide a financial incentive to rethink whether the hospital is going to benefit by reducing the length or extending the length of stay to try and reduce those readmissions."