Researchers find that hospitals are most likely to be responsible for readmissions within a week of discharge, but outpatient clinics and homecare givers are most likely responsible for later readmissions.
Hospital readmissions are not monolithic, and Medicare should change its readmissions penalty program time frame from 30 days to seven days, researchers say.
The researchers, whose study was published this week in the Annals of Internal Medicine, say Medicare's Hospital Readmissions Reduction Program (HRRP) often penalizes hospitals for patient outcomes that are out of their control.
"We found that readmissions within the first 7 days after hospital discharge were more likely to be preventable than those within a late period of 8 to 30 days," the researchers wrote. "Early readmissions were more likely to be amenable to interventions within the hospital and to be caused by factors for which the hospital is directly accountable, such as problems with physician decision making."
Outpatient facilities and home caregivers were more likely to be accountable for readmissions from eight to 30 days, the researchers wrote.
"Late readmissions were more likely to be amenable to interventions outside the hospital and to be caused by factors over which the hospital has less direct control, such as appropriate monitoring and managing of symptoms after discharge by the primary care team."
The study, which covered 10 academic medical centers from April 2012 through March 2013, included 822 adult patients:
- 301 patients (36.6%) were readmitted within seven days after discharge
- 521 (63.4%) were readmitted eight to 30 days after discharge
- 36.2% of early readmissions vs. 23.0% of late readmissions were deemed preventable
The researchers found that faulty physician decision making was the number one cause of early readmissions, associated with 28.9% of the cases.
Three primary variants of errant decision making were identified:
- Premature discharge in 16.3% of cases
- Inadequate treatment during hospital stay, 14.3%
- Missed diagnoses, 10.6%
Difficulty monitoring and managing symptoms was the number one cause of late readmissions, associated with 33.2% of cases. The researchers identified three primary variants of monitoring and managing difficulties:
- Lack of disease monitoring in 12.7% of cases
- Overly long wait times for follow-up appointments, 10.0%
- Inability to make follow-up appointments, 10.9%
The researchers say their data indicate several reasons why the HRRP timeframe should be switched from 30 days to seven days.
First, they found a significant difference in the preventability of early and late readmissions in the 30-day timeframe after discharge. "Early readmissions were associated with double the odds of preventability compared with late readmissions," the researchers wrote.
Second, a pair of physician adjudicators who reviewed the readmissions cases found hospitals were the best site to intervene and prevent early readmissions. The physician educators found outpatient clinics and home were the best settings to prevent late readmissions.
Third, the researchers found that erroneous physician decision making and premature discharge were leading causes of early readmissions.
"Taken together, these findings suggest that readmissions in the week after discharge are more preventable and more likely to be caused by factors over which the hospital has direct control than those later in the 30-day window," the researchers wrote.
Beyond narrowing HRRP's 30-day readmissions window to seven days, the researchers also offer five recommendations to promote readmissions prevention:
- Hospitals should try to decrease cognitive errors that impact diagnosis and treatment
- The impact of hospital efforts to increase throughput on premature discharge should be examined
- Outpatient facilities should boost multidisciplinary care management for post-discharge monitoring of patients after discharge
- Access to primary care clinicians should be expanded
- Accountability for readmissions 30 days after discharge should be shared between outpatient and inpatient facilities
"Shared accountability over the 30 days, possibly with weighted penalties by readmission timing, would engage outpatient practices in readmission reduction efforts and reduce unfair financial penalties on hospitals."
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Christopher Cheney is the senior clinical care editor at HealthLeaders.