Bradley Flansbaum
Posted 3/28/12 on The Hospitalist Leader
Of note, a very nice commentary in today’s NEJM regarding our inability to control 30-day readmissions, and the justifications (or lack thereof) for its continued use as a metric in judging inpatient quality. I suggest everyone who works on the front lines read it:
[…]Although a focus on readmissions may have good face validity, we believe that policymakers’ emphasis on 30-day readmissions is misguided, for three reasons. First, the metric itself is problematic: only a small proportion of readmissions at 30 days after initial discharge are probably preventable, and much of what drives hospital readmission rates are patient- and community-level factors that are well outside the hospital’s control. Furthermore, it is unclear whether readmissions always reflect poor quality: high readmission rates can be the result of low mortality rates or good access to hospital care. Second, although improving discharge planning and care coordination is a laudable goal, there are better, more targeted policies that are more likely to be effective in achieving it. Finally, because hospitals are expending so much energy on reducing readmissions, they have probably forgone quality-improvement efforts related to more urgent issues, such as patient safety. An evidence-based, holistic approach to quality improvement is far more likely to achieve what policymakers, clinicians, and the public all want: better care at lower cost.
[…] The growing body of evidence suggests that the primary drivers of variability in 30-day readmission rates are the composition of a hospital’s patient population3 and the resources of the community in which it is located — factors that are difficult for hospitals to change. We know that some of the most important drivers of readmissions are mental illness, poor social support, and poverty, which are often deeply ingrained. Therefore, readmission rates have weak signaling value for identifying high-quality hospitals. The current scheme to penalize hospitals with high readmission rates is likely to disproportionately affect institutions that care for poor or minority populations or those with a high burden of mental illness.
The drumbeat does seem to be getting louder, and it’s good to see a well-articulated piece stating what most of us already know, mainly, there are too many readmit elements beyond our province of control. It’s nice to blame “the system,” or the “other guy” occasionally, but in this instance, I am afraid it is the truth. The hospital as locus and its “failure” to deliver is not the solitary root cause for ER round trips.
When care is integrated and we repurpose how hospitals function in the community and we shift the resources, then yes. Until that day, keep yearning, and those who think otherwise need to visit their local community hospital. They will get an education.
PS–This is not the first well-done commentary piece on the subject. Here, a link to the recent Annals and JAMA reviews on risks and prevention strategies on readmits. Both had less than encouraging conclusions.
Care And Cost 
Granted the 30 day readmission rate may not be an ideal metric (and NEJM is not the first or only one to do so). However, you only allude to more “direct” measures. And what about the fact that this piece doesn’t mention the perverse incentive that has so far prevented providers from taking better care of patients in the first place. Cut off the wrong leg, by golly, we are sorry but now we can do the right leg and still bill for it. There is a reason we now have an explicit policy to not pay for “never-events”.
Those who are being asked to improve their performance cannot just say the 30 day readmit rate is a bad metric (and by extension, I don’t want to do it) without also saying, here’s a fairer way to assess performance. Because otherwise it looks too much like the child who hates peas and doesn’t want to eat it.