Readmission Drivers, Not Stabilizers

Bradley Flansbaum

First posted 9/25/11 on The Hospitalist Leader

I am always leery of briefs from think tanks and trade associations.  They are not ideal sources for balanced takes on important issues.  I am especially wary when the same bodies espouse viewpoints that might be similar to mine.  No individual is above self-reinforcement, and basking with like-minded souls in serene waters blinds us to the sirens call.  The call in this case, and the thrust of this post, is the accountability connection as it relates to hospitals and patient readmissions.

As hospital penalties for unnecessary readmits draw near, the attention to attribution, mainly, root causes for revisits, are accelerating debate and obliging those of us on the front lines to unmask pitfalls in conventional (CMS) thinking.

If a patient returns to the hospital in less than 30 days, liability “must” rest with the same facility, and by fiat, results from a shortcoming in their care delivery.  Hospitalists know readmissions are preventable.  The rates are also too varied, and chance alone is not the singular trigger:

However, there are other elements at play, and if we are to incent hospitals, and by default, hospitalists, on their ability to prevent ER return trips, we must critically examine the bevvy of influences underlying these occurrences.  This encompasses unmeasured covariates, as well as community factors—particularly socioeconomic dynamics—that are influencing this trend.  I have visited this trend before.

Below are tables and graphs from a recently released AHA brief illustrating these points.  It is quite good, and worth a look.  Again, it is not the final word on this topic, nor is it all-inclusive; however, it cites issues that need reconciliation if proceeding down the “penalty” path is our destiny.

Rather than expound on each, I will post them with a brief descriptor; please refer to the short brief for further details:

1.  Distinguishing planned from unplanned admissions, and new diagnosis versus old.  Currently we focus on quadrant 3 in red.  What about quadrants 1,2 and 4?

2.  Does risk adjustment encompass variables that may have a correlative effect on ER return trips?

3.  Do states with high readmission rates have higher or lower adjusted hospital mortality rates (higher hospital SMRs imply reduced numbers of “sicker and quicker” discharges).  Do current quality process measures associate?

Again, as this is a thumbnail sketch, balanced reviews are essential, and there is a panoply of literature on this question in the record.  However, there are intangibles unaccounted for with our current patient “revolving door” paradigm.  That is an essential point. These intangibles contribute to higher rates of emergency department return, as most hospital-based providers with experience can attest.  Their contribution is not small (my opinion).

Like the pushback (and failures) related to process of care measurement, the same cynicism will arise if the equivalent vagaries are not accounted for in this performance evaluation scheme.  That does not mean we should not proceed—see map number one after all—but it implies some recognition that this is harder than it looks, and version 1.0 of readmission accountability is brittle at best.

No hospitalist I speak with suspects CMS has this correct.  However, since hospitals are the deep pockets and the logical targets, the bullseye is on us.  In the end, we will be the conduits through which resources pass to repair determinants that were never under our jurisdiction to begin.  However, no one will acknowledge that detail when the problem is moderated a decade or two from now.  Let us hope not–we’ll need the emotional boost.

Hospitals these days make for good straw men, and some of it is deserved, but in no greater proportion than any other system participant–including patients and Uncle Sam. However, our role in a reformed system is still ill defined—it is easy to target an amorphous institution that is many things to many people.

What is our function after all, and how will we assess it.  I cannot say, but I am certain it will extend beyond our current walls into the communities we inhabit.

Brad Flansbaum is a hospitalist in New York City. He writes at The Hospitalist Leader.

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