Did I Say Unintended Consequences?

Paul Levy

Posted 10/20/11 on Not Running A Hospital

I raised lots of hackles in my recent post about penalizing hospitals for readmissions, generally and in the face of poor data to support such penalties.  Some commentors have said, in essence, “What can be the harm?  We’ll move the needle the right way, even if the methodology is not so precise.”

Well, here’s one example of the kind of harm that can occur when policies are not clearly thought out.  In December, Karen E. Joynt and Ashish K. Jha from Brigham and Women’s Hospital published an article in Circulation: Cardiovascular Quality and Outcomes, entitled, “Who Has Higher Readmission Rates for Heart Failure, and Why? Implications for Efforts to Improve Care Using Financial Incentives.”  I quote the abstract:

Background—Reducing readmissions for heart failure is an important goal for policymakers. Current national policies financially penalize hospitals with high readmission rates, which may have unintended consequences if these institutions are resource-poor, either financially or clinically.

Methods and Results—We analyzed national claims data for Medicare patients with heart failure discharged from US hospitals in 2006 to 2007.  We used multivariable models to examine hospital characteristics, 30-day all-cause readmission rates, and likelihood of performing in the worst quartile of readmission rates nationally.  Among 905 764 discharges in our sample, patients discharged from public hospitals (27.9%) had higher readmission rates than nonprofit hospitals (25.7%, P<0.001), as did patients discharged from hospitals in counties with low median income (29.4%) compared with counties with high median income (25.7%, P<0.001).  Patients discharged from hospitals without cardiac services (27.2%) had higher readmission rates than those from hospitals with full cardiac services (25.1%, P<0.001); patients discharged from hospitals in the lowest quartile of nurse staffing (28.5%) had higher readmission rates than those from hospitals in the highest quartile (25.4%, P<0.001).  Patients discharged from small hospitals (28.4%) had higher readmission rates than those discharged from large hospitals (25.2%, P<0.001).  These same characteristics identified hospitals that were likely to perform in the worst quartile nationally.

Conclusions—Given that many poor-performing hospitals also have fewer resources, they may suffer disproportionately from financial penalties for high readmission rates.  As we seek to improve care for patients with heart failure, we should ensure that penalties for poor performance do not worsen disparities in quality of care.  (Circ Cardiovasc Qual Outcomes. 2011;4:53-59.)

Paul Levy is a former CEO of a large Boston hospital. He writes at Not Running A Hospital.

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