The standard for studying readmissions, and what they say about hospital quality, has long been 30 days. The 30-day window is used by the federal government to penalize hospitals believed to provide lower-quality care because patients return to the hospital following discharge, but recent research suggests that window should be shortened.
Hospitals would get more meaningful data if they studied readmissions in the first week — or even sooner — because that would isolate factors within a hospital’s control, says David Chin, PhD, a postdoctoral scholar at the UC Davis Center for Healthcare Policy and Research and the Department of Public Health Sciences.
“When you look at the seven days following discharge, there are greater differences between hospital performance,” Chin says. “The 30-day implicitly ignores the fact that there are factors other than hospital quality that drive the patient back to hospital in that longer period.”
Chin and his colleagues recently published their study results in Health Affairs, recommending that CMS and other payers reconsider using the 30-day readmission rate as a basis for public reporting on hospital quality and reducing Medicare payments to hospitals. (An abstract of the study is available online at http://bit.ly/2d6ApWb.)
“Regulators should use measures that push hospitals to provide excellent inpatient care and reduce avoidable hospitalizations,” Chin says. “Thirty-day readmission rates, however, don’t accurately reflect what happens within hospitals or clearly distinguish quality differences from one hospital to another.”
Chin and the study team used information from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality, a comprehensive resource for data on hospital encounters. The researchers focused on patients aged 65 or older who were hospitalized for common medical and surgical conditions in four states with large, diverse populations: Arizona, California, Florida, and New York. More than 66 million hospital discharges were evaluated for unplanned readmissions between one and 90 days. They looked for the day or days following discharge in which the true variation in hospital performance was the largest.
The results showed that a five- to seven-day post-discharge timeframe is when hospital-attributable factors have the greatest effect on readmissions. After that, readmissions are more heavily influenced by factors outside the hospital’s control.
Focusing on shorter post-hospital periods will better isolate the effect of hospital care from other drivers of readmissions such as a patient’s home, social, economic, and community circumstances, Chin explains.
“The bottom line is that when you look at hospitals in the 30-day interval, the hospitals all look pretty much the same,” Chin says. “When you contract that interval closer to seven days, you start to be able to tie individual hospitals to the readmission.”
Stronger Correlation in Early Days
There is nothing magical about the seven-day mark, Chin explains, but the tie to hospital quality is higher the closer you get to the discharge. It’s like a sliding scale, where readmissions in the first few days are more likely to be tied to hospital quality and the correlation becomes weaker with each additional day.
There is some question that focusing on a shorter time will miss patients who were readmitted at 30 days, for instance, for a reason directly tied to hospital quality. Chin says that is possible but those instances probably would be uncommon and not skew overall data analysis on readmissions.
Even without changing from a 30-day analysis, early contact with the patient is critical to preventing readmission, says Patricia Hines, PhD, RN, Managing Director with Novia Strategies, a national healthcare consulting firm based in Ploway, CA. Readmission strategies will frequently focus on a follow-up call to the patient within 48 hours and a physician office visit within 5-7 days’ post-discharge
“A seven-day time frame is critical to ensure that the patient understands the discharge plan, the importance of medication adherence, compliance with follow-up appointments, and that there is an opportunity to intervene if the situation warrants,” she says. “A seven-day time frame allows the healthcare team to reassess the patient’s clinical situation and course, and to correct the plan of care to ensure the quality outcomes and goals are met on behalf of the patient.”