Reducing readmissions requires better continuity of care

January 12th, 2015

I understand the thinking behind using 30-day readmissions as a measure of hospital quality – I really do. It’s relatively straightforward to measure, for one thing, and it stands to reason (if you don’t think too deeply about it) that if a hospital fixes a patient up right the first time then he or she shouldn’t have to come back for the same thing less than month later.

But people aren’t cars, and hospitals aren’t muffler shops, and there’s a pretty wide range of reasons for a bounce-back readmission that have little or nothing to do with the quality of the original care provided. Many of those reasons have to do with what happens after discharge. For example, does the patient have adequate family support? Does he or she understand when and how to take prescribed medication? Is the patient motivated to act on the instructions he or she was given at discharge, and is the patient’s home environment even safe?

Hospitals can address some of those issues with adequate post-discharge follow-up, but what about when a patient isn’t discharged home but to, say, an inpatient rehabilitation facility? How frequently do those patients end up readmitted to a hospital, and what are the reasons why? I was surprised to learn that, until recently, there hasn’t been a whole lot of research on the matter. But a study published in the February 12 issue of JAMA seems to have generated some interesting data on it.

The researchers analyzed the records of 736,536 Medicare fee-for-service beneficiaries who were discharged from 1365 inpatient rehab facilities between 2006 and 2011. The study focused on “the 6 most common reasons for receiving inpatient rehabilitation: stroke, lower extremity fracture, lower extremity joint replacement, neurologic disorders, brain dysfunction and debility,” according to a press release from JAMA about the study.

Overall, “Nearly 12 percent of Medicare patients who received inpatient rehabilitation following discharge from acute-care hospitalization are readmitted to the hospital within 30 days after discharge from the rehabilitation facility,” according to a press release from the University of Texas Medical Branch at Galveston, where the study’s lead author works.

The 30-day readmission rate was lowest (5.8%) for patients with lower extremity joint replacement and highest (18.8%) for patients with debility. According to the JAMA release, “Rates were highest in men, non-Hispanic blacks, and for persons with longer lengths of stay. Higher motor and cognitive ratings, indicating better patient function, were consistently related to lower readmission rates across all 6 categories.”

The researchers conclude that “Further research is needed to understand the causes of readmission.” That’s certainly true. But what’s also needed is more and better communication and cooperation among facilities at different levels of care, because whatever anyone might think of them, readmissions penalties aren’t going away. Are ACOs the answer, or something like ACOs? We’ll see. But it seems clear enough to me that in the new world of reformed healthcare, everyone’s going to have to be a little more up in each other’s business.