Thirty-Day Readmissions — Truth and Consequences

Nejm.org: Karen E. Joynt, M.D., M.P.H., and Ashish K. Jha, M.D., M.P.H., N Engl J Med 2012; 366:1366-1369, April 12, 2012

Reducing hospital readmission rates has captured the imagination of U.S. policymakers because readmissions are common and costly and their rates vary — and at least in theory, a reasonable fraction of readmissions should be preventable. Policymakers therefore believe that reducing readmission rates represents a unique opportunity to simultaneously improve care and reduce costs. As part of the Affordable Care Act (ACA), Congress directed the Centers for Medicare and Medicaid Services (CMS) to penalize hospitals with “worse than expected” 30-day readmission rates. This part of the law has stimulated hospitals, professional societies, and independent organizations to invest substantial resources in finding and implementing solutions for the “readmissions problem.”

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. Read more