Jha, Ashish K.

Journal of the American Heart Association

Harvard University - DASH 

 Reducing Readmissions: What Might it Take?  (Article begins on next page)The Harvard community has made this article openly available.Please share how this access benefits you. Your story matters.Citation Jha, Ashish K. 2014. “Reducing Readmissions: What Might itTake?” Journal of the American Heart Association: Cardiovascularand Cerebrovascular Disease 3 (3): e001080.doi:10.1161/JAHA.114.001080.http://dx.doi.org/10.1161/JAHA.114.001080.Published Version doi:10.1161/JAHA.114.001080Accessed February 17, 2015 10:16:59 AM ESTCitable Link http://nrs.harvard.edu/urn-3:HUL.InstRepos:13890617Terms of Use This article was downloaded from Harvard University's DASHrepository, and is made available under the terms and conditionsapplicable to Other Posted Material, as set forth athttp://nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of-use#LAAReducing Readmissions: What Might it Take?Ashish K. Jha, MD, MPHWhy do some patients discharged from a hospital comeback whereas others do not? This is a question thathas been vexing clinical and policy leaders over the past5 years. Spurred by the Hospital Readmissions ReductionProgram, hospitals have begun to focus on ensuring thatpatients are not readmitted soon after they are discharged.Efforts include improving discharge planning, setting up moreeffective follow-up, and improving clinical quality so thatpatients are not readmitted for complications of care. Theseefforts have worked to an extent. Five years after publicreporting of readmission rates went into effect, we havestarted to see the frequency with which patients arereadmitted decrease. The latest data suggest that readmis-sion rates have fallen by 1 percentage point, from approxi-mately 19% of all discharges to 17.8% of all discharges in theMedicare population.1Although this is an improvement, we are not nearly done.There is emerging consensus that some drivers of readmissionsare accountable to the hospital providing the initial acute care,but a large component of readmissions may be driven bypatient socioeconomic factors or community-level factors. It isin that context that the study by Brown and colleaguespublished in this issue of JAHA provides important empiricalinsight. Using national Medicare data, they ﬁnd that hospitalswith more medical admissions, more physicians, and greaterintensity of health care utilization had higher readmissions.2What do these insights tell us?First and foremost, we know that admissions andreadmissions are linked. Readmissions are, at their simplestform, an admission for a patient who was discharged withinthe last 30 days. I trained in San Francisco. When I moved toBoston, I was surprised to ﬁnd that we would admit peoplewho would have been treated as outpatients in the Bay Area.However, it was unclear which place provided better care—itwas simply only different care. Some hospitals have a lowerthreshold for admitting someone and that translates into bothlower admission and readmission rates, a relationship thathas been consistently born out in Medicare literature.3Second, whereas the notion that having a higher per capitarate of primary care physicians is associated with higherreadmission rates will strike many casual observers ascontradictory, it is quite consistent with the broader literature.Primary care is supposed to prevent these readmissions.However, empirical data suggest that our mental model forwhy people are readmitted may need updating. In manyinstances, having more primary care physicians—and, indeed,more primary care visits—may simply increase the chancesthat someone will pay close attention and ensure that peoplewho are ill get additional care.4 It is unsurprising that greaterclinical attention—and greater clinical intensity—is associ-ated with a higher likelihood of returning to the hospital.All of this gets to the broader point about readmissions andwhat they represent. They are, ultimately, a narrow way togauge the quality and costs of care for patients dischargedfrom the hospital. Some patients, because of poor hospitalcare or poor transitions, may die or spend weeks inrehabilitation hospitals or nursing homes. None of thosecount as a readmission and therefore get little scrutiny.However, the patient who returns for a short readmission4 weeks after discharge is seen as a clinical failure. These arethe consequences of a narrowly tailored measure. Though thereadmission rate as a utilization measure occasionally signalsquality failures, we can and need to do better. One approach isto look at the totality of care that occurs in the days to weeksafter discharge. We know that the risk of readmission remainselevated out to nearly 90 days after the patient leaves thehospital.5 A better way to gauge and pay hospitals might be tocreate a longer bundle—ask hospitals to be accountable for abroader swath of services (not just readmissions) and buildstrong quality metrics that ensure that we are not simplydenying access to critical services as a way to save money.Our nation has embarked on a series of important newreforms that seek to change the way we deliver and pay forcare. This is a good thing—the old way of doing things wasnot working well ﬁnancially or for our patients. The article byBrown et al. is an important reminder that the story ofThe opinions expressed in this article are not necessarily those of the editorsor of the American Heart Association.From the Department of Health Policy and Management, Harvard School ofPublic Health, Boston, MA.Correspondece to: Ashish K. Jha, MD, MPH, Department of Health Policy andManagement, Harvard School of Public Health, 677 Huntington Ave, Kresge409, Boston, MA 02115. E-mail: ajha@hsph.harvard.eduJ Am Heart Assoc. 2014;3:e001080 doi: 10.1161/JAHA.114.001080.ª 2014 The Authors. Published on behalf of the American Heart Association,Inc., by Wiley Blackwell. This is an open access article under the terms of theCreative Commons Attribution-NonCommercial License, which permits use,distribution and reproduction in any medium, provided the original work isproperly cited and is not used for commercial purposes.DOI: 10.1161/JAHA.114.001080 Journal of the American Heart Association 1EDITORIALreadmissions is a complex one—affected not just bydischarge planning, but also by the broader milieu of carethat exists outside the hospital. If we want hospitals to beresponsible for improving care and reducing costs, we willhave to think beyond admissions and readmission.DisclosuresNone.References1. Statement of Jonathan Blum, Acting Principal Deputy Administrator andDirector, Center for Medicare, Centers for Medicare & Medicaid Services onDelivery System Reform: Progress Report from CMS, before the U.S. SenateFinance Committee. February 28, 2013.2. Brown JR, Chang CH, Zhou W, MacKenzie TA, Malenka DJ, Goodman DC. Healthsystem characteristics and rates of readmission after acute myocardialinfarction in the United States. J Am Heart Assoc. 2014;3:e000714doi:10.1161/JAHA.113.000714.3. Epstein AM, Jha AK, Orav EJ. The relationship between hospital admission ratesand rehospitalizations. N Engl J Med. 2011;365:2287–2295.4. Weinberger M, Oddone EZ, Henderson WG. Does increased access to primarycare reduce hospital readmissions? Veterans Affairs Cooperative Study Groupon Primary Care and Hospital Readmission. N Engl J Med. 1996;334:1441–1447.5. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in theMedicare fee-for-service program. N Engl J Med. 2009;360:1418–1428.Key Words: Editorials ￿ health policy and outcomesresearch ￿ health services research ￿ readmission ￿ systemsof careDOI: 10.1161/JAHA.114.001080 Journal of the American Heart Association 2Reducing Readmissions JhaEDITORIAL

Reducing Readmissions: What Might it Take?

http://dash.harvard.edu/bitstream/handle/1/13890617/4309111.pdf?sequence=1

Reducing Readmissions: What Might it Take?

Abstract

Similar works

Full text

Available Versions

Harvard University - DASH