Author + information
- Demi Adedinsewo, MD, MPH∗ (, )
- Eric Chang, MD,
- Titilope Olanipekun, MD, MPH and
- Anekwe Onwuanyi, MD
- ↵∗Division of Cardiology, Department of Internal Medicine, Morehouse School of Medicine, Grady Memorial Hospital, 80 Jesse Hill Jr. Drive Southeast, Atlanta, Georgia 30303
The article by Pandey et al. (1) regarding the 30-day readmission metric for heart failure (HF) provides additional evidence that this metric may not be a great measure of hospital quality or performance. Readmissions as defined by the Center for Medicare and Medicaid Services (CMS) are admissions to a hospital within 30 days of discharge from the same or another hospital. It was interesting to find that there were no differences in performance measures, defect-free care, or 1-year clinical outcomes (mortality and all-cause readmission rates) between hospitals with low and those with high-risk-adjusted 30-day readmission rates.
The authors acknowledge that unplanned readmissions pose a huge economic burden, making it a top health policy priority to target readmissions as an intervention to lower health care costs. The federal Hospital Readmissions Reduction Program, which became effective in 2012, enforces a payment reduction model for hospitals with a high calculated excess readmission ratio for specific health conditions, including HF (2). Cost was not evaluated as an outcome by the authors, even though this remains an important factor in the management of chronic HF. Although patients with high readmission rates may not differ in long-term clinical outcomes compared to those with lower rates, they are probably more likely to cost the health system much more. There have been concerns about increased patient mortality as a possible reason for relatively low readmission rates in some hospitals, but the authors showed that this difference was not statistically significant. Given that readmissions continue to be the main driver of cost, the 30-day readmission metric may not be going away anytime soon. This metric will most likely force hospitals to consider system-based interventions geared toward socioeconomic barriers to care, challenges to care transitions, and essential health education. We believe that readmissions within 30 days of discharge are likely more reflective of the process and transition of care during an index admission, whereas readmissions beyond 30 days are more likely related to disease progression. The information lacking at this time is whether the cost of implementing comprehensive heart failure programs to reduce readmissions ultimately saves health care dollars compared to readmission costs. Stauffer et al. (3) conducted a budget impact analysis of an advanced practice nurse-led transitional care program for HF, and they demonstrated that it reduced the hospital financial contribution margin by reducing 30-day readmission rates.
In order to develop a valid and comprehensive metric for evaluating quality of care and cost effectiveness, the entire continuum of care needs to be considered, which includes patient demographics, patient-to-physician ratio, patient socioeconomic conditions, hospital referral base, hospital facilities, hospital staff (professional and ancillary), and other factors, and this is difficult to capture completely. However, until then, we may have to rely on the current, albeit imperfect, metric to save health care costs and learn from the hospitals that have been successful at reducing readmissions.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2017 American College of Cardiology Foundation
- Pandey A.,
- Golwala H.,
- Xu H.,
- et al.
- ↵Readmissions Reduction Program. Centers for Medicare and Medicaid Services. 2016. Available at: https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html. Accessed April 4, 2016.