The Disappointing Impact of Interventions to Prevent Hospital Readmissions

Reducing rates of rehospitalization has attracted attention from policymakers as a way to improve quality of care and reduce costs. However, we have limited information on the frequency and patterns of rehospitalization in the United States to aid in planning the necessary changes. We analyzed Medicare claims data from 2003-2004 to describe the patterns of rehospitalization and the relation of rehospitalization to demographic characteristics of the patients and to characteristics of the hospitals. Almost one fifth (19.6%) of the 11,855,702 Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days, and 34.0% were rehospitalized within 90 days; 67.1% [corrected] of patients who had been discharged with medical conditions and 51.5% of those who had been discharged after surgical procedures were rehospitalized or died within the first year after discharge. In the case of 50.2% [corrected] of the patients who were rehospitalized within 30 days after a medical discharge to the community, there was no bill for a visit to a physician's office between the time of discharge and rehospitalization. Among patients who were rehospitalized within 30 days after a surgical discharge, 70.5% were rehospitalized for a medical condition. We estimate that about 10% of rehospitalizations were likely to have been planned. The average stay of rehospitalized patients was 0.6 day longer than that of patients in the same diagnosis-related group whose most recent hospitalization had been at least 6 months previously. We estimate that the cost to Medicare of unplanned rehospitalizations in 2004 was $17.4 billion. Rehospitalizations among Medicare beneficiaries are prevalent and costly. 2009 Massachusetts Medical Society

Patients with complex care needs who require care across different health care settings are vulnerable to experiencing serious quality problems. A care transitions intervention designed to encourage patients and their caregivers to assert a more active role during care transitions may reduce rehospitalization rates. Randomized controlled trial. Between September 1, 2002, and August 31, 2003, patients were identified at the time of hospitalization and were randomized to receive the intervention or usual care. The setting was a large integrated delivery system located in Colorado. Subjects (N = 750) included community-dwelling adults 65 years or older admitted to the study hospital with 1 of 11 selected conditions. Intervention patients received (1) tools to promote cross-site communication, (2) encouragement to take a more active role in their care and to assert their preferences, and (3) continuity across settings and guidance from a "transition coach." Rates of rehospitalization were measured at 30, 90, and 180 days. Intervention patients had lower rehospitalization rates at 30 days (8.3 vs 11.9, P = .048) and at 90 days (16.7 vs 22.5, P = .04) than control subjects. Intervention patients had lower rehospitalization rates for the same condition that precipitated the index hospitalization at 90 days (5.3 vs 9.8, P = .04) and at 180 days (8.6 vs 13.9, P = .046) than controls. The mean hospital costs were lower for intervention patients ($2058) vs controls ($2546) at 180 days (log-transformed P = .049). Coaching chronically ill older patients and their caregivers to ensure that their needs are met during care transitions may reduce the rates of subsequent rehospitalization.

Background: Many experts believe that hospitals with more frequent hospital readmissions provide lower quality of care, but little is known about how the preventability of readmissions might change over the post-discharge timeframe. Objective: To determine whether readmissions within 7 days of discharge are different from readmissions between 8 and 30 days after discharge with respect to preventability. Design: Prospective cohort study. Setting: 10 US academic medical centers. Patients: 822 adults readmitted to a general medicine service. Measurements: At each site, 2 physician assessors used a structured survey instrument to determine whether each readmission was preventable and to measure other characteristics of the readmission. Results: 36.2% of early readmissions versus 23.0% of late readmissions were preventable (median risk difference 13.0%, 25 th , 75 th percentile 5.5, 26.4). The hospital was identified as a better location to prevent an early readmission than a late readmission (47.2% vs. 25.5%, [median risk difference 22.8%, 25 th , 75th percentile 17.9, 31.8]). In contrast, the outpatient clinic (15.2% vs. 6.6%, [median risk difference 10%, 25 th , 75th percentile 4.6, 12.2]) and home (19.4% vs. 14%, [median risk difference 5.6%, 25 th , 75th percentile −6.1, 17.1]) were identified as better locations to prevent late readmissions than early readmissions. Limitations: Physician assessors were not blinded to readmission timing. In addition, community hospitals were not included in the study, and readmissions to non-study hospitals were not included in the results. Conclusions: Early readmissions were more likely to be preventable and amenable to hospital-based interventions. Late readmissions were less likely to be preventable and were more amenable to ambulatory and home-based interventions.