Higher Readmissions, Better Outcomes?
When it comes to rating hospital quality, 30-day readmission rates have become a key indicator of a facility’s clinical care. Readmissions, as conventional wisdom goes, often occur when providers fail to properly manage patients’ treatment during their initial stay and they are hospitalized again a few weeks later. However, a new study from Johns Hopkins casts doubt on the underlying assumption by suggesting that hospitals with higher readmissions rates actually have better mortality rates for several medical conditions.
The study, published in the Journal of Hospital Medicine, examined three years of mortality data at 4,500 hospitals, specifically rates for heart attack, pneumonia, heart failure, stroke, COPD, and coronary artery bypass. Surprisingly, hospitals with higher readmissions rates scored higher in survival rates for heart failure, COPD, and stroke. The discrepancy was particularly evident in heart failure mortality rates, and hospitals in the lowest third by readmissions performed nearly twice as well as those in the first. An analysis of Definitive Healthcare data is consistent with Johns Hopkins’ findings. When divided into quartiles by readmission percentile, the lowest quartile does score better than the first by about 4.5 percent for COPD, 2.7 percent for stroke, and 4.2 percent for heart failure.
Avg Mortality Rates by Hospital Readmission Rate Quartile
|First Quartile||Second Quartile||Third Quartile||Fourth Quartile|
Source: Definitive Healthcare
How could hospitals with substantially higher readmission rates outperform better-scoring hospitals on mortality rates? The authors of the Johns Hopkins study give several possibilities, mostly concerning how mortality rates are measured. For instance, some hospitals may place patients in hospice programs rather than care for them as inpatients for longer periods, in which case the death of a patient undergoing palliative care would not count against the hospital’s mortality rate. Also, they speculate that attempts to delay patients’ readmissions to the hospital could end up delaying medically necessary care. In addition, a hospital that better manages a patient’s inpatient treatment until discharge may have a higher readmission rate than a hospital that does worse and whose patient dies outside of its care.
Does the inverse readmission-to-outcome trend hold true for other quality measures? A look at the latest Definitive Healthcare quality data for 2016 alone suggests that hospitals with higher readmissions tend to fare worse in most other categories, especially hospital-acquired infections. Using the same quartiles, hospitals with fewer readmissions had substantially lower rates of MRSA, C Diff, and central-line-associated blood stream infections and; as well as lower rates of serious complications and serious blood clots after surgery. While not as statistically rigorous as the Johns Hopkins study, the results suggest that higher readmission rates appear to be associated with some negative quality outcomes.
The study’s findings pose special significance for CMS and its Readmission Reduction Program, as it could be penalizing hospitals for low scores in a potentially misleading metric. While hospitals are also assessed for their mortality rates through the Value-Based Purchasing Program, CMS weighs readmission scores more heavily to calculate each hospital’s reimbursement penalty. Critics have long complained that CMS’ quality initiatives, including the Readmission Reduction Program, fail to account for factors like patient demographics, and the Johns Hopkins study offers some support to their argument. Of course, the study is not conclusive, and its authors point out that more thorough research is needed. What’s more, they also suggest that mortality rates alone may not adequately measure a hospital’s quality and a low number could disguise inadequate care. What is certain, though, is that CMS, or any analysts for that matter, have not yet devised a single metric for hospital quality that pleases everyone.
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