Hospital Readmissions: in search of potentially avoidable costs (Text Version)
On September 14, 2009, Bernard Friedman made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (646 KB).
Hospital Readmissions: in search of potentially avoidable costs
Bernard Friedman, PhD
Center for Delivery, Organization, and Markets
AHRQ Conference, 2009
- Multiple uses of readmission data
- Quality of inpatient care
- Effectiveness of management of chronic illness outside the hospital
- Efficiency in arrangements for post-hospital care
- Accountability for health plans: consumer choice and P4P
- Measurement choices depend on motives
- Types of index admisssion, length of follow-up, eligible readmissions
- Tracking readmissions for the NHQR - it's evolving
- Recent research project: Contrast Medicare FFS vs. Advantage plan patients
Some AHRQ Published Studies on Readmissions
- Joanna Jiang was the lead author at AHRQ on several published studies of diabetes discharges.
- One finding was that half of the discharges or hospital costs in a year are for people with multiple discharges for diabetes and its complications.
- I examined (with Joy Basu) all readmissions within 6 months for people with 16 Potentially Preventable initial admissions.
- Large variety of principal diagnoses for the RE-admission
- Just the re-admissions in the 16 categories of potentially preventable within 6 months had a projected national cost of about $1.4 Billion in 2008$. This covered only 4 states with 15% of the U.S. population.
Readmissions and Quality of Inpatient Care
- 3.) William Encinosa and Fred Hellinger recently published "The Impact of Medical Errors on 90 Day Costs and Outcomes: An Examination of Surgical Patients". Health Services Research, 2008
- About $1.5 billion of cost in 3 months subsequent to the initial discharge due to safety events. Some of that was readmissions.
- 4.) B. Friedman, J. Jiang, W. Encinosa, R. Mutter, "Do patient safety events contribute to readmissions?" Medical Care, 2009.
- Risk of a readmission within 1 month or 3 months after a surgical admission was raised about 20% by a safety event.
Effective Management of Chronic Conditions
- 5.) B. Friedman, with Joanna Jiang and Anne Elixhauser,
- "Costly Hospital Readmissions and Complex Chronic Illness", Inquiry, Winter, 2008/2009
- About 5 million adults were covered by the data
- Shows importance of the number of different chronic conditions in predicting readmission rates and annual cost. ("complexity")
- Not easily "fixed" with disease-specific management protocols. But there is literature on demonstrations of other approaches.
- 8% of the hospital costs for adults could be saved if you could bring down the extra readmissions for the 25% of hospitalized adulsts with 5 or more chronic conditions.
- There have been a couple dozen demonstration projects of how to do that. It isn't free, of course.
NHQR 2008 Readmissions
- Tracking system quality and system efficiency
- Congestive Heart Failure, readmission for same.
- Readmission within 30 days (to any hospital)
- Short enough to implicate the discharge planning, handoff, patient counseling
- Not apportioning blame (could be other factors)
- The national burden of readmissions: one person can have more than one readmit during the year qualifying to be counted (30 days from previous admit).
- Comparison of states within age groups (big difference between states, but not between age groups)
Choices for Future Years NHQR
- Suggestions should go to Ernie Moy or Ryan or ...
- Multiple index admissions, with statistical controls
- Readmission after elective treatment, after delivery
- State or area rates with risk adjustment.
Do Medicare Advantage Patients Have Fewer Readmissions?
- Coauthors: B. Friedman, J. Jiang, John Bott, Claudia Steiner.
- Database: 5 states in HCUP with breakdown of type of Medicare coverage and with person identifiers.
- Theory: superficially, it seems that the Advantage plans have both the motive (capitated revenue) and the means to reduce readmissions in comparison to FFS Medicare.
- Same 1-month rate of readmission (10%)
- Somewhat lower 3-month readmission rate (21% vs. 22.5%).
- However, Advantage patients tend to be
- A little younger
- Less severely ill even when hospitalized
- Less likely to have a major operative procedure.
- Use risk adjustment and control for selection bias (predictors for joining an Advantage plan)
- Manuscript available on methods
- Advantage patients are one third more likely to have a readmission (in 30 days, 13% vs. 10%; in 90 days, 30.5% vs. 22.5%).
- How reconcile with incentives?
- Maybe we did something wrong....
- Enrollees have no comparative data
- FFS more discharges to LTC and other facilities
- Advantage plans might be spending less on outpatient service and quality than we expected?