Among fee-for-service Medicare beneficiaries discharged alive after hospitalization for HF, we found that recent risk-standardized hospital-specific 30-day readmission rates approached 25% across the United States in each of 3 years we studied, consistent with prior estimates,9
and that there were no clinically important changes in readmission rates over this time period. Our findings demonstrate that there has been no aggregate improvement, across the nation or in any geographic region, in readmission rates after HF hospitalization. Readmitting nearly a quarter of patients after HF hospitalization within 30 days is not likely to represent optimal care for patients and suggests that there is substantial room and a clear opportunity for improvement that might be achieved through enhancing the quality of inpatient care or through improved transitions from the inpatient to the outpatient environments. Paying greater attention to hospital readmission rates through surveillance efforts such as public reporting may be an important first step towards this goal.
We found similar heterogeneity among hospital performance in all three years. Half of U.S. hospitals were found to have RSRRs within 1.5% of one another, suggesting that there is little variability in the effectiveness of hospitals’ approach to managing transitions of care among patients discharged after HF hospitalization and that all U.S. hospitals appear to be facing similar challenges in preventing readmissions. Although the lack of practice variation prohibits our exclusion of the possibility that all hospitals are functioning at peak efficiency and are providing transition care of the highest quality, several clinical interventions have been shown to lower readmission rates below usual care. We cannot determine whether all the patients discharged after HF hospitalization were consistently provided with necessary services and medications, or whether they were taught how to manage their health and monitor their symptoms, or they had an appointment scheduled with their primary care physician, who had received necessary and critical information about the patient’s hospitalization, to ease the transition from the hospital to home. However, each of these actions represents a previously identified strategy to minimize hospital readmissions after HF hospitalization that ideally would be widely used and are likely to lower readmission rates within 30 days below 25%.13, 14, 18, 19, 21, 22
Despite randomized, controlled trials of post-discharge HF disease management repeatedly demonstrating patient benefits and reduced costs,14–16, 22
practices proven to be effective in U.S. studies have generally not been continued or expanded, mostly because of financial constraints, whereas similar practices proven to be effective in other countries have often become permanent.25
We hypothesize that the hospital performance we have observed is likely to be a function of the current fee-for-service payment system and future research is needed to examine readmission rates in health systems that do not use a fee-for-service payment system, such as the Veterans Health Administration. Rather than rewarding better outcomes, current CMS hospital and physician payment policy rewards greater volume. Piecemeal payment is an economic incentive for health care providers, both hospitals and physicians, to increase patient volume and service intensity during hospitalizations in order to increase revenue. In contrast, CMS payments are low or do not exist for the services that have been proven to lower hospitalization rates, such as disease management strategies. Appropriate delivery of these services may potentially reduce hospitalization revenue substantially without creating reciprocal revenue elsewhere, even if hospitals offer extensive ambulatory care services, which would in turn impede hospitals and physician groups from adopting such strategies.25
Fortunately, MEDPAC recently recommended that CMS alter its payment policy and re-align financial incentives, driving collaborations and clinical integration between hospitals, physicians, nurses, and other outpatient services by bundling payments around a hospitalization.3
Action needs to be taken to ensure that these reforms are enacted and financial incentives are established to improve transition care quality, thereby lowering readmission rates.
Public reporting of hospital readmission rates offers an important opportunity to provide a visible incentive for health care quality improvement by promoting informed patient choices, fostering hospital concern for protecting or enhancing its public image, and providing objective feedback that fuels professional desires to improve care.26–28
At the very least, ongoing public reporting efforts by CMS can be used to inform practice and policy, rather than being isolated from them as in the past,25
to identify high quality hospitals that can be subsequently examined in an effort to determine which structures and processes of care enable and sustain the provision of high quality care or low quality hospitals whose performance can be subsequently addressed.
Our study is among the first to describe national estimates of hospital-specific 30-day all-cause readmission rates after HF hospitalization, using a risk-standardization model to determine hospital performance that was endorsed by the National Quality Forum and validated using chart-abstracted data. However, there are considerations in interpreting our results. First, we examined readmission outcomes only for patients who had been discharged after hospitalization for HF, so that our results may not be generalized to other conditions. However, HF is among the most common hospital discharge diagnoses and readmission after HF hospitalization has been shown to be modifiable through controlled interventions, justifying our focus on the condition. Second, we only examined readmission outcomes for HF patients and did not address other important dimensions of quality, such as mortality, processes of care, health status outcomes or other patient care experiences, such as treatment satisfaction. Third, although our study provides insights for understanding health care delivery in the United States, it was limited to fee-for-service Medicare beneficiaries and the hospital readmission rates we estimated using this population may not be representative of the readmission rates of other populations. Finally, because of Medicare data availability, we only report on readmission trends through 2006. We are unable to determine whether other recent efforts outside of CMS to lower hospital readmission rates, such as the focus on readmission rates by the Institute for Healthcare Improvement, have had an impact over the past 2 years.
In conclusion, there has been no recent national or regional improvement in hospital readmission care among Medicare beneficiaries discharged alive after HF hospitalization. Recent national hospital-specific risk-standardized readmission rates approached 25% for the most common discharge diagnosis among Medicare beneficiaries and the distribution in hospital performance has not changed. Given the need to lower readmission rates, it is hoped that the upcoming efforts by CMS to publicly report HF RSRRs for all hospitals can offer an important opportunity to drive health care quality improvement.