There is broad interest among policymakers in improving the quality of care for HF patients, with a growing focus on reducing readmissions. We found that patients discharged from hospitals which tend to be resource-poor either for financial reasons, clinical reasons, or both – specifically, publicly-owned hospitals, hospitals located in counties with low median income, hospitals without cardiac capability or with low nurse staffing, and small hospitals – had consistently higher 30-day readmission rates. Although many of these differences were modest in size, for the hospitals, they translated into significantly higher odds of having HF readmission rates in the worst quartile nationally. When we chose other thresholds, such as the worst decile nationally, our results did not change meaningfully. Our findings suggest that if CMS or private pay-for-performance programs use cut points to determine financial penalties, these institutions may be at greater risk for reduced payments.
We found that patients discharged from public hospitals in the U.S. had modestly higher readmission rates than those discharged from non-profit hospitals, although the effect was attenuated by adding county income to the model. Public hospitals already suffer from insufficient and inconsistent funding,21
factors which have been independently linked with poor quality care,22
and have previously been shown to have more difficulty improving performance on publicly reported quality metrics,23–25
Whether the higher readmission rates are due to under-investment in case management and discharge planning, or due to caring for a more challenging and vulnerable patient population with less access to follow-up care, is unclear. Indeed, studies have shown that socioeconomic status impacts the risk of readmission for patients with HF, likely due to differential access to care.26, 27
This is congruent with our finding that patients discharged from hospitals counties with a lower median income have higher readmission rates, suggesting that the economic context surrounding hospitals and the patients they care for is important to their chances of having low readmission rates. If public hospitals, or hospitals located in poor communities are financially penalized for high readmission rates, disparities in care could be further exacerbated.
We found that better clinical capacity, whether defined as the presence of specific cardiac services or as a high level of nurse staffing, was associated with lower readmission rates for patients with HF, even after controlling for other hospital characteristics; we also found that clinical capacity explained some – though not all – of the impact of hospital size on readmissions. We suspect that our measures of cardiac services are markers of expertise in caring for cardiac patients, which in turn leads to better outcomes. Prior studies have shown that hospitals with cardiac surgical capability tend to have better adherence to process of care guidelines for MI,28, 28, 29
but there are no data that we are aware of that examines how hospitals with or without these services fare on outcomes for HF. Prior studies have also found that higher nurse staffing leads to better inpatient care and outcomes,17, 30
but the impact of nurse staffing on readmissions has not, to our knowledge, previously been explored. Finding ways to help hospitals without advanced cardiac services, perhaps through partnerships or alliances with more advanced hospitals, could lead to improved access to cardiac care at smaller or more remote hospitals and better outcomes for the Americans who receive their care there. Addressing nurse staffing levels might be more difficult; there is no national standard for staffing levels,17
and the nationwide nursing shortage, coupled with the economic challenges faced by hospitals in hiring new staff, present significant barriers.
Patients discharged from small hospitals had higher readmission rates, even after we adjusted for the availability of cardiac services at these hospitals. Whether this finding reflects inexperience with inpatient HF management, lack of adequate discharge planning, or lack of access to outpatient follow-up is unclear. Given that small rural hospitals often have fewer resources, less funding, fewer physicians and other care providers per capita, and fewer specialists,13
our findings may not come as a surprise. Further, small hospitals may have fewer financial resources and may not be able to easily justify investments in HF-specific discharge planning, care coordination, and transitions of care, elements which may reduce readmissions for patients with HF.31, 32
If hospital payments for readmissions are reduced, given their already-poor performance, further diminishing their resources with financial penalties may pose new challenges. As a result, small hospitals might transfer their sickest patients to larger referral centers or avoid them altogether – diminishing their own proficiency with treating HF patients and reducing access for their patient population.
Others have examined hospital characteristics and readmission rates. Krumholz et al found little difference in readmission rates for patients with HF between large and small hospitals, between teaching and non-teaching hospitals, and between hospitals with different ownership.33
However, they used a different method of risk adjustment,15
as discussed above, which almost surely explains the differences in the findings. Recent studies have found no difference in readmission rates between hospitals that perform well on the HQA quality measures and hospitals that perform poorly on these measures,8, 34
leaving us with little information to predict which hospitals might ultimately face financial penalties. Thus, our findings that there are specific hospital characteristics that are related to readmission rates may be helpful as policy makers grapple with how to target efforts in this area.