The Continued Challenges of Readmissions

Established through the Patient Protection and Affordable Care Act, the Hospital Readmissions Reduction Program (HRRP) allows Medicare to adjust payment in order to penalize hospitals for excessive readmission rates for specific diseases (e.g., heart failure). As noted in a recent Annals article, 30-day risk-standardized readmission rates decreased rapidly after the passage of the HRRP, especially among the hospitals with higher number of readmissions before the program (1). 

As a hospitalist who witnesses the suffering and burden that acute disease places on patients, I experience the challenges that remain despite the apparent success of the HRRP. In particular, what makes my work so challenging is trying to meet each patient’s needs while recognizing that readmissions place a significant burden on the health care system and economy and may reflect insufficient communication and coordination in the transition from hospital discharge to home.

My experience with Mr. J exemplified this well. An elderly man with long-standing hypertension, diabetes, and ischemic cardiomyopathy, Mr. J had been admitted 4 times over the course of 6 months and a few times within a 30-day span for acute decompensated heart failure. His condition was also affected by obesity hypoventilation syndrome and active smoking.

The care team worked on implementing multiple interventions as part of Mr. J’s care. Despite the low strength of evidence reported in a recent Annals paper (2), we nonetheless worked to achieve a lower predischarge NT-pro-BNP threshold to reduce Mr. J’s risk for mortality and readmission. Beyond clinical interventions, we also worked on accurate and thorough medication reconciliation and educated Mr. J about heart failure, diabetes, and smoking cessation. We set him up with home health services and early follow-up appointments with a primary care physician, cardiologist, and pulmonologist. Despite these interventions, Mr. J’s quality of life did not improve. He continued to struggle with poor function and treatment adherence, with subsequent readmissions that negatively affected his personal and professional life.

What can be gleaned from the fact that hospitals have successfully reduced readmissions overall while many clinicians encounter challenging cases like Mr. J’s? One major lesson is well-described but is worth reiterating: Because of strong socioeconomic determinants of care, such as poverty, education, transportation, there is most likely a limit to organizational success in decreasing readmissions until these factors are appropriate addressed. This is a reality that clinicians caring for high-need patients know through experience.

Certainly, hospitals and physicians must continue striving to be better and to do the right thing for patients. We need mechanisms to ensure that educational interventions are delivered at the appropriate reading level but are not rushed; that medication reconciliation is thorough, complete, and accurate; and that doctors, nurses, and pharmacists spend time and treat patients empathetically. However, several years into the HRRP and despite overall progress, the question remains: As we assume increasing accountability for patient outcomes and extend interventions to patients like Mr. J, how will patients and other stakeholders be encouraged to assume accountability in this process as well?

References

1. Wasfy JH, Zigler CM, Choirat C, Wang Y, Dominici F, Yeh RW. Readmission rates after passage of the hospital readmissions reduction program: a pre-post analysis. Ann Intern Med. 2017;166:324-31. [PMID: 28024302] doi:10.7326/M16-0185
2. McQuade CN, Mizus M, Wald JW, Goldberg L, Jessup M, Umscheid CA. Brain-type natriuretic peptide and amino-terminal pro-brain-type natriuretic peptide discharge thresholds for acute decompensated heart failure: a systematic review. Ann Intern Med. 2017;166:180-90. [PMID: 27894126] doi:10.7326/M16-1468