The Continued Challenges of Readmissions - Annals of Internal Medicine: Fresh Look Blog


Wednesday, April 11, 2018

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?

  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


  1. Dear Dr. Auron,
    I found your letter on the difficulty of managing older heart failure patients with multiple co-morbidities interesting. I am sure that it resonates with many hospitalist physicians. From my perspective, I noted two main issues in the care of heart failure patients that were not mentioned; addressing cognitive impairment and palliative care.

    The first is addressing the possibility of cognitive impairment and its impact on the patient's ability to manage complex medical issues at home. You noted extensive education provided to the patient; however, we and others have found that the majority of patients over 70 hospitalized with heart failure have inadequate executive function to manage their complex regimens. Heart failure management requires the ability to process information and to act upon it effectively. We and Gordoreski studied this issue and found heart failure patients with cognitive impairment identified by a Mini-Cog had a significantly higher readmission risk than heart failure patients with normal Mini-Cogs. I believe in this case, it would be critical to screen for cognitive impairment, especially executive function, and to provide education to caregivers and family if impairment is present.

    Secondly, it seems that this patient should be evaluated and considered for palliative care goals as none of his medical conditions are curable and his mortality escalates each time he is readmitted. Dr. Gorodeski also wrote a recent article on an "Outpatient Palliative Cardiology Service embedded within a Heart Failure Clinic". It is extremely difficult with multiple comordities to estimate prognosis; however, as we see his difficulty with management of heart failure symptoms and quality of life declining, it seems palliative approaches should be considered.
    I hope that these suggestions are helpful.

    Kathryn Agarwal, MD
    Section of Geriatrics
    Baylor College of Medicine
    Houston TX

    Outpatient Palliative Cardiology Service Embedded Within a Heart Failure Clinic: Experiences With an Emerging Model of Care. Gandesbery B, Dobbie K, Gorodeski EZ.
    Am J Hosp Palliat Care. 2018 Apr;35(4):635-639. doi: 10.1177/1049909117729478.

    Mini-cog performance: novel marker of post discharge risk among patients hospitalized for heart failure. Patel A, Parikh R, Howell EH, Hsich E, Landers SH, Gorodeski EZ. Circ Heart Fail. 2015 Jan;8(1):8-16. doi: 10.1161/CIRCHEARTFAILURE.114.001438.

    Unrecognized Cognitive Impairment and Its Effect on Heart Failure Readmissions of Elderly Adults. Agarwal KS, Kazim R, Xu J, Borson S, Taffet GE. J Am Geriatr Soc. 2016 Nov;64(11):2296-2301. doi: 10.1111/jgs.14471.

  2. Dear Dr. Agarwal,

    Your comments are extremely insightful and pertinent and I couldn't agree more.

    We often tend to miss the forest for the trees. Having a "larger picture" perspective is paramount and indeed, a formal assessment of cognitive functioning is fundamental, especially among elderly patients. More importantly, earlier introduction of palliative medicine services are also required in a large number of patients.

    However, a significant barrier to this, is the decreased insight that either the patient or the family have around their overall health condition. They don't see readmissions as a marker of poor functioning. And this is an opportunity that we have the enhance the dialogue with our patients and their families.

    I really appreciate your enthusiastic and well reasoned response.

  3. Hi Moises, great piece and enjoyed reading! Having worked in many safety net hospitals I can relate to the vignette you shared. I think there is a lot of promise that lies in using technology to help patients and ensuring that data is actionable and can be actively used and incorporated into a patient's daily life whether that is by the patient directly, a family member, a friend or another caretaker. I think that when people readily have access to actionable data then broader conversations can be held which will facilitate shared decision making leading to better solutions and better care.


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