Readmission causes, timing and reductions analyzed

Readmissions of recently hospitalized patients were the focus of several studies published last week in the Jan. 23/30 Journal of the American Medical Association.

The first study assessed Medicare patients who were hospitalized between 2007 and 2009 for heart failure (HF), acute myocardial infarction (MI) or pneumonia. Within 30 days of discharge, 24.8% of HF patients had been readmitted, as had 19.9% of MI patients and 18.3% of pneumonia patients. However, most of these patients were readmitted for a reason other than the primary diagnosis of their initial hospitalizations. Researchers also looked at the timing of readmissions, finding that the median time to readmission was 10 days for MI and 12 for HF and pneumonia, but that readmissions were frequent throughout the month. Based on these findings, the authors called for broader approaches to preventing readmissions, rather than efforts focused on specific diseases or limited time periods after discharge.

The second study looked at how often recently hospitalized patients had treat-and-release visits to emergency departments (EDs), in addition to being readmitted. The prospective study included more than four million patients 18 and older hospitalized in California, Florida and Nebraska in 2008 to 2009. Researchers found that 17.9% of hospitalizations resulted in another acute care encounter within 30 days. Most of these encounters were hospital readmissions, but 39.8% were treat-and-release ED visits. The rate of ED visits varied by condition, with digestive disorders and psychosis being the highest-volume causes. The most common reasons for returning to the ED were related to the diagnosis of the initial hospitalization. Study authors concluded that the many studies and interventions focused solely on 30-day readmissions miss these common ED encounters.

Finally, the third study reported on a successful effort to reduce readmissions, conducted by the Centers for Medicare and Medicaid Services. A multicomponent care transitions intervention was applied in 14 communities in 2009 to 2010, and 30-day readmission rates were compared before and after in the intervention communities and 50 control communities. The mean rate of 30-day readmissions dropped in both groups, but more significantly in the intervention communities; intervention communities dropped from 15.21 readmissions per 1,000 beneficiaries per quarter in 2006 to 2008 to 14.34 in 2009 to 2010 versus from 15.03 per 1,000 to 14.72 in control communities over the same time periods (P=0.03). The overall mean rate of hospitalizations followed a similar trend, with the result that readmissions didn't decrease as a percentage of all hospitalizations. The authors noted that the project's interventions (such as better elder care in the community, palliative care counseling, disease management, and care plans) were intended to improve the quality of care transitions.

Combined, the findings of these studies support a patient-centered approach to improving care and reducing readmissions, concluded an accompanying editorial. The studies highlight the fragmentation of care under the current system. Attempts to correct this and reduce readmissions should be broadly focused, using multiple solutions and engaging the community, the editorialist wrote.