Readmissions, Observation, and the Hospital Readmissions Reduction Program

Hospital readmissions are an ongoing issue in many communities. In attempt to correct this issue, the Hospital Readmissions Reduction Program, which is part of the Affordable Care Act (2010), applies financial penalties to hospitals that have higher-than-expected readmission rates for specific conditions. It is a concern, however, that reductions in readmissions are being achieved by keeping the returning patients in observation units for a longer period of time instead of formally readmitting them. The purpose of this study was to examine changes in readmission rates and stays in observation units over time. This study also assessed whether hospitals that had greater increases in observation-service use had greater reduction in readmissions.

During this study, hospital-level rates of readmission and observation-service use within 30 days after discharge were compared monthly among Medicare beneficiaries. This study took place between October 2007 and May 2015 and 3387 hospitals were analyzed. From 2007 to 2015, readmission rates for targeted conditions declined from 21.5% to 17.8%. Also, rates for non targeted conditions declined from 15.3% to 13.1%. Furthermore, stays in observation units for targeted conditions increased from 2.6% in 2007 to 4.7% in 2015. Overall, there was no significant association between changes in observation-unit stays and readmissions after implementation of the ACA in 2010.

Readmission trends seem to be consistent with hospitals’ responding to incentives to reduce readmissions. There was no conclusive evidence supporting that changes in observation-unit stays solely accounted for the decrease in readmissions.

Zuckerman, Rachael B., Sheingold, Steven H., Orav, John., et al. Readmissions, Observation, and the Hospital Readmissions Reduction Program. N Engl J Med. 2016.

In-Hospital Outcomes and Costs Among Patients Hospitalized During a Return Visit to the Emergency Department

In this article, researchers explored what types of outcomes patients experience as well as what resources are utilized when patients are hospitalized during a unscheduled return visit to the ED.  The study looked at parameters including in-hospital mortality, ICU admission, length of stay, and inpatient costs.

Unexpectedly, patients who returned to the ED after initially being discharged had a lower in-hospital mortality rate. They also had lower ICU admission rates, lower hospital costs, and longer lengths of stay.  They article attempts to suggest that the idea of readmission as a negative might not tell the whole story.  It may not be as telling about deficits in the quality of care as we previously thought.

The problem that I have with these findings is that the data seems to suggest that patients who are initially admitted to the ED are not receiving a high quality of care.  In both cases, being discharged or returning, something is not going right.  If a patient is leaving the ED, they should be able to rest assure that they were taken care of properly.  They should not worry about having to return when their condition worsens.

One way I believe we could fix this problem is with the use of pharmacists.  In POP we learned about the many mistakes patients make with their medication upon discharge.  Having a pharmacist on staff to explain medications to the patients might help to reduce the number of readmissions.

Sabbatini AK, Kocher KE, Basu A, et al. In-hospital outcomes and costs among patients hospitalized during a return visit to the emergency department. JAMA. 2016;315(7):663-671.