Readmission Rates Tell Only Part of the Story

Study by RWJF Clinical Scholars finds many patients visit emergency departments after discharge, revealing possible flaw in the way new federal incentive programs assess hospital care.

    • January 22, 2013

In recent years, hospital readmission rates have become an increasingly important measure of the quality of care hospitals provide their patients, with Medicare now structuring financial incentives and penalties around the measure, and other payers following suit. But a new study by researchers at the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program at Yale University, supported through a collaboration with the U.S. Department of Veterans Affairs, suggests that the focus on readmissions overlooks another important measure that could be used to assess the quality of hospital care: the rate of emergency department (ED) visits by recently discharged patients. The study was published in the Journal of the American Medical Association.

Led by Anita Vashi, MD, (VA Scholar) the research team studied data on more than 4 million adult patients who were treated and discharged from hospitals in California, Florida and Nebraska in 2008-2009. Some of those patients were hospitalized more than once, bringing the total number of hospitalizations in the study to more than 5 million. Vashi and her team tracked what happened to patients in the month after their discharge and found that 148 of every 1,000 hospital discharges were followed by readmission to the hospital, usually for a condition related to the original hospitalization. In addition, they found that 97 of every 1,000 discharges were followed by "treat-and-release" ED visits.

Those treat-and-release visits to the ED represented nearly 40 percent of all hospital-based acute care use after discharge, the authors write, suggesting that the current focus on measuring readmission rates is overlooking a vitally important measure of the quality and efficiency of patient care. "Focusing solely on readmissions would have missed nearly half a million ED treat-and-release encounters in these three states and substantially underestimated acute care use following medical and surgical inpatient discharges," they write. "These ED visits are likely to result in fragmented care following discharge and consequently contribute to duplication of services, conflicting care recommendations, medication errors, patient distress or higher costs."

"We need to broaden our scope, from focusing solely on hospital readmission rates to include emergency department visits," Vashi says. "We're starting to use the hospital readmission as a marker of quality of care. But as an ER doctor, I see so many patients who have just left the hospital, and I've realized that hospital readmissions are just the tip of the iceberg. To really understand the problem, we have to broaden the focus. Otherwise we'll underestimate patient needs."

Some Patients More Likely to Visit ED

The research team's data came from the Healthcare Cost and Utilization Project, a group of databases developed through a public-private partnership sponsored by the Agency for Healthcare Research and Quality. In addition to calculating readmission and ED visit totals for the 4 million patients as a whole, they also examined data for specific medical conditions. They found that some conditions generated a greater volume of treat-and-release ED visits; these included enlarged prostates, digestive disorders, psychosis, gall bladder removal and cesarean delivery.

Vashi's co-author, Cary Gross, MD, co-director of the RWJF Clinical Scholars program at Yale, agrees that the study points to the need to consider rates of post-discharge visits to the ED. "The number of patients needing to be readmitted or seen in the ED suggests we need to do a better job plugging patients into primary care providers," he says. "The results show us there's a great deal of health burden imposed right after patients are leaving the hospital. So it's clear that this 30-day post-discharge period is a time when patients are very vulnerable, and really need close care. We need to figure out how to best care for them."

Gross points out the policy implications of the study. "There's a tremendous focus on hospital readmission rates," he says. "But policy-makers need to look at ED use, as well. If there is a financial penalty to a hospital for readmission, and there's no penalty for ED visits, there could be an unintended consequence of the readmission measure: a disincentive for EDs to readmit patients, increasing the likelihood that patients discharged from the hospital will visit the ED, get treated, but then bounce back to the ED later. That won't serve patients or anyone else very well."

Vashi adds that the study highlights the need for better communication between providers and patients, and also between hospital staff and patients' personal physicians. "Patients shouldn't leave the hospital without a plan for follow-up in place," she says. "And the plan shouldn't just be, 'see your doctor in two weeks.' We're not educating patients well enough about how to transition from the hospital to home."

"We also need to think about the resources we need on a system level to meet these patients' needs," she continues. "We need creative solutions to address patients' needs outside of hospitals, particularly for patients with the conditions likely to cause them to return to the ED at high rates. That could include follow-up programs with nurses and physician assistants contacting patients, for example, or identifying other settings where they can be seen."

Read the study.
Learn more about the Robert Wood Johnson Foundation Clinical Scholars Program.
For an overview of RWJF scholar and fellow opportunities, visit www.RWJFLeaders.org.