The Revolving Door Syndrome: Patients Returning to Hospital Within Days of Being Released

Washington, D.C.—The Robert Wood Johnson Foundation (RWJF) today released a report showing that one in eight Medicare patients were readmitted to the hospital within 30 days of being released after surgery in 2010, while patients in the hospital for reasons other than surgery returned at an even higher rate of one in six. Both rates were virtually unchanged from 2008.

• The highest regional rate for 30-day medical readmissions was 18.1 percent in Bronx, N.Y., compared to a low of 11.4 percent in Ogden, Utah. The national average was 15.9 percent.
• The highest regional rate for 30-day surgical readmissions was 18.3 percent in Bronx, N.Y., compared to a low of 7.6 percent in Bend, Ore. The national average was 12.4 percent.

The findings are based on data that includes readmission rates for states, hospital referral regions, and more than 3,000 hospitals from the Dartmouth Atlas Project, largely funded by RWJF. The analysis shows that the overall lack of improvement in readmissions extends back to 2004, the earliest year that the Dartmouth Atlas has studied, with the national rate for readmissions following a medical discharge remaining the same in 2010 as it was in 2004 (15.9%).

The report, “The Revolving Door: A Report on U.S. Hospital Readmissions,” also includes the results of a novel series of in-depth interviews with patients and providers that shed light on why so many patients end up back in the hospital and what hospitals, doctors, nurses, and others are doing to limit avoidable readmissions.

The issue of patients being readmitted to the hospital is considered important because many readmissions are avoidable and, as the report notes, can occur because of differences in patient health status; the quality of inpatient care, discharge planning, and care coordination; the availability and effectiveness of local primary care; and the threshold for admission in the area. The Centers for Medicare & Medicaid Services (CMS) began reductions in Medicare reimbursement last year for hospitals with high rates of readmissions.

“Although hospitals are a key venue of care, the one thing that’s clear is that this is not just a hospital problem,” said RWJF President and CEO Risa Lavizzo-Mourey, MD. “Patients, families, friends, and the entire community have a role to play in reducing avoidable readmissions, and to succeed we need to face this problem together.”

The report will be featured at a February 13 event in Washington, D.C. to celebrate promising practices for reducing avoidable readmissions. The event is part of RWJF’s Care About Your Care initiative, a month-long effort to focus attention on the national problem of avoidable readmissions, spotlight how hospitals and communities are working to improve care, and help patients understand their role. The initiative is endorsed by leading public and private health care organizations representing hospitals, health care providers, caregivers, and patients.

In the first section of the report, Dartmouth researchers examined five Medicare patient populations: those discharged for medical conditions, for surgical conditions, and for common causes of medical hospitalization: congestive heart failure, acute myocardial infarctions, and pneumonia. The Dartmouth Atlas website also reports additional measures of patient care after hospitalization: emergency room visits and clinician visits.

The data show that the chances of readmission after patients leave the hospital varies markedly across regions and hospitals and that overall readmission rates did not decline meaningfully for any of the five patient groups from 2008 to 2010.

“While there are certainly pockets of improvement, as a nation, we have a long ways to go,” said David C. Goodman, MD, MS, co-principal investigator for the Dartmouth Atlas Project. “Variation in the quality of care between health systems is hard for patients and practicing physicians to see, but the differences are substantial. And many patients are readmitted simply because they live in a region where the hospital is used more frequently at the site of care.”

For example, there was marked variation in the percentage of Medicare patients readmitted to the hospital within 30 days of an initial medical discharge in 2010. Two other Utah regions—Provo (12.1%) and Salt Lake City (12.9%)—also had relatively low rates. Readmission rates were also high in Detroit (17.8%) and Chicago (17.7%).

Thirty-day readmission rates following surgical discharge varied more than twofold. Regions with rates below 10 percent other than Bend, Ore. included Boise, Idaho (8.4%), Santa Barbara, Calif. (9.0%), Spokane, Wash. (9.5%), and Seattle (9.9%). Readmission rates following surgery were nearly twice as high not only in the Bronx, but in other regions in the New York City area, including White Plains (17.4%), East Long Island (16.3%), and Manhattan (16.0%).

The study excluded patients who had any acute care hospitalizations in the 90 days prior to the admission date used to calculate readmission rates. The definition used by CMS only excludes acute care hospitalizations in the 30 days prior to the admission date, so the rates differ slightly.

The report’s second section includes findings from 32 interviews conducted by the research firm PerryUndem between December 2012 and January 2013 in metropolitan Washington, D.C., New York City, and Dallas to find out why people make so many return trips to the hospital and what is being done to improve their care. This storytelling project focused on patients, caregivers, and health care providers and involved interviews with 16 patients who have experienced a recent readmission, four family caregivers, and 12 health care providers who care for patients who have been readmitted.

Additional resources for patients, such as a tip sheet on how to avoid being readmitted to the hospital, and a hospital discharge checklist and care transition plan, are also available online.

About the Robert Wood Johnson Foundation

The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation’s largest philanthropy devoted exclusively to health and health care, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, measurable, and timely change. For 40 years the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that affect the health and health care of those it serves. When it comes to helping Americans lead healthier lives and get the care they need, the Foundation expects to make a difference in your lifetime. Follow the Foundation on Twitter (www.rwjf.org/twitter) or Facebook (www.rwjf.org/facebook).