Several articles published on Jan. 22 in the Journal of the American Medical Association focused on the increasingly hot topic of hospital readmissions. In particular, three of the studies looked at the role of quality improvement organizations in reducing rates of rehospitalizations; rates of emergency department (ED) visits within 30 days of discharge from an acute care facility; and 30-day readmissions for Medicare fee-for-service (FFS) beneficiaries, hospitalized for heart failure (HF), acute myocardial infarction (MI) or pneumonia, respectively.

Among Medicare patients living in Quality Improvement (QI) Organizations' intervention communities, all-cause 30-day rehospitalization and all-cause hospitalization declined when compared to patients in communities without QI implementation; however, there was no significant reduction in the rate of all-cause 30-day rehospitalization as a percentage of hospital discharges.

The study looked at 14 interventional communities with between 22,070 and 90,843 Medicare FFS beneficiaries, and compared the communities before and during QI implementation with 50 non-QI communities. Results showed the mean rate of 30-day all-cause rehospitalization per 1,000 beneficiaries per quarter was 15.21 in 2006-2008 and 14.34 in 2009-2010 in the intervention communities, compared to 15.03 in 2006-2008 and 14.72 in 2009-2010 in the other communities with the pre-post between-group difference showing larger reductions in rehospitalizations in interventional communities (by 0.56/1000 per quarter; 95 percent CI, 0.05-1.07; P=.03). Further, the mean rate of hospitalizations per 1,000 beneficiaries per quarter was 82.27 in 2006-2008 and 77.54 in 2009-2010 in interventional communities and was 82.09 in 2006-2008 and 79.48 in 2009-2010 in comparison communities, with the pre-post between-group differences showing larger reductions in hospitalization in interventional communities (by 2.12/1000 per quarter; 95 percent CI, 0.47-3.77; P=.01).

The authors note that their study shows "an additional significant association between care transitions improvement interventions initiated by 14 QI [organizations] and reductions in rehospitalization and hospitalization."

"The challenge is that the study changed endpoints in midstream and there was no significant effect on hospital readmission rates," notes Harlan Krumholz, MD, SM, FACC, Harold H. Hines Jr. professor of medicine and epidemiology and public health at the Yale University School of Medicine. "The association with overall community hospitalization rates is intriguing – but we will need more studies to validate the finding before we would want to embrace the intervention."

For patients discharged from acute care hospitals, a separate study found that emergency department (ED) visits within 30 days were common among adults and accounted for 39.8 percent of postdischarge hospital-based acute care visits. The study, which looked at 4,028,555 patients, showed in the 30 days following discharge, 17.9 percent (95 percent CI, 17.9 percent – 18 percent) of hospitalizations resulted in at least one acute care encounter. Of these, ED visits comprised 39.8 percent (95 percent CI, 39.7 percent – 39.9 percent). According to the study authors, additional research is necessary to further understand the drivers of postdischarge ED use and the clinical and financial efficiency associated with providing such acute care in the ED.

Meanwhile, 30-day readmissions were frequent throughout the month after hospitalization among Medicare FFS beneficiaries hospitalized for HF, acute MI or pneumonia, according to another study. These readmissions resulted from a similar spectrum of readmission diagnoses regardless of age, sex, race, or time after discharge. The study, which looked at Medicare claims data from 2007-2009, showed there were 329,308 30-day readmissions after 1,330,157 HF hospitalizations (24.8 percent readmitted); 108,992 30-day readmissions after 548,834 acute MI hospitalizations (19.9 percent readmitted); and 214,239 30-day readmissions after 1,168,624 pneumonia hospitalizations (18.3 percent readmitted). Further, of all readmissions within 30 days of hospitalization, the majority occurred within 15 days of hospitalization: 61.0 percent, HF cohort; 67.7 percent, acute MI cohort; and 62.6 percent pneumonia cohort. Median time to 30-day readmission was 12 days for patients initially hospitalized for HF, 10 days for acute MI, and 12 days for pneumonia.

The authors note that the broad range of conditions responsible for readmissions may reflect a posthospitalization syndrome – "a generalized vulnerability to illness among recently discharged patients, many of whom have developed new impairments both during and after hospitalization." They add that "programs to reduce 30-day readmissions should, therefore, be correspondingly broad in scope in the diagnoses they target and effective for at least the full month following hospitalization."

In a related editorial comment, Mark Williams, MD, from the Northwestern University Feinberg School of Medicine, notes the findings of these three reports illustrate "the increasing fragmentation of patient care and consequent inappropriate use." He adds that "while some health policy researchers bemoan the choice of 30-day readmissions as a quality measure, adoption of this metric appears to have succeeded in focusing hospitals on the need to address the hospital discharge transition and fragmentation faced by patients."

"Efforts moving forward should involve implementation of broad patient-centered approaches that engage all members of a care team, especially the front line clinicians, and use proven quality improvement methods such as statistical process control to identify helpful interventions," he adds.

Keywords: Hospitals, Health Policy, Myocardial Infarction, Pneumonia, Fee-for-Service Plans, Emergency Service, Hospital, Universities, Patient Discharge, Quality Improvement, Public Health, Patient Readmission, Heart Failure, Medicare, Hospitalization, United States