Why 30-Day Readmissions Are High

There weren’t a lot of patients who were readmitted 2 days later for the same condition, which might indicate that they had been discharged too soon, Dr. Ryan said. More often, patients return to the hospital a week or several days later with a new problem. That tends to indicate that their medications may not have been adjusted correctly or that they were unable to access services in the outpatient world, he said.

There is very little evidence to support the idea that a longer initial length of stay would lead to either better use of evidence-based therapies or produce better clinical outcomes, said Dr. Gregg C. Fonarow, director of the Cardiomyopathy Center at the University of California, Los Angeles. Though there’s plenty of evidence to show that more time in the hospital increases patients’ risk for hospital-acquired infection, he added.

Over the last 2 decades, readmissions for heart failure patients have gone up as length of stay has decreased. But, Dr. Fonarow points out, during that same time the total number of days patients spent in the hospital has actually gone down, along with mortality. So from a global resource utilization perspective, patients are spending less time in the hospital and having better outcomes, he said.

"It’s important to have appropriate comparisons," he said.

Dr. Fonarow cautioned that there aren’t simple solutions to this problem. While there are many opportunities to improve readmission rates, there are also many rehospitalizations that are unavoidable or unrelated to the cardiovascular condition responsible for the initial hospitalization. Many patients hospitalized with acute MI, and to an even greater degree with heart failure, have multiple other cardiovascular and noncardiovascular comorbid conditions, he said.

"Efforts to try and reduce preventable readmissions have to go well beyond even the primary disease state that led to the hospitalization," Dr. Fonarow said. "They need to involve multiple components of care that go beyond just treating the single acute condition and focus on the multiple comorbid conditions that exist within that patient."

To make it even more complicated, patients who are hospitalized with heart failure tend to be older and to have multiple comorbid conditions. These individuals may face other challenges such as cognitive impairment, frailty, and poor socioeconomic support.

"It’s really a complex problem," he said.

Ensuring Needed Care

The looming Medicare readmission penalties have caused many hospital administrators, and in turn physicians, to look closely at the factors behind readmissions for the first time over the last few years.

"Everyone’s trying to figure this out because they do see the shift coming in the payment system," said Dr. John Rumsfeld, National Director of Cardiology at the Veterans Health Administration and Chief Science Officer for the American College of Cardiology’s National Cardiovascular Data Registry.

And the payment cuts for excessive readmissions aren’t the only way that CMS is focusing on the issue, Dr. Rumsfeld said. Readmissions are also at the heart of pilot projects Medicare is launching for Accountable Care Organizations and bundled payments.

Dr. Rumsfeld said he’s concerned that physicians are getting the message that all readmissions are bad. "This is a potentially dangerous message for clinical care," he said.

The conversation needs to shift to unnecessary or potentially preventable readmissions, he said. It’s often underappreciated, Dr. Rumsfeld said, that patients who are having recurrent chest pain or severe shortness of breath after an acute MI should be admitted to the hospital for care. "There shouldn’t be anything in the system that disincentivizes that," he said.

Dr. Clyde W. Yancy, Chief of the Division of Cardiology at Northwestern University and Associate Director of the Bluhm Cardiovascular Institute at Northwestern Memorial Hospital in Chicago, agrees.

"We’re beating the drum about this problem mostly because it’s a health care utilization problem," Dr. Yancy said. "In the process of beating the drum, we have to have enough wherewithal as clinicians and administrators to realize that there are those – and not a small number – who should in fact be readmitted because their disease is unstable, or it’s advanced, or it requires that attention."

The fate of safety net hospitals is also a concern. Safety net hospitals are unlikely to have the money to undertake a major overhaul of their discharge and care coordination systems, which could leave them with higher than average readmissions, even after the data is risk adjusted for their sicker patients, Dr. Yancy said. Then, if CMS cuts their reimbursement due to their excessive readmission rates, they will be left to care for sicker patients with even fewer resources.