By Carl van Walraven MD MSc, Alison Jennings MA, Monica Taljaard PhD, Irfan Dhalla MD MSc, Shane English MD, Sunita Mulpuru MD, Saul Blecker MD, Alan J. Forster MD MSc
CMAJ (Canadian Medical Association), August 22, 2011
Urgent, unplanned hospital readmissions are increasingly being used to measure institutional or regional quality of care. The public reporting of readmissions and their use in considerations for funding suggest a belief that readmissions indicate the quality of care provided by particular institutions. However, urgent readmissions are an informative metric only if we know what proportion of them are avoidable. If they are rarely avoidable, they would be a poor gauge of the quality of patient care.
Current estimates of the proportion of urgent readmissions that are avoidable are unreliable. In a systematic review of 34 studies that reviewed how many readmissions were avoidable, 3 of the studies relied solely on combinations of administrative diagnostic codes, and most used undefined or subjective criteria. In addition, most of the studies were conducted at a single centre and used only one reviewer. The proportion of readmissions deemed avoidable varied widely, from 5.1%6 to 78.9%,7 which reflected in part the lack of standardized and reliable methods to identify avoidable readmissions.
We conducted a multicentre prospective cohort study to elicit judgments from multiple practising physicians who used standard implicit review methods to determine whether urgent re admissions were potentially avoidable. We analyzed these judgments using a latent class analysis. We also measured the proportion of readmissions deemed avoidable and compared hospital-specific proportions of all-cause and avoidable readmissions.
Conclusion
Urgent readmissions deemed potentially avoidable were relatively uncommon, comprising less than 20% of all urgent readmissions following hospital discharge. Hospital-specific proportions of patients who were readmitted were not related to proportions of those whose readmissions were deemed avoidable.
Given the variety of causes and circumstances of the potentially avoidable readmissions in our study, interventions to decrease the risk of readmission need to be multifactorial in nature and malleable to be appropriately tailored for each situation.
Our study has important implications for research into the quality of hospital care. First, determining whether urgent readmissions were avoidable is a subjective judgment that requires detailed patient data, multiple reviewers and an analysis that accounts for differing reviewer accuracy when collating judgments. Such judgments cannot be determined accurately on the basis of administrative data alone, given the infinite combinations of patient, hospital, treatment and post-discharge factors that can influence urgent readmissions. Second, we found no association between hospital-specific proportions of all-cause and avoidable readmissions. Therefore, urgent readmissions should be used with caution to gauge the quality of hospital care.
http://www.cmaj.ca/content/early/2011/08/22/cmaj.110400.full.pdf+html
Comment:
By Don McCanne, MD
This Canadian study provides a great example of how we, in the United States, “think up” policies to control health spending while improving quality, and then apply those policies simply because they “should work.” Many of these policy decisions are used to divert our attention from much more effective measures such as a single payer national health program.
In this instance, the theory is that unplanned readmissions after a previous stay in the hospital are avoidable with appropriate in-hospital and post-discharge management. If the professionals and other personnel would do their jobs right, quality would improve and the costs of re-hospitalization would be avoided.
Although the Canadians, with their single payer system, evaluated readmissions from the perspective of improving quality, the emphasis in the United States, with its market medicine, has been on costs (e.g., refuse payment for re-admissions).
This study demonstrates that the reasons for readmission are very complex and highly variable and have very little relationship to either human or systems failure. Readmission rates should not be a major driver of policy.
Through this distraction, we’ve been fooled again. It’s not lousy health care professionals who are the source of our problems, it is the inhumane and outrageously expensive market-based health care financing and allocation system that is the problem. That’s what we need to fix. Then we could set aside issues of greed and concentrate on health care quality instead, like the Canadians are doing.