Hospital readmissions occurring within 7 days post-discharge may be more preventable than later readmissions

1. The percentage of preventable early readmissions (within 7 days post-discharge) and late readmissions (between 8 and 30 days post-discharge) were 36.2% and 23.0%, respectively, which suggests that a 7-day window may be more accurate than a 30-day window for measuring quality of hospital care.

2. In terms of the best location to make changes in prevention, hospitals and outpatient clinics were identified as being better for early and late readmissions, respectively.

Evidence Rating Level: 1 (Excellent)

Study Rundown: The Patient Protection and Affordable Care Act allows the Centers for Medicare & Medicaid Services to financially penalize hospitals that have an inordinate number of readmissions within 30 days post-discharge.  The 30-day window was selected because lawmakers suspected that readmissions during this time window were due to lower quality of care.  However, it is unknown how the ability to prevent readmission may change over time after discharge.  In order to evaluate whether preventability differed between early readmissions and late readmissions, the authors of this prospective cohort study evaluated 822 adults with readmissions to a general medicine service at 10 U.S. academic medical centers.  They found that early readmissions had a greater likelihood of being prevented and being responsive to hospital-based interventions.  Late readmissions had a lower likelihood of being prevented and a greater likelihood of being responsive to home-based and ambulatory interventions.  The authors suggest that using a 7-day window may help avoid unnecessary penalization and provide higher accuracy for evaluating quality of hospital care.

Despite the potential negative ramifications on hospitals of being measured according to the 30-day post-discharge window, there is little scientific foundation for its selection.  A strength of the study was that it provides data towards determining what might be a more accurate time window.  Limitations of the study included the lack of blinding for physician adjudicators to the timing of readmission, exclusion of community hospitals, and exclusion of readmissions to hospitals not in the study.

Click to read the study, published in Annals of Internal Medicine

Relevant Reading: Physician Perspectives on Factors Contributing to Readmissions and Potential Prevention Strategies: A Multicenter Survey

In-Depth [prospective cohort]: Researchers used data from the 10 U.S. academic medical centers in the Hospital Medicine Reengineering Network (HOMERuN) that had available readmission timing data.  The patients studied were ≥18 years of age and had been unexpectedly readmitted within 30-days after being discharged from a service in general medicine.  The authors used a random-digit generator to select ≤5 readmissions per week per site between April 2012 and March 2013 to be evaluated.  Two site-specific physician adjudicators were used for each readmission.  The adjudicators utilized a structured survey instrument to evaluate the preventability of the readmission.  The authors found that overall, the percentage of readmissions that could have been prevented were 36.2% and 23.0% for early and late readmissions, respectively.  In terms of the best location to make changes in prevention, hospitals and outpatient clinics were identified as being better for early and late readmissions, respectively.

Image: PD

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