Quality improvement interventions may reduce readmissions

1. In this systematic review and meta-analysis, readmissions rates for both general and heart failure populations decreased after implementation of quality improvement projects, which usually included assessing patients’ needs and risks, discussing with patients and caregivers, and connecting patients with their usual providers.

2. Even though readmission rates were significantly decreased, there was no associated decrease in healthcare costs in both populations.

Evidence Rating Level: 2 (Good)

Study Rundown: Quality improvement (QI) initiatives that aim to decrease hospital readmissions ideally decrease healthcare costs, however the economic impact of these QI projects may not be fully appreciated. The authors of this systematic review and meta-analysis aimed to systematically review economic evaluations of QI interventions designed to reduce readmissions.

Based on the meta-analysis, readmissions across QI interventions declined by 12% for heart failure patients, and 6% for the general patient population based on interventions that included assessing patients’ needs and risks, discussing with patients and caregivers, and connecting patients with their usual providers. However, the associated health care costs were not significantly different for both populations, thus reflecting no true cost savings after reductions in readmissions due to these QI interventions. Among patients from the general population, interventions that engaged patients and caregivers were associated with statistically significant net savings. Limitations of this study included lack of generalizability as QI projects are meant to study frontline issues of an existing facility, and thus projects implemented at one institution may not be effective at another.

Click to read the study, published in JAMA Internal Medicine

Relevant Reading: An effectiveness and cost-benefit analysis of a hospital-based discharge transition program for elderly Medicare recipients

In-Depth [meta-analysis]: This systematic review and meta-analysis searched PubMed, Econlit, the Center for Reviews and Dissemination Economic Evaluations, New York Academy of Medicine’s Grey Literature Report and Worldcat from January 2004 to July 2016. Two reviewers looked for studies that evaluated structural or organizational changes aimed to reduce hospital readmissions and that reported the readmission related costs. The reviewers extracted data on intervention characteristics, study design and quality, clinical effectiveness and costs. Risk differences and net costs were calculated from this data and weighted least square regression analyses were used. Main outcomes measured included risk difference in readmission rate and incremental net cost.

There were 5205 articles initially reviewed resulting in 50 eligible articles. Half of these articles (25) were limited to the heart failure patient population, 21 were for general populations and 4 for unique populations (patients with cirrhosis, post-op percutaneous gastrostomy, suicidal ideation and the chronically critically ill). Fifteen studies had interventions that lasted up to a month whereas the rest had interventions ranging from 6 to 24 months. Regression results showed reduction in readmission rates for both the heart failure (risk difference 12.1%, 95% CI 8.3%-15.9%; P<0.001) and general populations (risk difference 6.3%, 95% CI 4.0%-8.7%; P<0.001). However there was no significant difference in overall net savings to the health care system per patient in either population. However, within the general population, interventions that engaged patients and caregivers was associated with a greater net savings ($1714 vs. -6568; P=0.006), however the implications for patients and their families is unclear from this study.

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