Hospital Readmissions: in search of potentially avoidable costs (Text Version)

On September 14, 2009, Bernard Friedman made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (646 KB).

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Slide 1

Hospital Readmissions: in search of potentially avoidable costs

Bernard Friedman, PhD
Center for Delivery, Organization, and Markets
AHRQ Conference, 2009 

Slide 2

Agenda

• Multiple uses of readmission data
  • Quality of inpatient care
  • Effectiveness of management of chronic illness outside the hospital
  • Efficiency in arrangements for post-hospital care
  • Accountability for health plans: consumer choice and P4P
• Measurement choices depend on motives
  • Types of index admisssion, length of follow-up, eligible readmissions
• Tracking readmissions for the NHQR - it's evolving
• Recent research project: Contrast Medicare FFS vs. Advantage plan patients 

Slide 3

Some AHRQ Published Studies on Readmissions

1. Joanna Jiang was the lead author at AHRQ on several published studies of diabetes discharges.
   • One finding was that half of the discharges or hospital costs in a year are for people with multiple discharges for diabetes and its complications.
2. I examined (with Joy Basu) all readmissions within 6 months for people with 16 Potentially Preventable initial admissions.
   • Large variety of principal diagnoses for the RE-admission
   • Just the re-admissions in the 16 categories of potentially preventable within 6 months had a projected national cost of about $1.4 Billion in 2008$. This covered only 4 states with 15% of the U.S. population. 

Slide 4

Readmissions and Quality of Inpatient Care

• 3.) William Encinosa and Fred Hellinger recently published "The Impact of Medical Errors on 90 Day Costs and Outcomes: An Examination of Surgical Patients". Health Services Research, 2008
  • About $1.5 billion of cost in 3 months subsequent to the initial discharge due to safety events. Some of that was readmissions.
• 4.) B. Friedman, J. Jiang, W. Encinosa, R. Mutter, "Do patient safety events contribute to readmissions?" Medical Care, 2009.
  • Risk of a readmission within 1 month or 3 months after a surgical admission was raised about 20% by a safety event. 

Slide 5

Effective Management of Chronic Conditions

• 5.) B. Friedman, with Joanna Jiang and Anne Elixhauser,
• "Costly Hospital Readmissions and Complex Chronic Illness", Inquiry, Winter, 2008/2009
  • About 5 million adults were covered by the data
  • Shows importance of the number of different chronic conditions in predicting readmission rates and annual cost. ("complexity")
  • Not easily "fixed" with disease-specific management protocols. But there is literature on demonstrations of other approaches.
  • 8% of the hospital costs for adults could be saved if you could bring down the extra readmissions for the 25% of hospitalized adulsts with 5 or more chronic conditions.
  • There have been a couple dozen demonstration projects of how to do that. It isn't free, of course. 

Slide 6

NHQR 2008 Readmissions

• Tracking system quality and system efficiency
• Congestive Heart Failure, readmission for same.
• Readmission within 30 days (to any hospital)
  • Short enough to implicate the discharge planning, handoff, patient counseling
  • Not apportioning blame (could be other factors)
• The national burden of readmissions: one person can have more than one readmit during the year qualifying to be counted (30 days from previous admit).
• Comparison of states within age groups (big difference between states, but not between age groups) 

Slide 7

Choices for Future Years NHQR

• Suggestions should go to Ernie Moy or Ryan or ...
• Possibilities:
  • Multiple index admissions, with statistical controls
  • Readmission after elective treatment, after delivery
  • State or area rates with risk adjustment. 

Slide 8

Do Medicare Advantage Patients Have Fewer Readmissions?

• Coauthors: B. Friedman, J. Jiang, John Bott, Claudia Steiner.
• Database: 5 states in HCUP with breakdown of type of Medicare coverage and with person identifiers.
• Theory: superficially, it seems that the Advantage plans have both the motive (capitated revenue) and the means to reduce readmissions in comparison to FFS Medicare. 

Slide 9

Raw Comparisons

• Same 1-month rate of readmission (10%)
• Somewhat lower 3-month readmission rate (21% vs. 22.5%).
• However, Advantage patients tend to be
  • A little younger
  • Less severely ill even when hospitalized
  • Less likely to have a major operative procedure. 

Slide 10

Results

• Use risk adjustment and control for selection bias (predictors for joining an Advantage plan)
• Manuscript available on methods
• Advantage patients are one third more likely to have a readmission (in 30 days, 13% vs. 10%; in 90 days, 30.5% vs. 22.5%).
• How reconcile with incentives?
  • Maybe we did something wrong....
  • Enrollees have no comparative data
  • FFS more discharges to LTC and other facilities
  • Advantage plans might be spending less on outpatient service and quality than we expected?