Tag Archives: Readmissions

An Improvement Project!

A very well written article describes an improvement project in a hospital in Ohio.[1] The idea was to reduce readmissions of patients with chronic obstructive pulmonary disease COPD. The intervention was based on an in-house analysis of the quality of care, and was designed to improve care by remedying identified deficiencies. Many, but certainly not all, of these deficiencies related to use of inhalers. This was identified both by analysis of discharge prescriptions and testimony from patients themselves. Indeed, it is a nice example of patient participation in designing improved care models. The intervention was followed by, and likely caused, a sharp drop in the readmission rate. The reduction in the readmission rate for patients who received all five components of the care bundle was nearly 11%. I worry about “regression to the mean” in such single centre studies showing impressive improvements. However, the authors’ were aware of this risk and carried out a long-run time series showing that readmission rates had been stable for many years prior to the intervention. Furthermore, the individual components of the bundle were all evidence-based and relevant to identified problems in the index hospital. The other problem I have with improvement projects is that they show what can be done, rather than would be achieved by widespread adoption of the same method. That is to say, they are subject to publication bias. In this particular case, the findings are open to two different interpretations. The results could be interpreted to mean that other centres should follow the same overall development pathway, tailoring an intervention to problems identified in each particular hospital. Alternatively, the results could be interpreted to mean that the bundle could be used by other hospitals, on the basis of that, similar problems are likely to be ubiquitous.

I shall invite members of the Chronic Diseases theme of the CLAHRC WM to consider these two interpretations and perhaps consider a replication study locally.

— Richard Lilford, CLAHRC WM Director

Reference:

  1. Zafar MA, Panos RJ, Ko J, et al. Reliable adherence to a COPD care bundle mitigates system-level failures and reduces COPD readmissions: a system redesign using improvement science. BMJ Qual Saf. 2017; 26: 908-18.
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Declining Readmission Rates – Are They Associated with Increased Mortality?

I have always been a bit nihilistic about reducing readmission rates to hospitals.[1][2] However, I may have been overly pessimistic. A new study confirms that it is possible to reduce readmission rates by imposing financial incentives.[3] Importantly, this does not seem to have caused an increase in mortality – as might occur if hospitals were biased against re-admitting sick patients in order to avoid a financial penalty. “False null result” (type two error), do I hear you ask? Probably not, since the data are based on nearly seven million admissions. In fact, 30 day mortality rates were slightly lower among hospitals that reduced readmission rates.

— Richard Lilford, CLAHRC WM Director

References:

  1. Lilford RJ. If Not Preventable Deaths, Then What About Preventable Admissions? NIHR CLAHRC West Midlands News Blog. 6 May 2016.
  2. Lilford RJ. Unintended Consequences of Pay-For-Performance Based on Readmissions. NIHR CLAHRC West Midlands News Blog. 13 January 2017.
  3. Joynt KE, & Maddox TM. Readmissions Have Declined, and Mortality Has Not Increased. The Importance of Evaluating Unintended Consequences. JAMA. 2017; 318(3): 243-4.

Predicting Readmissions on the Basis of a Well-Known Risk of Readmission Score

A recent NIHR CLAHRC West Midlands study examined a score based on co-morbidities, hospital use before the index admission, length of stay, and rate of admission – the LACE score.[1] The findings broadly corroborate the score and previous evidence – high scores are statistically associated with risk of readmission, but predictive accuracy is low and hardly likely to improve on clinical assessment; no doctor would use such a test to identify patients. This is an inpatient study based on over 90,000 admissions. We do not want every clinical action to be codified in a score – it is a waste of time. Moreover, most readmissions are caused by a new problem.[2] So a more sensible way forward, from my point of view, would be a general index of risk of deterioration to cover patients at all points in their journey. Would the ‘frailty index’ [3] [4] serve this purpose perfectly well?

— Richard Lilford, CLAHRC WM Director

References:

  1. Damery S, Combes G. Evaluating the predictive strength of the LACE index in identifying patients at high risk of hospital readmission following an inpatient episode: a retrospective cohort study. BMJ Open. 2017; 7: e016921.
  2. Lilford RJ. Unintended Consequences of Pay-for-Performance Based on Readmissions. NIHR CLAHRC West Midlands News Blog. 13 January 2017.
  3. Lilford RJ. Future Trends in NHS. NIHR CLAHRC West Midlands News Blog.
  4. Clegg A, Bates C, Young J, et al. Development and validation of an electronic frailty index using routine primary care electronic health record data. Age Ageing. 2016.

Unintended Consequences of Pay-For-Performance Based on Readmissions

Introducing fines for readmission rates crossing a certain threshold has been associated with reduced readmissions. Distilling a rather wordy commentary by Friebel and Steventon,[1] there are problems with the policy since it might not lead to optimal care:

  1. The link between quality of care and readmission is not good according to most studies, so that there is a risk that patients who need readmission will not get it.
  2. In support of the above, less than a third of readmissions are for the condition that caused the previous admission (which is not to say that none are preventable, but it suggests that a high proportion might not be).
  3. Risk-adjustment is at best imperfect.
  4. And this probably explains why ‘safety net’ hospitals caring for the poorest clientele come off worst under the pay-for-performance system.

I refer it my iron law of incentives – ‘only use them when providers truly believe that the target of the incentive lies within their control.’

— Richard Lilford, CLAHRC WM Director

Reference:

  1. Friebel R, Steventon A. The multiple aims of pay-for-performance and the risk of unintended consequences. BMJ Qual Saf. 2016.

Effect of Financial Penalties on Health Outcomes

A CLAHRC WM study showed that financial penalties implemented in the West Midlands region, but not elsewhere, resulted in a sharp increase in a desired outcome – increased use of home haemodialysis.[1] A time series study of financial penalties for readmission of patients with certain target conditions (heart failure, pneumonia, and myocardial infarction) found a step change reduction in 30 day readmission rates from 22% to 18% after the implementation of the penalty.[2] Interestingly, readmissions for non-targeted conditions decreased by a similar amount. Use of observation-units was increasing gradually throughout the observation period, so it was possible that some readmissions were circumvented by sequestering patients in the observation-unit. However, hospitals with a greater increase in such wards did not have a greater reduction in readmission rates. Whether there was a price to pay in sick patients being sent home we cannot say. Also, in the absence of contemporaneous controls it is not clear that the change was caused by the intervention. The intervention was instituted as a result of a general concern about readmission rates among commissioners and providers, such that the change could have occurred as part of a ‘rising tide’.[3]

— Richard Lilford, CLAHRC WM Director

References:

  1. Combes G, Allen K, Sein K, Girling A, Lilford R. Taking hospital treatments home: a mixed methods case study looking at the barriers and success factors for home dialysis treatment and the influence of a target on uptake rates. Implement Sci. 2015; 10: 148.
  2. Zuckerman RB, Sheingold SH, Orav J, Ruhter J, Epstein AM. Readmissions, Observation, and the Hospital Readmissions Reduction Program. New Engl J Med. 2016; 374: 1543-51.
  3. Chen YF, Hemming K, Stevens AJ, Lilford RJ. Secular trends and evaluation of complex interventions: the rising tide phenomenon. BMJ Qual Saf. 2015. [ePub].

If Not Preventable Deaths, Then What About Preventable Admissions?

This is the same problem re-written. Since the great majority of readmissions are non-preventable we are stuck with signal to noise problems in database studies. And case note review is equally unreliable, with preventability rates varying from 5% to 79%.[1] But deaths have one big advantage as an outcome measure – they are a very bad thing from the perspective of the patient. A recent article on readmissions [2] finds that they do not even satisfy this criterion; patients are not greatly concerned by readmission. Let us forget readmissions as a useful measure of quality, and concentrate instead on adverse events (as a whole) and process measures.[3]

— Richard Lilford, CLAHRC WM Director

References:

  1. van Walraven C, Bennett C, Jennings A, et al. Proportion of hospital readmissions deemed avoidable: a systematic review. CMAJ. 2011; 183: E391–402.
  2. Soong C, & Bell C. Identifying preventable readmissions: an achievable goal or waiting for Godot? BMJ Qual Saf. 2015; 24(12): 741-3.
  3. Yao G, et al. Evaluation of a predevelopment service delivery intervention: an application to improve clinical handovers. BMJ Qual Saf. 2012;21(s1):i29-i38.

Penalties for Readmissions Reduce Readmissions at New York Hospitals, but at the Cost of Increasing Attendance at Emergency Departments.

The CLAHRC WM Director is always concerned about possible perverse effects of incentives. Sure, do all you can to ensure a decent handover of care, but only a small proportion of readmissions are avoidable. Anyway, a recent difference in difference analysis in New York State [1] suggests that financial penalties, while reducing readmissions, were associated with a small but significantly increased rate of attendance at the Emergency Department. Again the law of unintended consequences.

— Richard Lilford, CLAHRC WM Director

Reference:

  1. McGarry B, Blankley A, Li Y. The Impact of the Medicare Hospital Readmission Reduction Program in New York State. Med Care. 2016; 54(2): 162-71.