Team of MD Leaders Calls for Phase Out of Readmission Reduction Program

Is it time for health care policy leaders—and leaders of patient care organizations—to move beyond limiting inpatient readmissions as a primary measure of quality performance? That’s exactly what three physicians who are leaders in healthcare policy say in an online opinion piece on gamma network.

In fact, the title of the piece was quoted by Peter Cram, MD, Robert M. Wachter, MD, and Bruce E. Landon, MD, in the article title, “Reducing readmissions as a measure of hospital quality: time to move on to more pressing concerns?”—Published online in the “Viewpoint” section of gamma network On October 6th.

Furthermore, these are particularly outstanding doctors Dr. WachterHe is the chair of the Department of Medicine at the University of California, San Francisco School of Medicine, and is best known for authoring the 2017 book The Digital Doctor: Hope, Hype, and Harm at the Dawn of the Computer Age in Medicine. while, Dr. Kram is the chair of the Department of Internal Medicine at the University of Texas Medical Branch at Galveston (UTMB).; Dr. Landon is Professor of Health Care Policy in the Department of Health Care Policy at Harvard Medical School. And the Dr. Landon is Professor of Medicine and a practicing internist at Beth Israel Deaconess Medical Center (Boston).

And these three leaders of health care policy are clear about their disagreement in their editorial for JAMA, writing: “In this view, we argue that the continued focus on readmission over the past decade, although it has undoubtedly led to some improvements in care, has Minimum demonstrable benefits.Moreover, HRRP [Hospital Readmissions Reduction Program] Distracting clinicians and health system leaders from other critical quality concerns. As with many other quality standards, HRRP has led to gaming mastery (described below) as hospitals take predictable actions in their coding practices, acceptance processes, and protocols in an effort to reduce the likelihood of receiving penalties. It is time to refocus hospital quality improvement efforts where they can be more effective and beneficial, which means de-emphasizing the humanitarian response plan and human rights.”

The article’s authors note that “In a 2009 study, Jencks et al reported that of the 11.8 million Medicare beneficiaries who were hospitalized from 2003 to 2004, 19.6 percent were readmitted in the first month after hospitalization, and these readmissions accounted for Estimated cost $41 billion annually Researchers and policy makers conclude that if a large proportion of readmissions result from failures in the health care system—whether due to inadequate treatment during initial hospitalization or failure to coordinate care after hospital discharge—the adoption of policies Designed to reduce inappropriate readmissions would be justified, especially because hospitals receive additional payments when patients are readmitted.” Not only did the Jencks study lead to an intense focus on readmission as a primary indicator of the quality of inpatient care; The HRRP ended up becoming an integral part of the Affordable Care Act (ACA) in 2010, and thus became a concrete policy, with a payment reduction system created to penalize hospitals with very high readmission rates.

Now though? Cram, Wachter, and Landon write that “[A] A growing body of literature now indicates that the reported reductions in readmissions may be overstated. Wadhera et al found that an increasing number of patients who would have previously been readmitted were treated under the observational condition. Other investigators have found that much of the purported decrease in readmissions can be explained by a concurrent change in billing criteria that has allowed hospitals to provide a greater number of co-morbid diagnoses when submitting claims, thus increasing the expected number of readmissions. Furthermore, McWilliams et al. found that much of the decline in readmissions can be explained by contemporary reductions in the rate of hospitalizations for all Medicare beneficiaries. Several studies also reported that HRRP was associated with a small but significant increase in mortality after hospital discharge for patients with pneumonia and congestive heart failure, although there is disagreement on this point. “

And they believe a key element in all of this is that “in the decade since the implementation of the Human Rights Humanitarian Response Plan, there has been a greater understanding of why it is so difficult to prevent readmissions into health systems. Graham et al 10 found that less than 36 percent of early readmissions (within 7 days of discharge) and 23 percent of late readmissions (8-30 days after discharge) could have been prevented.Moreover, hospitals were identified as the ideal location to target readmissions that could be prevented in less than half (47 percent) of early readmissions and 26 percent of late readmissions Instead, patient home was identified as the ideal goal in 14 percent of early readmissions and 19 percent of late readmissions; outpatient clinic in 7 and emergency department, at 4 percent for both. There were also significant gains in estimating the critical contribution of deprivation and negative social determinants of health in driving readmissions at the individual and hospital level.”

In this context, they wrote, “Given the challenge of making hospitals accountable for preventing readmission and the limited success of the HRRP, it is important to question whether health systems can be better served by channeling limited quality improvement resources, including personnel and finances.” investments, toward improving the aspects of care that they control more directly.”

The three doctors believe that while measures based on reduced readmission should not be completely abolished. “Instead,” they write, “re-admissions should continue to be measured and tracked, but financial penalties associated with the humanitarian response plan can be withdrawn into the response.” They recommend that HRRP be phased out over time and that the “body of patient safety practices with evidence-based support much stronger than readmission” defined by the 2013 Agency for Healthcare Research and Quality Expert Committee, be considered for measurement instead. Those measures were “surgical and preoperative anesthesia checklists, clinical packages and order kits to prevent catheter-associated infection, and expanded use of clinical pharmacists to reduce adverse drug events.” They add that “other potential opportunities for improvement, such as clinician and hospital staff wellness, patient experience, addiction treatment services, and palliative care, also require attention.”

Ultimately, the authors concluded, “In 2010, reducing hospital readmissions appeared to be a fruitful goal of quality improvement. In 2022, after more than a decade of concerted efforts, it is time to focus limited hospital resources on more traceable, established goals. on evidence and directly under the control of hospitals.”

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