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Research Letter |

Contemporary Data About Hospital Strategies to Reduce Unplanned Readmissions:  What Has Changed? FREE

Elizabeth H. Bradley, PhD1,2; Heather Sipsma, PhD3; Leora I. Horwitz, MD, MHS4,5; Leslie Curry, MPH, PhD1,2; Harlan M. Krumholz, MD, SM1,2,4,6
[+] Author Affiliations
1Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
2Robert Wood Johnson Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
3Department of Women, Children and Family Health Science, University of Illinois at Chicago College of Nursing, Chicago, Illinois
4Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut
5Section of General Internal Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
6Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
JAMA Intern Med. 2014;174(1):154-156. doi:10.1001/jamainternmed.2013.11574.
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Published online

Almost 1 in 5 hospitalized Medicare beneficiaries will experience an unplanned readmission within 30 days, with an estimated cost to Medicare of more than $17 billion annually.1 In response, many hospitals have enrolled in quality collaboratives or campaigns to implement evidence-based strategies to reduce readmission rates. However, we have little information on the changes in practice that have occurred among the nation’s hospitals. Such information is important to understand hospital responses to the policy changes.

We examined changes from 2010 to 2012 in the use of commonly recommended strategies to reduce unplanned readmissions in a national sample of hospitals participating in the Hospital to Home Quality Improvement Initiative,2 an initiative of the American College of Cardiology and Institute of Healthcare Improvement to reduce readmissions of patients with cardiovascular disease. Of the 594 hospitals that had enrolled in the initiative between October 1, 2009, and July 1, 2010, 537 (90.4%) completed the baseline web-based survey, which was conducted from November 2010 to May 2011. A total of 437 of these hospitals (81.4%) completed a follow-up survey approximately 12 to 18 months later from November 2011 to October 2012. We determined differences in implementation of recommended strategies between the 2 time points using McNemar χ2 tests and Bowker tests of symmetry, with a significance threshold of P < .01 to account for multiple comparisons. About 35% of the hospitals were teaching hospitals, 30% had 400 or more beds, 5% were rural, 73% were part of a multihospital system, and 22% were for-profit. Institutional review board approval was obtained for the surveys.

Statistically significant changes of substantial magnitude were apparent for several specific strategies (Table 1). At the follow-up survey, significantly more hospitals were partnering with other local hospitals to reduce readmissions (30.7% vs 22.9%; P = .002), were discharging patients with a follow-up appointment already made (61.1% vs 52.4%; P = .005), and were tracking the percentage of patients who were discharged with follow-up appointments within 7 days (43.0% vs 32.2%; P < .001) and those readmitted to other hospitals (19.0% vs 12.0%; P = .001). More hospitals were estimating risk of readmission in a formal way (34.6% vs 22.5%; P < .001), using electronic forms for medication reconciliation (81.0% vs 72.8%; P < .001), and using “teach-back” techniques, in which health care providers ask patients to state in their own words clinical instructions given or decisions about treatment made (80.8% vs 68.9%; P < .001). Last, more hospitals were providing action plans to discharged patients with heart failure (60.0% vs 52.2%; P = .005) and calling patients after discharge to follow up on postdischarge needs or provide additional education (71.4% vs 62.9%; P < .001).

Table Graphic Jump LocationTable 1.  Strategies Adopted by Significantly More Hospitals by Follow-upa

For many of the strategies, however, we found no significant change in the proportion of hospitals implementing them (Table 2). At the follow-up survey, less than 40% of hospitals had in place a process for alerting outpatient physicians about discharges within 48 hours or for following up on test results that are returned after the patient was discharged; less than one-quarter of hospitals always sent the discharge summary to the primary care physician, and less than two-thirds always conducted nurse-to-nurse report before discharge to nursing homes. Results did not differ substantially for hospital subgroups based on numbers of beds, teaching status, ownership type, census region, or multihospital affiliation.

Table Graphic Jump LocationTable 2.  Strategies Not Adopted by Significantly More Hospitals by Follow-upa

Despite financial incentives for hospitals to reduce readmission rates, many hospitals are not implementing recommended strategies that have been shown to be associated with lower hospital risk-standardized readmission rates.36 Our work provides national data among a group of hospitals most likely to engage in improvement activities and may partially explain the slow rate of improvement in readmission rates nationally. More consistently implemented strategies to promote safe transitions from hospital to home are likely critical for reducing readmission rates in the years ahead.

Corresponding Author: Elizabeth H. Bradley, PhD, Department of Health Policy and Management, Yale School of Public Health, 60 College St, PO Box 208034, New Haven, CT 06520-8034 (Elizabeth.Bradley@yale.edu).

Published Online: October 21, 2013. doi:10.1001/jamainternmed.2013.11574.

Author Contributions: Drs Bradley and Sipsma had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Bradley, Horwitz, Curry, Krumholz.

Acquisition of data: Bradley.

Analysis and interpretation of data: Bradley, Sipsma, Horwitz, Curry, Krumholz.

Drafting of the manuscript: Bradley, Sipsma.

Critical revision of the manuscript for important intellectual content: Bradley, Sipsma, Horwitz, Curry, Krumholz.

Statistical analysis: Sipsma.

Obtained funding: Bradley, Krumholz.

Administrative, technical, or material support: Sipsma.

Study supervision: Bradley.

Conflict of Interest Disclosures: Dr Krumholz has received a research grant from Medtronic through Yale University and chairs a cardiac scientific advisory board for United Health Care. Dr Walsh has served as a consultant to United Health Care and Eli Lilly. No other disclosures are reported.

Funding/Support: Dr Horwitz is supported by the National Institute on Aging, Bethesda, MD (K08 AG038336) and by the American Federation for Aging Research, New York, NY through the Paul B. Beeson Career Development Award Program. Dr Horwitz is a Pepper Scholar with support from the Claude D. Pepper Older Americans Independence Center at Yale University School of Medicine (No. P30AG021342 NIH/NIA). Funding was provided by The Commonwealth Fund and the Center for Cardiovascular Outcomes Research at Yale University, supported by the National Heart Lung, and Blood Institute (No. U01HL105270-03).

Role of the Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of The Commonwealth Fund, the National Institute on Aging, the National Institutes of Health, or the American Federation for Aging Research.

Previous Presentation: This study was presented at the 2013 Academy Health Annual Research Meeting; June 24, 2013; Baltimore, MD.

Jencks  SF, Williams  MV, Coleman  EA.  Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428.
PubMed   |  Link to Article
H2H Quality Improvement Initiative. http://www.h2hquality.org/. Accessed September 2012.
Hernandez  AF, Greiner  MA, Fonarow  GC,  et al.  Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA. 2010;303(17):1716-1722.
PubMed   |  Link to Article
Brock  J, Mitchell  J, Irby  K,  et al; Care Transitions Project Team.  Association between quality improvement for care transitions in communities and rehospitalizations among Medicare beneficiaries. JAMA. 2013;309(4):381-391.
PubMed   |  Link to Article
Hansen  LO, Young  RS, Hinami  K, Leung  A, Williams  MV.  Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med. 2011;155(8):520-528.
PubMed   |  Link to Article
Phillips  CO, Wright  SM, Kern  DE, Singa  RM, Shepperd  S, Rubin  HR.  Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis. JAMA. 2004;291(11):1358-1367.
PubMed   |  Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1.  Strategies Adopted by Significantly More Hospitals by Follow-upa
Table Graphic Jump LocationTable 2.  Strategies Not Adopted by Significantly More Hospitals by Follow-upa

References

Jencks  SF, Williams  MV, Coleman  EA.  Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428.
PubMed   |  Link to Article
H2H Quality Improvement Initiative. http://www.h2hquality.org/. Accessed September 2012.
Hernandez  AF, Greiner  MA, Fonarow  GC,  et al.  Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA. 2010;303(17):1716-1722.
PubMed   |  Link to Article
Brock  J, Mitchell  J, Irby  K,  et al; Care Transitions Project Team.  Association between quality improvement for care transitions in communities and rehospitalizations among Medicare beneficiaries. JAMA. 2013;309(4):381-391.
PubMed   |  Link to Article
Hansen  LO, Young  RS, Hinami  K, Leung  A, Williams  MV.  Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med. 2011;155(8):520-528.
PubMed   |  Link to Article
Phillips  CO, Wright  SM, Kern  DE, Singa  RM, Shepperd  S, Rubin  HR.  Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis. JAMA. 2004;291(11):1358-1367.
PubMed   |  Link to Article

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