Revisits Have Increased Since Implementation of Program Intended to Reduce Hospital Readmissions

Findings suggest focusing solely on 30-day readmissions provides an incomplete picture of hospital performance and health care use in the post-discharge period

Researchers at Beth Israel Deaconess Medical Center (BIDMC) found that total 30-day hospital revisits have increased since implementation of the Hospital Readmissions Reduction Program (HRRP), a federal program implemented as part of the Affordable Care Act (ACA) in 2012 intended to address readmission rates for Medicare patients.

In the United States, 30-day readmissions are increasingly used to measure quality of care and evaluate hospital performance. As a result, readmission rates for targeted conditions – heart attack, heart failure, or pneumonia – have declined, an improvement policymakers have attributed to streamlined care transitions and coordinated post-discharge care. However it is possible that these declines are obscuring something else: patients who return to the hospital after discharge are more likely to be managed in Emergency Departments (EDs) and as observation stays.

Rishi K. Wadhera, M.D., M.P.P., M.Phil., an investigator in the Smith Center for Outcomes Research in Cardiology at BIDMC, and colleagues evaluated whether there has been a change in total hospital revisits within 30 days of discharge – including emergency department visits, observation stays and inpatient readmissions – after a hospitalization for one of the three target conditions from 2012 to 2015. Wadhera and colleagues also characterized these trends by type of revisit: ED revisit (not leading to readmission), observation stays (not leading to readmission) and inpatient readmissions. Their analysis showed the increase in 30-day hospital revisits was due to a rise in post-discharge emergency department visits and observation stays, which on a national level, exceeded the decline in readmissions. This suggests that focusing solely on 30-day readmissions provides an incomplete picture of hospital performance and health care use in the post-discharge period. The findings were published today in the British Medical Journal.

“If readmission reductions were solely due to improved discharge planning, care transitions, and post-discharge care, as intended by the HRRP, total hospital revisits would also be expected to fall,” said Wadhera. “Instead, patients are returning to the hospital more often within 30 days of discharge, and declines in readmissions appear to be due to intensified efforts to manage patients who return in emergency departments and as observation stays. Policymakers should consider using 30-day total hospital revisits as a measure to evaluate quality of care and performance under value-based programs.”