Are Readmission Rates The Best Measure of Hospital Quality?

October 17, 2022 - Readmission rates are one of the top measures of hospital quality, with most hospitals even putting their revenue on the line if they have excess hospital readmissions. However, a group of doctors argues in a JAMA Viewpoint article that it is time to move past readmission rates as an indicator of hospital quality and deemphasize value-based payment models that make it a central measure.

“[W]e argue that the persistent focus on readmissions during the past decade, although undoubtedly leading to some improvements in care, has had minimal demonstrable benefit,” writes Peter Cram, MD, MBA, of the University of Texas Medical Branch and University of Toronto, Robert M. Wachter, MD, of the University of California’s Department of Medicine, and Bruce E. Landon, MD, MBA, of Harvard Medical School and Beth Israel Deaconess Medical Center.

Cram, Landson, and Wachter add that the Hospital Readmissions Reduction Program (HRRP), a Medicare-run initiative that penalizes hospitals for excess readmissions, has “distracted clinicians and health system leaders from other crucial quality concerns.”

HRRP was enacted in 2010 and puts up to 3 percent of a hospital’s Medicare reimbursement at risk based on an excess readmission ratio for specified conditions, including acute myocardial infarction, heart failure, pneumonia, chronic obstructive pulmonary disease, coronary artery bypass surgery, and total joint replacement.

“As with many other quality measures, the HRRP has led to gamesmanship…whereby hospitals have taken predictable actions in their coding practices and admission processes and protocols in an effort to minimize the probability of receiving penalties,” Cram et al. write.

“It is time to refocus hospital quality improvement efforts where they can be most effective and beneficial, which means deemphasizing the HRRP,” they state.

Research indicates that previously-found reductions in hospital readmission rates may have been overstated and could be explained by changes in hospital delivery protocols and billing practices. Additionally, a 2019 study has suggested that there has been an overall decrease in hospital readmissions among Medicare beneficiaries.

Moreover, hospitals are dedicating millions of dollars to preventing readmissions that are largely out of their control, the doctors say.

“Given the challenge of making hospitals responsible for preventing readmissions and the limited success of HRRP, it is important to question whether health systems might be better served by directing their limited quality improvement resources, including both personnel and financial investments, toward improving aspects of care that they control more directly,” they write.

Patient safety and quality practices, such as reoperative surgical and anesthesia checklists, clinical bundles and order sets to prevent catheter-associated infections, and expanded use of clinical pharmacists to reduce adverse drug events, may serve as better measurements of hospital quality, the doctors explain.

“Other potential opportunities for improvement, such as clinician and hospital personnel wellness, patient experience, addiction treatment services, and palliative care, also warrant attention,” they say.

That being said, the doctors do not call for the elimination of readmission rates from quality programs. Rather, it may be time to sunset HRRP as a stand-alone program and incorporate the readmissions ratio into other hospital value-based payment programs.

“In 2010, reducing hospital readmissions appeared to be a fruitful target for quality improvement. In 2022, after more than a decade of concerted effort, it is time to focus limited hospital resources on more tractable and evidence-based targets that are more directly under the control of hospitals,” they conclude.