Are hospital readmissions an accurate quality measure? These 2 researchers aren't so sure

CMS rolled out its Hospital Readmissions Reduction Program in 2012, transforming hospital readmissions into a widely accepted measure of hospitals' care quality among payers and other policymakers.

While improvement efforts have helped lower readmissions for various conditions, current readmission measures do not consider observation stays, which two healthcare researchers describe as a crucial component missing from the quality equation in an op-ed published May 31 in The New England Journal of Medicine.

Here are the article's authors:

  • Amber K. Sabbatini, MD, MPH, an emergency physician at Seattle-based Harborview Medical Center and an assistant professor in the department of emergency medicine at Seattle-based University of Washington

  • Brad Wright, PhD, an assistant professor of health management and policy at the University of Iowa's College of Public Health in Iowa City

Hospitals are increasingly using observation stays as an alternative to short inpatient hospitalizations, which payers discourage, according to Drs. Sabbatini and Wright. They believe the increased reliance on observation stays holds important implications for using hospital readmissions to assess quality, since hospitals do not track readmissions for patients admitted under observation, and these stays are not included in calculations for hospitals' 30-day readmission rate.

"Therefore, unscheduled hospitalizations billed as observation stays are missing from both the numerator and the denominator of the readmission-rate equation, which omits critical information about the quality of care transitions for many patients hospitalized for acute conditions," Drs. Sabbatini and Wright wrote.

To assess the effect of observation stays on readmission measures, they analyzed 2007-15 claims data from about 250 commercial payers nationwide housed in the Truven Health Analytics MarketScan Commercial Claims and Encounters Database. The data contained information on about 5 million emergency department visits per year.

Drs. Sabbatini and Wright found the 30-day readmission rate for inpatients decreased from 17.8 percent in 2007 to 15.5 percent in 2015. However, readmission rates for patients admitted under observation increased from 10.9 percent to 14.8 percent over the same time period. The authors noted this increase was likely driven by repeat observation stays, which jumped from 3.6 percent in 2007 to 6.9 percent in 2015.

Drs. Sabbatini and Wright suggested this increase may be due to hospitals admitting increasingly sicker patient populations for observation stays, rather than inpatient stays. Observation patients may also have less access to care coordination resources than those admitted as inpatients.

"Although additional research is needed to understand and address the effect of observation stays on readmission measures, our findings indicate that a large and increasing proportion of hospital care transitions are falling out of the current quality equation," the authors concluded.

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