Higher Hospital Readmissions Aren't Linked To Fewer Deaths, Study Finds
By Jordan
Rau
KHN Staff Writer
Feb 12, 2013 - Kaiser Health News
Some hospitals with high readmission rates say theyfre saving lives by
bringing patients back at the first hint of trouble. The evidence for this is
that a handful of hospitals with high readmission rates also have extremely low
death rates among Medicare patients.
But a study published Tuesday finds that there's no major link between
hospitals with high readmissions and those with low mortality rates. The
findings come as Medicare ramps up financial penalties for hospitals with higher
readmission rates in an effort to improve quality and contain costs.
Writing in the Journal of the American Medical Association,
researchers found no relationship between readmissions and mortality rates for
Medicare patients who had heart attacks or pneumonia between 2005 and 2008. The
paper did find a "modest" inverse relationship between readmissions and death
rates for heart failure patients, where hospitals with low death rates tended to
have somewhat higher readmission rates. But that was only for a small portion of
hospitals and not strong even then.
"I feel we've dispelled the notion that your performance in mortality will
dictate your performance in readmission," said Dr. Harlan Krumholz of Yale University School of Medicine,
the lead author of the study. "This result says they appear to be measuring
different things, they're not strongly related to each other and you can clearly
do well on both."
Krumholz does work for the Centers for Medicare & Medicaid Services (CMS)
in developing and assessing measures of hospital quality, including the ones for
readmissions and mortality.
His study has not quelled the debate among researchers, including ones from
the Cleveland Clinic, who previously suggested that higher readmission rates might be
the consequence of successful care.
Dr. Bruce Lytle, chairman of The Cleveland Clinic's heart
and vascular programs, said he considered the Krumholz's finding about heart
failure readmissions more significant than Krumholz gave it credit for. "He got
very similar results from what we noted," Lytle said. "He tends to feel it's not
a big inverse association. But big and small are a matter of
interpretation."
Medicare data released last year showed that two hospitals, Beth Israel Deaconess Medical
Center in Boston and Olympia Medical Center in Los Angeles, had higher than
average readmission rates for all three conditions that Medicare tracks
publicly: heart attack, heart failure and pneumonia, but lower rates of
mortality within 30 days of discharge for patients with those three conditions.
Thirty-one hospitals other than Israel and Olympia had low mortality for heart
failure patients even though they had high readmission rates.
Dr. Ashish
Jha, a professor at the Harvard School of Public Health who has written skeptically about the readmission measure, said
Krumholzfs analysis strengthened his concerns that readmissions are not a
trustworthy way to gauge the quality of hospitals.
Jha said that most hospital quality measures tend to move in tandem: for
instance a hospital that frequently follows the appropriate methods of care also
tends to do well in keeping patients alive. But Jha said Krumholz's study showed
there was no connection between hospitals that do well on keeping patients alive
and keeping them from returning.
"This paper offers strong evidence that readmissions is not a good measure of
the quality of hospital care," Jha said. "It may be a good way to promote
greater accountability for what happens to patients after they leave. But, as a
measure of hospital quality, not as much."
This year, 2,217 hospitals are getting lower Medicare payments because too many patients
were readmitted. Hospitals have been objecting to the readmissions penalties,
which under the federal health law will rise incrementally to a maximum of 3
percent of all regular Medicare payments in October 2015.
A widely cited study by researchers at the David Geffen School
of Medicine at UCLA in Los Angeles backed the notion that more aggressive care
can save lives. The study of heart failure patients at California teaching
hospitals found that the hospitals that used more resources during the 180 days
after a patient was admitted had lower mortality rates.
Dr. Michael Ong, an author of the UCLA study, called
Krumholzfs study "probably the most helpful study to date on this question"
because it included more than just heart failure patients. But he said it will
still be important to monitor patient health as hospitals take more substantial
steps to reduce readmissions now that the penalties have kicked in.
"In the drive to reduce costs, I think it's important for people who are
doing evaluations to track both [readmissions and mortality] outcomes to ensure
they are not causing harm," Ong said.
The American Hospital Association has strongly criticized the readmissions penalties. An AHA
research brief in 2011 said: "[G]rowing evidence reveals that mortality and
readmissions may in fact be inversely associated with one another, calling into
question the assumption that low readmission rates are always desirable."
In an interview Tuesday, Nancy Foster, an AHA vice president, said the
Krumholz paper was a good start at examining the relationship between
readmissions and patient outcomes but she wasn't persuaded that there arenft
adverse consequences when hospitals cut readmissions.
The analysis on which Krumholz's paper was based was performed as part of a
contract Krumholz and fellow Yale researchers have with CMS. The Yale New
Haven Health
Services Corporation Center for Outcomes Research and Evaluation produces an
annual performance report on readmission and mortality measures for CMS. The
most recent report found a wide variation among hospitals not
only for readmissions for heart and pneumonia patients but also for complication
and readmission rates for those who underwent hip and knee replacements –
indicating that some hospitals do a better job than others in making sure
patients in elective surgeries heal properly.
jrau@kff.org
This article was produced by Kaiser Health News
with support from The SCAN
© 2013 Henry J. Kaiser Family Foundation. All rights reserved.