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Hospitals may take too much of the blame for unplanned readmissions

July 12, 2018

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A major goal of hospitals is to prevent unplanned readmissions of patients after they are discharged. A new study reveals that the preventability of readmissions changes over time: readmissions within the first week after discharge are often preventable by the hospital, whereas readmissions later are often related to patients' difficultly accessing outpatient clinics.

"Patients discharged from a hospital are usually recovering from a serious medical condition as well as managing other chronic medical conditions, and they often encounter new logistical challenges adapting to this recovery period," said Kelly Graham, MD, MPH, Director of Ambulatory Residency Training at BIDMC and an Instructor in Medicine at Harvard Medical School. "Hospitals and outpatient clinics must work together more seamlessly to ensure that patients are equipped to manage these challenges at home."

For their study, published in the Annals of Internal Medicine, Graham and her colleagues examined information on 822 general medicine patients readmitted to 10 academic medical centers in the United States. Overall, 36.2% of early readmissions versus 23.0% of late readmissions were deemed preventable. Hospitals were identified as better locations for preventing early readmissions, whereas outpatient clinics and home were better for preventing late readmissions.

Premature discharge and problems with physician decision-making related to diagnosis and management during the initial hospitalization were likely causes of readmissions in the early period. More likely to be amenable to interventions outside the hospital, later readmissions were most often caused by factors over which the hospital has less direct control, such as monitoring and managing of symptoms after discharge by primary care clinicians, as well as end-of-life issues.

Taken together, the findings suggest that readmissions in the week after discharge are more preventable and more likely to be caused by factors over which the hospital has direct control than those later in the 30-day window. In the current US system, however, unplanned readmissions within the 30 days after hospital discharge are considered uniformly preventable by hospitals, and thus hospitals are punished with financial penalties for these events.

"Our findings suggest that the 30 days following hospital discharge are not the same with regard to what influences outcomes for sick patients, and that the current model over-simplifies this high-risk time," said Graham. "One potential unintended consequence of this is that outpatient environments have not been involved in efforts to manage this high-risk timeframe, which results in poorly coordinated care and worse outcomes for our patients."

Graham noted that interventions to improve outcomes after hospital discharge should engage the ambulatory care system, with attention to improving access to primary care. "We should also be careful not to put too much focus on reducing length of stay in the hospital, which may be a driver of premature discharge and early readmissions," she said.
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In addition to Graham, co-authors include Roger B. Davis, ScD, Julius Yang, MD, PhD, Edward R. Marcantonio, MD, SM, and Shoshana J. Herzig, MD, MPH, of Beth Israel Deaconess Medical Center and Harvard Medical School; Andrew D. Auerbach, MD, MPH, of University of California, San Francisco; Jeffrey L. Schnipper, MD, MPH, of Harvard Medical School and Brigham and Women's Hospital; Scott A. Flanders, MD, of University of Michigan Medical School; Christopher S. Kim, MD, MBA, of University of Washington; Edmondo J. Robinson, MD, MBA, of Value Institute, Christiana Care Health System; Gregory W. Ruhnke, MD, MS, MPH, University of Chicago; Larissa R. Thomas, MD, MPH, of University of California, San Francisco; Sunil Kripalani, MD, MSc, of the Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center; Eduard E. Vasilevskis, MD, MPH, of the Center for Quality Aging at Vanderbilt University Medical Center and VA Tennessee Valley Healthcare System Geriatric Research Education and Clinical Center; Grant S. Fletcher, MD, MPH, Harborview Medical Center, University of Washington; Neil J. Sehgal, PhD, MPH, of University of Maryland School of Public Health; Peter K. Lindenauer, MD, MSc, of University of Massachusetts Medical School; Mark V. Williams, MD, of the Center for Health Services Research, University of Kentucky; Joshua P. Metlay, MD, PhD, of Massachusetts General Hospital.

Financial support was provided by an unrestricted research grant from the American Association of Medical Colleges. This work was done with support from Harvard Catalyst, The Harvard Clinical and Translational Science Center, through award UL1 TR001102 from the National Institutes of Health, and ?nancial contributions from Harvard University and its af?liated academic health care centers. Graham is funded by the Eleanor and Miles Shore 50th Anniversary Fellowship Program for Scholars in Medicine at Beth Israel Deaconess Medical Center and Harvard Medical School. Herzig is funded by grant K23AG042459 from the National Institute on Aging. Marcantonio was supported in part by grants R01AG030618 and K24AG035075 from the National Institute on Aging. Vasilevskis was supported by National Institute on Aging award K23AG040157, the Veterans Affairs Clinical Research Center of Excellence, and the Geriatric Research Education and Clinical Center.

Beth Israel Deaconess Medical Center

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