A new study in Health Affairs from researchers at Vanderbilt University Medical Center and Boston University finds that hospitals’ 30-day readmission rates were lower if they had a larger supply of primary care physicians, nursing homes or palliative care services nearby. The research team also found higher rates of hospital readmission in areas where there were more home health agencies and nurse practitioners.
Since 2013, the Hospital Readmissions Reduction Program has penalized hospitals with higher-than-expected readmissions for heart attack, heart failure and pneumonia. Penalties for coronary artery bypass grafts, elective hip or knee replacements and chronic obstructive pulmonary disease were added in later years.
“The quality and type of care that you receive after you leave the hospital is dependent on what is available where you live. If you live in an isolated rural area, you may have no choice to return to the emergency room if you experience complications. And yet, the federal government does not currently take this into account when rewarding or penalizing hospitals,” said Kevin Griffith, PhD, assistant professor of Health Policy at VUMC and lead author of the study.
The researchers found in statistical analyses that post-discharge care options varied widely by geography. Large urban centers like Chicago, Los Angeles and New York had larger raw numbers of some facilities, like skilled nursing facilities, but not an oversupply based on population. More sparsely populated areas across the Great Plains showed higher per capita availability of skilled nursing facilities, however the researchers noted that there are still potential barriers to access due to physical distance and transportation access.
The differences in facility availability could cause hospitals to discharge to specific facilities that are more common, but also might reflect a greater need for certain types of care options. “If not already doing so, hospitals should track readmission performance by discharge site and see whether there are opportunities to improve quality of care and lower readmission rates through reengineered discharge planning,” the study said.
The study has important policy implications for both hospitals and the Centers for Medicare and Medicaid Services, which monitors readmission rates and assigns penalties to hospitals. The authors suggest hospitals should take a more active role to develop post-discharge care options in their communities. For instance, hospitals could start their own palliative care service or steer patients toward post-acute care options with lower readmission rates. At the federal level, the authors suggest CMS should realign its risk-adjustment algorithm to emphasize community-level characteristics more than it does currently.
“Congress’ intent was to penalize hospitals based on the quality of care they provide, not the communities they serve. We need to start accounting for the fact that some areas simply have more resources than others, and that is going to affect patient outcomes,” Griffith said.
