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Hospital Readmissions: in search of potentially avoidable costs

Hospital Readmissions: in search of potentially avoidable costs. Bernard Friedman, PhD Center for Delivery, Organization, and Markets AHRQ Conference, 2009. Agenda. Multiple uses of readmission data quality of inpatient care

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Hospital Readmissions: in search of potentially avoidable costs

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  1. Hospital Readmissions: in search of potentially avoidable costs Bernard Friedman, PhD Center for Delivery, Organization, and Markets AHRQ Conference, 2009

  2. Agenda • Multiple uses of readmission data • quality of inpatient care • effectiveness of management of chronic illness outside the hospital • efficiency in arrangements for post-hospital care • accountability for health plans: consumer choice and P4P • Measurement choices depend on motives • types of index admisssion, length of follow-up, eligible readmissions • Tracking readmissions for the NHQR – it’s evolving • Recent research project: Contrast Medicare FFS vs. Advantage plan patients

  3. Some AHRQ Published Studies on Readmissions • 1.) Joanna Jiang was the lead author at AHRQ on several published studies of diabetes discharges. • One finding was that half of the discharges or hospital costs in a year are for people with multiple discharges for diabetes and its complications. • 2.) I examined (with Joy Basu) all readmissions within 6 months for people with 16 Potentially Preventable initial admissions. • Large variety of principal diagnoses for the RE-admissions • Just the re-admissions in the 16 categories of potentially preventable within 6 months had a projected national cost of about $1.4 Billion in 2008$. This covered only 4 states with 15% of the U.S. population.

  4. Readmissions and Quality of Inpatient Care • 3.) William. Encinosa and Fred Hellinger recently published “The Impact of Medical Errors on 90 Day Costs and Outcomes: An Examination of Surgical Patients”. Health Services Research, 2008 • about $1.5 billion of cost in 3 months subsequent to the initial discharge due to safety events. Some of that was readmissions. • 4.) B. Friedman, J. Jiang, W. Encinosa, R. Mutter, “Do patient safety events contribute to readmissions?” Medical Care, 2009. • risk of a readmission within 1 month or 3 months after a surgical admission was raised about 20% by a safety event.

  5. Effective Management of Chronic Conditions • 5.) B. Friedman, with Joanna Jiang and Anne Elixhauser, “Costly Hospital Readmissions and Complex Chronic Illness”, Inquiry, Winter, 2008/2009 • about 5 million adults were covered by the data • shows importance of the number of different chronic conditions in predicting readmission rates and annual cost. (“complexity”) • not easily “fixed” with disease-specific management protocols. But there is literature on demonstrations of other approaches. • 8% of the hospital costs for adults could be saved if you could bring down the extra readmissions for the 25% of hospitalized adulsts with 5 or more chronic conditions. • There have been a couple dozen demonstration projects of how to do that. It isn’t free, of course.

  6. NHQR 2008 Readmissions • Tracking system quality and system efficiency • Congestive Heart Failure, readmission for same. • readmission within 30 days (to any hospital) • short enough to implicate the discharge planning, handoff, patient counseling • not apportioning blame (could be other factors) • the national burden of readmissions: one person can have more than one readmit during the year qualifying to be counted (30 days from previous admit). • comparison of states within age groups (big difference between states, but not between age groups)

  7. Choices for future years NHQR • Suggestions should go to Ernie Moy or Ryan or ... • Possibilities: • multiple index admissions, with statistical controls • readmission after elective treatment, after delivery • state or area rates with risk adjustment.

  8. Do Medicare Advantage Patients Have Fewer Readmissions? • Coauthors: B. Friedman, J. Jiang, John Bott, Claudia Steiner. • Database: 5 states in HCUP with breakdown of type of Medicare coverage and with person identifiers. • Theory: superficially, it seems that the Advantage plans have both the motive (capitated revenue) and the means to reduce readmissions in comparison to FFS Medicare.

  9. raw comparisons • same 1-month rate of readmission (10%) • somewhat lower 3-month readmission rate (21% vs. 22.5%). • However, Advantage patients tend to be • a little younger • less severely ill even when hospitalized • less likely to have a major operative procedure.

  10. Results • Use risk adjustment and control for selection bias (predictors for joining an Advantage plan) • Manuscript available on methods • Advantage patients are one third more likely to have a readmission (in 30 days, 13% vs. 10%; in 90 days, 30.5% vs. 22.5%). • How reconcile with incentives? • maybe we did something wrong.... • enrollees have no comparative data • FFS more discharges to LTC and other facilities • Advantage plans might be spending less on outpatient service and quality than we expected?

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