(Reuters Health) - Fewer - not more - patients die when the number of repeat hospital admissions declines, according to a new U.S. study that suggests efforts to curb so-called readmissions may not endanger lives.
Under the Affordable Care Act (ACA) hospitals got financial incentives to reduce the number of patients readmitted within 30 days of going home, a policy designed to reward higher quality care. But the fear was that hospitals might lower readmission rates by delaying needed follow-up care to avoid penalties, said lead study author Dr. Kumar Dharmarajan, a researcher at Yale University in New Haven, Connecticut.
"We actually found the opposite," Dharmarajan, also chief scientific officer at Clover Health, a San Francisco-based health insurance startup company, said by email. "Hospitals with greater readmission rate reductions tended to have greater reductions in mortality after discharge, and this relationship grew even stronger when we examined 90-day mortality rates rather than 30-day mortality rates after discharge."
Nationwide, the ACA has led to reductions in 30-day readmission rates for heart failure, heart attacks and pneumonia, all common reasons for older adults to wind up in the hospital, researchers note in JAMA.
For the current study, researchers examined data on readmission rates for patients 65 and older insured by Medicare from 2008 to 2014. The study included 2.96 million heart failure admissions, 1.23 million admissions for heart attacks and 2.54 million pneumonia admissions.
Patients were typically in their late 70s or early 80s and had average hospital stays of about five days. Researchers adjusted readmission and mortality rates to account for patient age, sex, other medical conditions, season and the duration of the hospital stay.
At the start of the study period in January 2008, about 25 percent of heart failure patients were readmitted to the hospital within 30 days of discharge and 8.4 percent died.
With heart attacks, 19 percent of patients were readmitted within 30 days and 7.6 percent died. For pneumonia, the 30-day readmission rate was 18 percent and the mortality rate was 8.5 percent.
By the end of the study period in 2014, readmission rates declined slightly for all three conditions.
These decreases were also associated with a small but statistically meaningful decline in 30-day mortality rates, the study found.
However, the study isn't a controlled experiment designed to prove that reducing readmissions will directly cause lower death rates, the authors note. It also focused only on three conditions and admissions for older adults, and results might be different with other health problems or younger patients.
Even so, the authors conclude, the results make it unlikely that reducing readmission rates could lead to an rise in mortality rates.
"The things that hospitals are generally doing to reduce readmissions are things like hiring discharge coordinators, scheduling early follow-up visits or using electronic functionalities to share information with outpatient providers," said Dr. Karen Joynt Maddox, a researcher at Washington University School of Medicine in St. Louis and author of an accompanying editorial.
"These are all patient-centered things that are unlikely to have negative consequences in terms of mortality," Maddox said by email.
Even though some in the medical community have expressed concerns that efforts to lower readmissions might give doctors an incentive to inappropriately keep patients out of the hospital who need to return for additional care, the study offers fresh evidence that this doesn't happen, said Dr. Karl Bilimoria, director of the Surgical Outcomes and Quality Improvement Center at Northwestern University’s Feinberg School of Medicine in Chicago.
"While some may suggest this, most of us have not given this argument credence - doctors will still do the right thing and readmit patients when it is medically needed," Bilimoria, who wasn't involved in the study, said by email.
"In this case, the right thing to do is the easy thing," Bilimoria said. "You can't manage a complex patient with a serious deterioration in their condition in the outpatient setting."
SOURCE: http://bit.ly/2tmT9ID and http://bit.ly/2uzxFYs JAMA, online July 18, 2017.
