Hospital Readmissions: in search of potentially avoidable costs

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 its
  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 isnt free, of
  course.

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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)

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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.

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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?