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A requirement to reduce readmissions: take care of the patient, not just the disease.

THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) Hospital Readmissions Reduction Program initiated a seismic shift in US hospitals’ attitudes toward coordinating transitions of care. Effective October 2012, more than 2000 hospitals began losing money (national total of~$300 million the first year) to financial penalties for excess readmissions, and this penalty could triple for some hospitals by 2014 under provisions stipulated by §3025 of the Patient Protection and Affordable Care Act. This program aims to slow growth in hospital inpatient costs (a quarter of the more than half trillion dollars in annual Medicare expenditures) and increase the value of medical care delivered to its beneficiaries. Despite representing less than 0.1% of the overall CMS budget, these penalties for excess readmissions of patients discharged after hospitalizations for heart failure, acute myocardial infarction, or pneumonia are driving change across the United States. Numerous programs emerged in the past 5 years to reduce readmissions among patients discharged after hospitalization for these 3 conditions, especially heart failure. Not surprisingly, the customary silo approach to health care prompted national organizations to develop diseasefocused programs. Results from 3 studies published in this issue of JAMA add to the description of the saga that patients and caregivers experience as they transition among hospitals, emergency departments (EDs), skilled nursing facilities, and home during episodes of acute illness with a background of chronic diseases. These reports also bolster support for a patient-centered approach instead of the standard disease-focused efforts that have previously been financially rewarded by the current fee-for-service system. Two observational studies examining large national and multistate data sets revealed important factors that should be considered in efforts to optimize care transitions for patients. The study by Dharmarajan and colleagues analyzed Medicare data from 2007 to 2009 to determine the diagnoses and timing of readmission following 1 330 157 hospitalizations for heart failure (24.8% readmitted), 548 834 hospitalizations for myocardial infarction (19.9% readmitted), and 1 168 624 hospitalizations for pneumonia (18.3% readmitted). The authors found that a “diverse spectrum of diagnoses that usually differ from the cause of the index hospitalization” were responsible for readmission within 30 days after hospitalization among Medicare patients with these 3 conditions. These patients had “heightened vulnerability to readmission from a wide variety of illnesses” and were readmitted steadily across the entire 30-day period after hospital discharge. These findings are not surprising given previous work by this research group that showed the high level of illness and complexity among Medicare patients admitted with heart failure—their average age was 80 years and more than one-third also had hypertension, diabetes mellitus, or chronic obstructive pulmonary disease. Based on their findings from the current report, the authors assert that efforts targeting the admitting diagnosis only or specific durations will not be as effective as those broad in scope while hospitals and health systems attempt to reduce 30-day readmissions. The study by Vashi and colleagues evaluated patterns of acute care following hospital discharge for more than 5 million hospital admissions among more than 4 million adults (age 18 years) in 3 states from July 2008 to September 2009, and found that nearly 18% of hospital discharges were followed by an acute care encounter within 30 days, including ED treat-and-release visits (9.75% of discharges) and hospital readmissions (14.7% of discharges). These findings suggest that ED visits should be included as a focus of posthospital care. Too often the ED serves as a source of outpatient follow-up (40% of all hospital-based, acute care use during the postdischarge period according to their findings), compounding the problems of ED overcrowding. Notably, Vashi et al reported that digestive disorders and psychosis were the highest volume reasons for 30-day posthospital discharge ED treat-and-release visit rates, not the 3 diseases currently measured by CMS for 30-day readmissions among Medicare beneficiaries. The researchers also found that “ED treat-and-release visits were always related to the index hospitalization.” This suggests that compre-