Hospital Readmissions—Not Just a Measure of Quality

Hospital readmissions are common and costly. Policies from the Centers for Medicare & Medicaid Services (CMS) will soon penalize hospitals when its patients are frequently readmitted within 30 days of discharge. As a result, clinicians, health care leaders, and policy makers are searching for ways to reduce readmissions.

The current understanding of what drives readmission focuses on the quality of the inpatient discharge process and on patients' health status (Figure). Health care administrators have relied on this narrow framework to conclude that the best approach to reduce readmission rates is to improve the discharge process for medically high-risk patients. This strategy may yield disappointing results because it misses important factors that contribute to readmission. In this Commentary, we propose a broader framework that can be used to identify alternative strategies to reduce readmissions.

Although the current policy debate would suggest otherwise, readmission rate is not a quality metric.¹ Nor is it a measure of patients' health status. Readmission rate is, by definition, a measure of health service use. And while this use is influenced by the quality of care and patients' health status, it is also a function of access to health services and to socioeconomic resources like income or social support.² To the extent these determinants remain unrecognized, hospitals will have difficulty reducing readmissions among patients with limited access to medical or socioeconomic resources.

A framework in which readmission rates are determined by access, social determinants of health, and regulatory policies is more appropriate (Figure). Access describes ease of entry into a health care system. Quality describes how well a patient is cared for after that point. A patient may have good access to high-quality inpatient care, but minimal access to even low-quality outpatient care. This patient is more likely than a patient with ready access to ambulatory services to access medical care through a hospital readmission. The medical and social conditions of the patient have an effect on readmission rates. Patient-level determinants of readmission include not only health status, but also access to socioeconomic resources such as stable housing, social support, and food. These factors affect patients' ability to adhere to hospital discharge recommendations and thus influence readmission risk.^{3 - 5} Regulatory policies such as financial penalties for high rates of readmission can create an economic and regulatory environment that influences health care services.

Several scenarios illustrate how access to health services and socioeconomic resources can influence a patient's likelihood of readmission.

It should not be surprising when socioeconomically vulnerable patients experience relapse and readmission, even if they received high-quality inpatient and discharge care. Lack of access to transportation, child care, or social support can make it difficult for patients to comply with discharge recommendations.⁴ In addition, when these patients seek outpatient care, they are less likely to receive timely appointments and more likely to be referred to an emergency department.^{6 - 7} With limited access to socioeconomic resources that enable self-care and to outpatient medical follow-up, these patients are at higher risk of readmission.

Many hospitals leaders have expanded access to postdischarge health services such as home care only to see readmission rates remain unchanged or even increase. A landmark Veterans Affairs study⁸ revealed that intensive postdischarge medical care increased rather than decreased readmission rates. This paradox may be secondary to “pent-up demand,” whereby increasing access to medical care for socioeconomically vulnerable patients leads to an increase in health care use.⁹ This occurs because patients still lacking access to the socioeconomic resources that enable self-care are at high risk of relapse.^{4 - 5} Increased access to health services facilitates closer monitoring of these relapses and higher rates of referral back to the hospital.

For an admission to occur, patients must have a minimum level of access to inpatient care. Therefore, it is possible for hospitals to reduce readmission rates by decreasing access. For example, uninsured patients have been shown to be less likely to be admitted than insured patients with similar clinical circumstances.¹⁰ As hospitals face readmission penalties, emergency department physicians may be under increasing pressure to justify each readmission. Financial incentives could increase the likelihood that socioeconomically vulnerable patients are discharged home in high-risk situations that depend on self-care and follow-up, resources these patients often lack.

Based on our proposed framework, reducing readmissions among vulnerable patients will require improving access to both outpatient health services and socioeconomic resources. Three strategies may help health care leaders achieve these goals.

First, hospitals should consider social factors when determining readmission risk. Strategies for assessing social risk range from the use of administrative indicators (such as insurance status or zip code as a proxy for socioeconomic status) to the use of screening instruments for issues like food insecurity or social support. This will enable hospitals to recognize patients who lack the resources to follow challenging health behaviors after discharge and may allow targeting of specific resources.

Second, policy makers should monitor the consequences of readmission penalties, especially among socioeconomically vulnerable patients. In addition to 30-day readmission rates, the CMS should monitor 90- and 180-day rates, emergency department and observation service use, and mortality.

Lastly, the readmission penalty incentivizes hospitals to expand their scope beyond traditional health services. Although hospitals cannot assume responsibility for all patients' social needs, they can serve as a vehicle for connecting high-risk patients to resources like addiction counseling and community centers. This may require investments in social work programs within hospitals as well as partnerships with community-based organizations that can effectively link patients to existing socioeconomic resources. The Community-Based Care Transitions Program created by the US Patient Protection and Affordable Care Act offers an opportunity to support development of such partnerships.

Readmission policy could reward hospitals that address the root causes of readmission. Unfortunately, the penalties also have the potential to create new access barriers. Health care leaders who recognize the drivers of readmission can view CMS policies not as an obstacle, but as an opportunity to improve care for socioeconomically vulnerable patients.