Rand’s Technical Report, “Preventing emergency readmissions to hospital”

Rand’s Technical Report, “Preventing emergency readmissions to hospital” (Nolte, Roland, Guthrie, Brereton, 2012) is a comparison of healthcare internationally. The 14-point summary starts with evaluating outcomes of care efficiency as a measure of progress.  Item 2 discusses the use of the readmission as a alternative evaluate of preventable adverse effects after the preliminary admission but also challenges the assertion to use as a quality or performance metric. The rationale relates to other unlinked causes to care can influence variances of care.

Point 3 uses analysis of data and probability of use on readmissions with in 28 days of discharge as a marker with current studies of systematic review.  Point 4 finds the studies suggest 5 to 59% were avoidable. The weighted average was 20.6 %.  Some authors warn using standard thresholds for the percentage, but rather use neighboring best practice of improvement over time as a threshold. Indications imply rational readmission rates 15-20 %.
Point 5 suggests methodologies using specific diagnoses, considered principally avoidable can; manufacture diverse statistical percentages of avoidable readmissions. Nevertheless, the drawback is that not including individual conditions into the description. Analyses of detailed evidence to identify differences with percentages assessed as avoidable is accomplishable however the report does not support the use of analyses due to the differences of population characteristics and methodologies used.  It stresses the need future reports to evaluate the percentage of avoidable readmissions.

Interesting to note the studies reviewed use medical influences associated with the readmission and further suggests the need for review of organizational causes related to readmission or changes to avoid readmission.  The diagnosis for readmissions does not identify a specific illness as a cause. Patients requiring readmissions are in poor health. Surgical patients requiring readmission identify shortcomings in original care. Readmissions also lack follow up care once discharged. Currently Medicare has targeted specific diagnoses to monitor for readmissions, however the report discusses the use of excluding including behavioral health, cancer chemotherapy, obstetric care, and end of life care. Medicare is also gathering data on the entire populous. These results could skew the results.

Item 11 identifies in the United States some hospitals approach to the problem to improve cash flow by admitting less serious patients. Some facilities might shift coding from emergency to elective if the incentive is right…or wrong. 

Other related factors in need of data capture include socio-demographical, age, and culture as potential risk adjustment. However, the drawback for socio-demographic adjustment can mask inequalities in care. One cannot overlook the severity and morbidity of individual cases either. Most diagnoses alone will not be sufficiently reliable estimations annually. This must be done on a larger group such as medical or surgical for greater accuracy or by providing multi-annual averages.