US not sure how to evaluate hospital performance; don't know if they will cause more deaths if they punish high readmission rates

Hospital deaths and readmissions not linked: study
By Andrew M. Seaman
Feb 12, 2013
(Reuters Health)

A measure used by Medicare to penalize hospitals for poor performance is not linked to how many patients die after being admitted, suggests a new study.

The study, published in the Journal of the American Medical Association on Tuesday, suggests that hospitals can keep the number of patients who come back for more treatment low without having more of them die.

"The concern was that their performance in one area is going to compromise their performance in another," said Dr. Harlan Krumholz, the study's lead author from the Yale University School of Medicine in New Haven, Connecticut.

Currently, the U.S. Centers for Medicare and Medicaid Services (CMS), which oversees the federal government's insurance programs for the elderly, disabled and poor, uses those measures to judge a hospital's quality.

CMS also punishes hospitals with high readmission rates by reducing their payments. In 2013, CMS estimates hospitals will lose - on average - 0.3 percent of their funding, about $270 million overall (see Reuters Health story of January 22, 2013 here: reut.rs/Xwm984).

For the new study, Krumholz and his colleagues looked at whether there was a link between the number of people who died within 30 days of being admitted to hospitals and the number of people who came back for more treatment within 30 days after they were discharged.

They analyzed data on older Americans on Medicare who were admitted to U.S. hospitals between July 2005 and June 2008 with a heart attack, heart failure and pneumonia - the conditions CMS tracks.

They found about 20 percent of heart attack patients, 24 percent of heart failure patients and 18 percent of pneumonia patients came back to the hospital for more care. That compared to about 17 percent of heart attack patients and 11 percent of heart failure and pneumonia patients who died.

Overall, they found no relationship between the number of heart attack and pneumonia patients who were readmitted and those who died.

The researchers also found that between 5 percent and 9 percent of hospitals were able to have both low readmission and death rates, which Krumholz said should calm concerns that doing well in one area means doing poorly in the other.

"I think our goal should be to learn from the hospitals excelling in both areas and spread those ideas," said Krumholz, whose team created the measures CMS uses to judge hospital quality.

He added that the findings also suggest that readmission and death rates measure two different events, and one is not dependant on the other.

‘NO EASY PATH'

But Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association, said the new study does not close the door on questions about readmission and death rates.

"This question that has been raised around the link between readmission and mortality is beginning to be investigated. There is no easy path to know what the relationship is because it's a very complicated problem," said Foster, who was not involved with the new study.

Foster told Reuters Health that she believes the new study has flaws, including that the researchers adjusted the rates for smaller hospitals, which led to the findings. She added that there could be other reasons why hospitals performed well on both measures.

"I'd love to say that it's only to the hospitals' credit that they've done so well (to) have low levels of mortality and readmission. But in all fairness, we recognize that community and other factors have an important role," she said.