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Readmissions Based on Provider Supply, Poverty More Than Hospital Quality, Researchers Say

By Nellie Bristol, CQ HealthBeat Associate Editor

May 11, 2012 -- Variations in hospital readmission rates for heart failure were linked more to availability of care and socioeconomic factors than to severity of illness or hospital performance, researchers said at an American Heart Association conference in Atlanta.

Higher readmission rates occurred in communities with more physicians and hospital beds and separately, in areas with high poverty and large African American populations. Older people also were readmitted more frequently, according to the findings.

Readmission rates in the study ranged from 10 percent to 32 percent. What researchers dubbed "supply side factors" including the availability of doctors and beds, were the strongest predictors of regional variations in the rates, accounting for 17 percent. Poverty and racial makeup were tied to 9 percent of the variation. About 5 percent was linked to hospital performance and an additional 4 percent to the severity of the patient's illness.

Researchers looked at national billing records of more than 3,000 hospitals in 2008 and 2009 for more than 1 million Medicare patients with heart failure. Fifty-five percent of patients were female and 11 percent were African American. The average age was 81. The National Heart, Lung and Blood Institute funded the study.

Lead author Karen Joynt of the Harvard Medical School and Harvard School of Public Health said researchers don't fully understand why the factors studied affected readmissions the way they did. But she said the patterns were clear and warrant further review. She said the findings should inform Centers for Medicare and Medicaid Services (CMS) efforts to develop a financing mechanism for discouraging readmissions. Under current proposals, planned for implementation later this year, hospitals would be penalized for readmissions of Medicare patients within 30 days of an initial discharge.

If the policy is applied uniformly across hospitals, Joynt said, "CMS is likely going to be penalizing hospitals that serve a high proportion of poor and minority patients." Efforts to reduce readmissions need to take into account the neighborhoods in which hospitals are operating and engage caregivers other than just hospitals, she added.

"Our point in doing this is really to sort of say, 'look, community matters and community resources matter, and community poverty matters,'" Joynt said. "If we really want to be able to improve readmissions without widening disparities, maybe our policies need to think about ways to not only point out where hospitals are struggling, but also figure out what we can do to help them perform better."

Making changes to reduce readmissions will be easier for hospitals with more resources and better community connections, she added. "This is not ultimately a hospital problem. It's a health systems problem."

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