Current efforts to collect and publicly report data on discharge planning are unlikely to yield large reductions in unnecessary readmissions, according to study authors in the Dec. 31 issue of the New England Journal of Medicine.
The Centers for Medicare & Medicaid Services (CMS) has initiated a national effort to measure and publicly report on the conduct of discharge planning. Ashish K. Jha, MD, from the department of health policy and management at Harvard School of Public Health and the division of general medicine at Brigham and Women's Hospital in Boston, and colleagues noted that little is known about “how U.S. hospitals perform on the current discharge metrics, the factors that underlie better performance and whether better performance is related to lower readmission rates.”
The researchers examined hospital performance on the basis of two measures of discharge planning: the adequacy of documentation in the chart that discharge instructions were provided to patients with congestive heart failure, and patient-reported experiences with discharge planning.
The CMS Hospital Quality Alliance (HQA) program now publicly reports indicators that assess proper documentation of discharge planning in the medical records of patients with congestive heart failure. The HQA also includes the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which reports on patients' perceptions of the adequacy of their discharge planning.
Overall, a total of 2,222 hospitals reported performance on both chart-based and patient-reported discharge measures. Reporting hospitals provided 77 percent of all inpatient care for congestive heart failure and 78 percent of inpatient care for pneumonia; of the hospitals that did not report performance on both measures, 86 percent did not provide data on the patient-reported measure, 11 percent did not provide data on the chart-based measure and 3 percent did not provide data on either one.
The authors examined the association between performance on these measures and rates of readmission for congestive heart failure and pneumonia.
Jha and colleagues found a “weak correlation” in performance between the two discharge measures (r=0.05). Although larger hospitals performed better on the chart-based measure, smaller hospitals and those with higher nurse-staffing levels performed better on the patient-reported measure.
They also reported finding no association between performance on the chart-based measure and readmission rates among patients with congestive heart failure (readmission rates among hospitals performing in the highest quartile vs. the lowest quartile, 23.7 vs. 23.5 percent) and only a very modest association between performance on the patient-reported measure and readmission rates for congestive heart failure (readmission rates among hospitals performing in the highest quartile vs. the lowest quartile, 22.4 vs. 24.7 percent) and pneumonia (17.5 vs. 19.5 percent).
Based on their findings, the authors wrote: “To substantially reduce readmissions, additional efforts are needed…President Barack Obama's budget includes provisions to reduce payments for hospital readmission. This approach will probably be needed to realize a meaningful effect. However, whether these efforts will primarily reduce unnecessary readmissions or have unintended consequences will need to be tracked.”
Jha and colleagues also expressed “surprise” in finding “essentially no association” between performances on the two discharge measures. They speculated that hospitals, which document consistent provision of written discharge instructions to patients with congestive heart failure would have higher ratings on patients' reports of whether they were asked about having adequate help at home or received written discharge instructions. “Important differences between the two measures might explain the poor correlation,” the authors wrote.
The Commonwealth Fund financially supported the study.