Thursday, October 20, 2011

Did I say unintended consequences?

I raised lots of hackles in my post below about penalizing hospitals for readmissions, generally and in the face of poor data to support such penalties.  Some commentors have said, in essence, "What can be the harm?  We'll move the needle the right way, even if the methodology is not so precise."

Well, here's one example of the kind of harm that can occur when policies are not clearly thought out.  In December, Karen E. Joynt and Ashish K. Jha from Brigham and Women's Hospital published an article in Circulation: Cardiovascular Quality and Outcomes, entitled, "Who Has Higher Readmission Rates for Heart Failure, and Why? Implications for Efforts to Improve Care Using Financial Incentives."  I quote the abstract:

Background—Reducing readmissions for heart failure is an important goal for policymakers. Current national policies financially penalize hospitals with high readmission rates, which may have unintended consequences if these institutions are resource-poor, either financially or clinically.

Methods and Results—We analyzed national claims data for Medicare patients with heart failure discharged from US hospitals in 2006 to 2007.  We used multivariable models to examine hospital characteristics, 30-day all-cause readmission rates, and likelihood of performing in the worst quartile of readmission rates nationally.  Among 905 764 discharges in our sample, patients discharged from public hospitals (27.9%) had higher readmission rates than nonprofit hospitals (25.7%, P<0.001), as did patients discharged from hospitals in counties with low median income (29.4%) compared with counties with high median income (25.7%, P<0.001).  Patients discharged from hospitals without cardiac services (27.2%) had higher readmission rates than those from hospitals with full cardiac services (25.1%, P<0.001); patients discharged from hospitals in the lowest quartile of nurse staffing (28.5%) had higher readmission rates than those from hospitals in the highest quartile (25.4%, P<0.001).  Patients discharged from small hospitals (28.4%) had higher readmission rates than those discharged from large hospitals (25.2%, P<0.001).  These same characteristics identified hospitals that were likely to perform in the worst quartile nationally.

Conclusions—Given that many poor-performing hospitals also have fewer resources, they may suffer disproportionately from financial penalties for high readmission rates.  As we seek to improve care for patients with heart failure, we should ensure that penalties for poor performance do not worsen disparities in quality of care.  (Circ Cardiovasc Qual Outcomes. 2011;4:53-59.)


e-Patient Dave said...

So, Paul, if I recall correctly, you've always been the one to say "I know there will be things to be worked out, but there is a greater good to be pursued." In this case I can almost hear you: "Even aside from the obvious cost issues of redundant care caused by failed discharges, there is the human cost to the patient and the family of the worry, cost, lost productivity while caregiving, and returning to the risk of hospital-acquired infections, not to mention the just plain uncomfortable and unhealthy experience of trying to get a good night's sleep in a hospital while you're sick. Can't we agree that it's important to get started, and be vigilant about unintended consequences so we can fix them?"

What the heck is the flip-flop here?

Paul Levy said...

No flip-flop at all, Dave. I have always been wary of targeted financial penalties and incentives in the health care arena. I think there are more compelling ways to get improvement.

e-Patient Dave said...

> more compelling ways to get improvement

Well let's hear 'em! :-) (If I missed them in the original post, I apologize.)

Paul Levy said...

Stay tuned...

Anonymous said...

Having read both posts (but admittedly not the background articles) the problem does not seem to be with readmission rates as an indicator per se but the lack of a comparator. (I know what I am about to propose has ong run problems due to unintended consequences and peverse long-run incentives but I think it is worth mentioning for short run demonstration that change is possible.)

Why not compare readmission rates within an institution over time? e.g. the five-year average over 2013-2018 vs the five year average of 2006-2011? If financial incentives are frought with problems, make it a prize. $1 million and bragging rights for the Top 10 in 10 different categories.

Anonymous said...

The problem with readmission rates is not the problem with readmission NOR rates.

We will keep spinning these wheels until we understand that the systems that we have been trying to fix are microcosms of a larger ecology of care designed around providers, not around health. It is like fixing a flat tire on a car that can't climb the cliff in any case.

Readmissions are determined by everything that happened before a patient - a person - steps or is rolled into the door. It is the years of battered somatic capital - poor maternal health, elevated glucose, blood pressure, weakened immune system, high cortisol, obesity, malnutrition, stressed mental condition, neglected social crucibles. And everything about that environment that determines health when they are rolled out again with discharge 'education' in hand, family members whose jobs are threatened when they need to take more days off, and every risk factor patients left waiting at their door.

What medical school trains a physician - especially a surgeon - to ask: tell me about your life? What supports do you have? How close is a grocery store? How many fresh vegetables have you had this week? Do you have someone who can read the prescription bottles for you? Here's one. Can you tell me what it says?

We are trying to solve human infrastructural problems with the wrong tools. All of science bends to the answer, and it is not confined to the right protocol. It should not be lost to anyone that Anish Jha is a public health scientist.

There is so much that community hospitals can do - in fact, they do so much around care that is abandoned elsewhere. But we have no triage system to know which cases to send to the most expensive hospitals, and how many can be done locally, because we have no health infrastructure.

Paul, isn't this like repairing a valve when no one is thinking about water?

Paul Levy said...

Well put!