Access to Post-Acute Care Linked to Lower Hospital Readmission Rates

Hospitals in communities with more postdischarge care resources saw lower readmission rates, according to a study using national hospital-level data.

Among Medicare patients who were hospitalized for acute myocardial infarction (MI), heart failure, or pneumonia, hospital readmission rates were negatively associated with per-capita supply of primary care physicians (PCPs; -0.16 percentage points per standard deviation [pp/SD]) and licensed nursing home beds (-0.09 pp/SD), reported Kevin Griffith, PhD, of Vanderbilt University Medical Center in Nashville, and colleagues.

On the other hand, readmissions were positively associated with nurse practitioner availability (0.09 pp/SD) in adjusted models, they noted in Health Affairs.

The study authors found that availability of palliative care (-0.89 pp/SD), nursing home beds (-0.21 pp/SD), skilled nursing facility beds (-0.12 pp/SD), and PCPs (-0.21 pp/SD) were associated with lower acute MI readmissions.

As for heart failure, nursing home beds (-0.14 pp/SD), skilled nursing facility beds (-0.09 pp/SD), and PCPs (-0.20 pp/SD) were linked to lower readmissions, while home-health agencies (0.16 pp/SD) and nurse practitioners (0.15 pp/SD) were linked to higher readmissions.

PCPs were also associated with fewer pneumonia readmissions (-0.21 pp/SD), whereas nurse practitioners were associated with higher readmissions (0.13 pp/SD).

Griffith and team said they were surprised by their findings on nurse practitioners, since the expectation is that if a patient has a greater number of people available to provide care, the likelihood of readmission would be lower. However, nurse practitioners often work on care teams alongside physicians and it’s possible they may be looking after sicker patients, they suggested.

While prior studies have looked at one aspect of post-acute care in isolation or analyzed data from a certain geographic region, this study represents “the most rigorous” look at postdischarge care options to date, Griffith told MedPage Today.

He pointed out that when Congress authorized the Hospital Readmissions Reduction Program, the goal was to penalize hospitals based on the quality of care they provided, not based on the features of the communities they served. “However, the quality and type of care you receive after you leave the hospital is dependent upon what’s available, where you live,” Griffith said, adding that the availability of post-acute care resources varies by region.

The study authors explained that rehospitalizations are tied to increased morbidity, mortality, and health spending, and are widely seen as a “quality-of-care indicator.” Hospitals with 30-day readmission rates that outpace risk-adjusted national averages may be penalized with reduced Medicare payments.

But the federal government has a very basic risk adjustment model for 30-day hospital readmissions that doesn’t account for social determinants of health or other resources available in a given region, Griffith said. His group argued that Congress should include the supply of post-acute care resources in the CMS risk-adjustment algorithm for assessing readmission penalties.

Furthermore, hospitals could be doing more to support patients in choosing a post-acute care facility rather than simply handing patients a list of skilled facilities with a bit of information and some photos, he noted. For example, hospitals could share meaningful data with patients, such as showing how 30-day readmission rates compare between hospitals.

Hospitals and health systems should also invest in palliative care services and other post-acute care resources, he added, to help patients, but also to prevent penalties.

For this study, Griffith and team used national hospital-level data to assess whether the supply of postdischarge care options in hospitals’ catchment areas were associated with readmission rates for acute MI, heart failure, and pneumonia among Medicare patients.

They collected data on hospitals’ 30-day readmission rates from CMS’s Hospital Compare for 2013 to 2019, and included 50,592 hospital-condition-years from 3,042 unique hospitals. Most of the hospitals were private, not-for-profit; based in urban areas; and offered hospital-based palliative care services.

The authors adjusted their models for demographic variables, such as the percentage of uninsured residents in a hospital’s catchment area, and controlled for a variety of CMS adjustments to hospital payments, including the case-mix index, which represents the clinical complexity and resource needs in the hospital’s patient population.

Mean hospital-level crude readmission rates during the study period ranged from 17.5% for pneumonia, to 18.7% for acute MI, and 22.4% for heart failure.

Study limitations included its observational design and the inability to show “causal mechanisms,” Griffith and team noted. In addition, while they controlled for within-hospital death rates, “the geographic distribution of postdischarge care options may partially reflect the illness severity of patients who were discharged in those areas,” they wrote.

The authors also highlighted the challenges of parsing “indicated versus potentially avoidable readmissions,” pointing out that they “could not rule out the possibility that increased readmission rates in areas with a greater supply of nurse practitioners, for example, were due to increased identification of potentially dangerous complications that would otherwise remain untreated.”