Shifting the dialogue from hospital readmissions to unplanned care.

OBJECTIVES: To propose a new measurement strategy to evaluate the intended impact of hospital readmission reduction programs on healthcare utilization. STUDY
DESIGN: In Rhode Island, Healthcentric Advisors, the Medicare Quality Improvement Organization, has implemented a readmissions reduction program since 2008. We use data fromthis program to illustrate our proposed use of a bundled measure of unplanned post-hospital care.
METHODS: We examined Medicare Part A claims for all Rhode Island fee-for-service Medicare beneficiaries from January 1, 2009, through December 31, 2011.To capture potential cost shifting, we evaluated emergency department (ED) visits, observation stays, and hospital admission and readmission rates annually, and in the 30 days after discharge from an inpatient stay. We also aggregated these data into 2 composite measures: acute-care utilization and post-hospital unplanned care.
RESULTS: From 2009 through 2011 Rhode Island's annual and post-hospital ED and inpatient admissions rates decreased, while the corresponding observation stay rates (annual and post-hospital) increased. Both the acute-care utilization and post-hospital unplanned care decreased.
CONCLUSIONS: These data highlight the need to examine impact in the context of temporal trends and other environmental factors. Because readmissions are common and costly, national readmission reduction programs are proliferating. However, readmission rates provide an incomplete picture of unplanned care and costs and may lead to unintended consequences, such as increased observation stay rates. Our findings strengthen our argument that payers and policy makers should broaden their focus from readmission measures to unplanned care composite measures.