High readmission rates? Look at location, not hospital

Location, location, location. Almost 60 percent of variation in hospital readmissions may be attributed to the county where a hospital resides, according to a study published online April 9 in Health Services Research. The findings challenge Medicare’s use of financial penalties for hospitals with higher than expected readmission rates.

This year the Centers for Medicare & Medicaid Services (CMS) will withhold payment by 2 percent to hospitals with readmissions for acute MI, heart failure and pneumonia if the rates are higher than expected in risk-adjusted models. The penalty will rise to 3 percent in 2015.

CMS sees readmission rates as an indicator of quality care and initiated the program to improve quality and lower costs at the hospital level. A research team led by Jeph Herrin, PhD, of the cardiology division at Yale University School of Medicine in New Haven, Conn., and the Health Research and Educational Trust in Chicago, hypothesized that county-level factors play a role in readmissions for these conditions as well.

They designed a model that assessed patient-level factors, access to care and nursing home measures as potential contributors to hospital readmission rates. At the patient level they included factors beyond patient-risk used in adjustments such as sociodemographic characteristics, employment status, educational level and living alone. Access to care included primary care and specialists. For nursing homes, they focused on the number and quality of nursing homes.

They linked data from CMS reports for risk-standardized readmission rates for acute MI, heart failure and pneumonia between 2007 and 2010 to various resources that measured patient, access and nursing home variables. The final sample totaled 4,073 hospitals and 2,254 counties.

Herrin et al calculated that 58 percent of hospital variation was attributed to the county where the hospital was located. “Expressed differently, the results suggest that individual hospital performance accounts for only 42 percent of the variation in pooled readmission rates across the United States,” they wrote.

The number of Medicare beneficiaries per capita, the proportion of residents never married and low education status were associated with higher readmission rates. A higher number of specialists per capital was associated with higher readmission rates as well.

Rural areas and retirement areas, higher numbers of primary care physicians per capita and more nursing homes per capita were associated with lower readmission rates.

Adding hospital factors such as hospital ownership, teaching status, safety net status and number of beds changed the results only slightly.  

“That the majority of the unexplained variation in hospital readmission rates can be attributed to counties rather than hospitals suggests that narrowly targeting hospitals with reimbursement adjustments and other incentives can lead at best to marginal improvements in readmission rates; more effective policies might be directed at the wider system of care, including primary care and nursing home quality,” they proposed.

The study is observational and records used in the analyses listed one site for hospital systems that may span several counties.