Hospital readmission: quality indicator or statistical inevitability?

Hospital readmission rate has been a long-considered quality of care indicator in adult medicine, albeit with mixed reviews. As we begin to grapple with the quality significance and preventability of readmissions in pediatrics, however, we are outpaced by movement in the insurance industry. Section 3025 of the Affordable Care Act requires the Centers for Medicare and Medicaid Services to reduce payments to hospitals with excess readmissions, effective for discharges beginning on October 1, 2012. Although the Centers for Medicare and Medicaid Services started with targeting only 3 adult diagnoses, they are currently considering expansion of the number of diagnoses for which reimbursement will be decreased for hospitals with high readmission rates, and that consideration includes pediatric diagnoses such as “pneumonia due to respiratory syncytial virus” (International Classification of Diseases, 9th Revision, code 480.1). In this edition of Pediatrics, Dr. Berdach and colleagues studied a large database of pediatric admissions in California that calls into question readmission as a quality measure. They cite a lack of variability in rates of readmissions among hospitals in California. Few hospitals were identified as either highor low-performers for common pediatric diagnoses, limiting the ability of using diagnosis-specific readmission rate as a quality indicator. Interestingly, this is in contrast to another study of 500 000 pediatric patients from a cohort of children’s hospitals, which demonstrated variability in readmission rates by hospital. Although these studies differ in their cohort of hospitals and findings, neither study demonstrated that readmissions are a quality measure. Intuitively, it makes sense that readmission rate may be a quality indicator. We might assume that readmission is more likely in the setting of decreased handwashing or longer wait times in crowded and virus-laden emergency departments. We might assume premature discharge, especially of patients with illness such as bronchiolitis, may result in “bouncebacks.” At the same time, clearly factors outside the hospital may relate to readmission. Take asthma as an example. Inpatient action plans are currently mandated but do not seem to affect readmission rates in the largest study performed. From the same study, virtually every patient hospitalized received steroids and albuterol. But how does parental smoking relate to readmission? Distance lived from the hospital? Presence of competing health care institutions in the geographic area? Availability of primary care services and a true medical home? There is growing evidence that readmission is not a good measure of quality. One retrospective analysis of readmission rates and independent quality of care indicators demonstrated that in states with higher-quality of care, children’s hospitals had higher, not lower, readmission rates. In an outstanding recent study, careful review of AUTHORS: Brian K. Alverson, MD,a and James O’Callaghan, MDb Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, Providence, Rhode Island, and University of Washington School of Medicine, Seattle Children’s Hospital, Seattle, Washington