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Admitting What We Do Not Know About Pneumonia ReadmissionsPneumonia Readmissions FREE TO VIEW

Andrew F. Shorr, MD, MPH, FCCP; Marya D. Zilberberg, MD, MPH, FCCP
Author and Funding Information

From the Pulmonary and Critical Care Section (Dr Shorr), Medstar Washington Hospital Center; and Evimed Research Group (Dr Zilberberg).

CORRESPONDENCE TO: Andrew Shorr, MD, MPH, FCCP, Room 2A-68D, Medstar Washington Hospital Center, 110 Irving St NW, Washington, DC 20010; e-mail: Andrew.shorr@gmail.com


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following conflicts: Dr Shorr has served as a speaker, consultant, or received research support from Actavis plc, Astellas Pharma, Bayer AG, Cardeas Pharma, Cempra, Cubist Pharmaceuticals, Pfizer Inc, Hoffmann-La Roche, Tetraphase Pharmaceuticals, and Theravance Biopharma. He has no conflicts relative to the content of this editorial. Dr Zilberberg has served as a consultant to and/or received research funding from Cubist Pharmaceuticals, Astellas Pharma, Pfizer Inc, CareFusion Corp, and Theravance Biopharma.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(1):4-6. doi:10.1378/chest.14-2987
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Published online

Section 3025 of the Affordable Care Act created the Hospital Readmission Reduction Program (HRRP).1 Under the HRRP, the Centers for Medicare & Medicaid Services (CMS) is charged with working to reduce hospital readmissions for select conditions. The initial focus of the HRRP was on acute myocardial infarction, congestive heart failure, and pneumonia.1,2 Recently, conditions covered by the HRRP initiative have expanded to include other diseases, such as COPD and coronary artery bypass grafting, whose patients are cared for by pulmonary and critical care physicians. If a hospital’s actual readmission rate at 30 days for a specific disease covered by the HRRP exceeds the expected readmission rate, the penalty in fiscal year 2013 was an up to 1% payment reduction.1,2 In the first year of the program, nearly 2,200 hospitals faced payment penalties.3 Although the total savings to the CMS from this program are small in light of its huge budget, the implications for hospitals can be significant. Many institutions, be they community or academic, face substantial financial pressures under the changing health-care delivery environment and operate on small margins. The penalty rate increases to a 3% clawback by fiscal year 2015.1,2

The logic underlying the HRRP is premised on the observation that readmission rates are too high. In fact, 30-day readmission rates for pneumonia vary from 15% to 30% depending on the population studied.4-6 The HRRP also seems built on the notion that hospitals and their behaviors and policies are causally responsible for readmissions. That too many patients are readmitted to the hospital after discharge seems accepted by both physicians and policymakers. Less clear, though, is the role the hospital plays in the chain of events that leads to hospital readmissions.

In this issue of CHEST (see page 103), Andruska and colleagues7 present new data that helps inform this crucial policy debate. These investigators identified nearly 10,000 subjects with a discharge diagnosis of pneumonia, and approximately 10% of hospital survivors were readmitted at 90 days. The rate was similar in subjects who had pneumonia present on admission as opposed to some form of hospital-acquired pneumonia. Strikingly, the presence of potentially antibiotic-resistant bacteria was a key factor associated with readmission. In addition, a patient having a poor functional status significantly increased the risk of subsequent readmission. As most physicians would have predicted, the reasons for readmission had little to do with the initial pneumonia event. For example, one of the main reasons for readmissions was underlying lung disease.

Certainly, the study by Andruska and colleagues7 has a number of limitations, including its reliance on mainly administrative coding data. However, use of administrative data is the current means via which the CMS implements the HRRP program. In other words, one cannot precisely determine how many patients with a diagnosis of pneumonia actually had some other condition such as heart failure. Diagnostic precision is crucial to adjudicating correctly the readmission penalty; however, it is more important to properly design programs that actually help reduce readmissions. Andruska and colleagues7 also report a readmission rate that is relatively low compared with other reports. This may reflect the fact that they studied a population that included both Medicare-eligible and non-Medicare subjects. Alternatively, they may have missed readmissions to hospitals outside their catchment focus.

Despite these concerns, however, the value of their report lies in elucidating the main flaw with the current HRRP policy. The HRRP places the locus of causality at the level of the hospital. However, whether a patient presents with multiple comorbidities and a poor performance status or whether the patient has an infection with an antibiotic-resistant pathogen has nothing to do with the care provided by the hospital, its physicians, and its nurses. One possible nexus between an infection with an antibiotic-resistant organism and outcome may be related to the appropriateness and timeliness of the initial antibiotic therapy. Unfortunately, Andruska et al7 did not examine this crucial issue. However, another report suggests that there is no connection between rates of initially appropriate antibiotic therapy and hospital readmissions in pneumonia.8

The findings by Andruska and colleagues7 also suggest that cumbersome efforts to prevent pneumonia readmissions will not succeed. Finding a patient a medical home may improve the general quality of care and help with medication compliance but does nothing to retroactively alter the culprit pathogen in a case of pneumonia. Similarly, the Institute for Healthcare Improvement’s State Action on Avoidable Rehospitalizations (STAAR) program is a complex and multifaceted effort to address readmissions.9 However, to assume that what may prevent a readmission following heart failure or cardiac surgery will also prove effective in addressing pneumonia seems myopic.9

Rather, policymakers in the future should begin their work by attempting to understand key questions in health-care services research; namely, what leads to readmissions and how does one best predict them? Answers to these questions are necessary before the government enacts broad policy changes. Studies like those by Andruska and colleaguess7 provide granularity not achievable by relying on purely administrative data. In that sense, these types of efforts should precede and not follow major health-care policy shifts. At this point, hospitals are clearly being penalized for actions and forces beyond their control. The CMS should pause and undertake a critical look at the HRRP. Failing to reexamine and recalibrate the policy would suggest that the main issue driving the HRRP is not improved patient outcomes, but rather, cost containment.

References

Leppin AL, Gionfriddo MR, Kessler M, et al. Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Intern Med. 2014;174(7):1095-1107. [CrossRef] [PubMed]
 
Marks E. Complexity science and the readmission dilemma. JAMA Intern Med. 2013;173(8):629-631. [CrossRef] [PubMed]
 
Fontanarosa PB, McNutt RA. Revisiting hospital readmissions. JAMA. 2013;309(4):398-400. [CrossRef] [PubMed]
 
Krumholz HM, Lin Z, Keenan PS, et al. Relationship between hospital readmission and mortality rates for patients hospitalized with acute myocardial infarction, heart failure, or pneumonia. JAMA. 2013;309(6):587-593. [CrossRef] [PubMed]
 
Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363. [CrossRef] [PubMed]
 
Joynt KE, Jha AK. Characteristics of hospitals receiving penalties under the Hospital Readmissions Reduction Program. JAMA. 2013;309(4):342-343. [CrossRef] [PubMed]
 
Andruska A, Micek ST, Shindo Y, et al. Pneumonia pathogen characterization is an independent determinant of hospital readmission. Chest. 2015;148(1):103-111.
 
Shorr AF, Zilberberg MD, Reichley R, et al. Readmission following hospitalization for pneumonia: the impact of pneumonia type and its implication for hospitals. Clin Infect Dis. 2013;57(3):362-367. [CrossRef] [PubMed]
 
Boutwell AE, Johnson MB, Rutherford P, et al. An early look at a four-state initiative to reduce avoidable hospital readmissions. Health Aff (Millwood). 2011;30(7):1272-1280. [CrossRef] [PubMed]
 

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References

Leppin AL, Gionfriddo MR, Kessler M, et al. Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Intern Med. 2014;174(7):1095-1107. [CrossRef] [PubMed]
 
Marks E. Complexity science and the readmission dilemma. JAMA Intern Med. 2013;173(8):629-631. [CrossRef] [PubMed]
 
Fontanarosa PB, McNutt RA. Revisiting hospital readmissions. JAMA. 2013;309(4):398-400. [CrossRef] [PubMed]
 
Krumholz HM, Lin Z, Keenan PS, et al. Relationship between hospital readmission and mortality rates for patients hospitalized with acute myocardial infarction, heart failure, or pneumonia. JAMA. 2013;309(6):587-593. [CrossRef] [PubMed]
 
Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363. [CrossRef] [PubMed]
 
Joynt KE, Jha AK. Characteristics of hospitals receiving penalties under the Hospital Readmissions Reduction Program. JAMA. 2013;309(4):342-343. [CrossRef] [PubMed]
 
Andruska A, Micek ST, Shindo Y, et al. Pneumonia pathogen characterization is an independent determinant of hospital readmission. Chest. 2015;148(1):103-111.
 
Shorr AF, Zilberberg MD, Reichley R, et al. Readmission following hospitalization for pneumonia: the impact of pneumonia type and its implication for hospitals. Clin Infect Dis. 2013;57(3):362-367. [CrossRef] [PubMed]
 
Boutwell AE, Johnson MB, Rutherford P, et al. An early look at a four-state initiative to reduce avoidable hospital readmissions. Health Aff (Millwood). 2011;30(7):1272-1280. [CrossRef] [PubMed]
 
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