Rethinking Thirty-Day Hospital Readmissions: Shorter Intervals Might Be Better Indicators Of Quality Of Care

Abstract

Public reporting and payment programs in the United States have embraced thirty-day readmissions as an indicator of between-hospital variation in the quality of care, despite limited evidence supporting this interval. We examined risk-standardized thirty-day risk of unplanned inpatient readmission at the hospital level for Medicare patients ages sixty-five and older in four states and for three conditions: acute myocardial infarction, heart failure, and pneumonia. The hospital-level quality signal captured in readmission risk was highest on the first day after discharge and declined rapidly until it reached a nadir at seven days, as indicated by a decreasing intracluster correlation coefficient. Similar patterns were seen across states and diagnoses. The rapid decay in the quality signal suggests that most readmissions after the seventh day postdischarge were explained by community- and household-level factors beyond hospitals' control. Shorter intervals of seven or fewer days might improve the accuracy and equity of readmissions as a measure of hospital quality for public accountability.

Keywords: Hospital Quality Signal; Hospital Readmissions Reduction Program; National Healthcare Policy; Quality Measurement; Readmission Interval.

EXHIBIT 2. Intracluster correlation coefficient estimates at specific readmission intervals from one to ten days, for acute myocardial infarction, heart failure, and pneumonia

SOURCE Authors’ analysis of data from the Healthcare Cost and Utilization Project, State Inpatient Database, and State Emergency Department Database: Arizona (2005–07); California (2005–11); Florida (2005–12); and New York (2006–11). NOTE Data represent unadjusted base models by cohort.

EXHIBIT 3. Intracluster correlation coefficient estimates at specific readmission intervals from one to ninety days for acute myocardial infarction, heart failure, and pneumonia

SOURCE Authors’ analysis of data from the Healthcare Cost and Utilization Project, State Inpatient Database, and State Emergency Department Database: Arizona (2005–07); California (2005–11); Florida (2005–12); and New York (2006–11). NOTE Base and geodemographic-extended models by cohort; see text for explanation.