Are all readmissions the same?

Abstract

The Patient Protection and Medicare Affordable Care Act (PPACA) is designed to improve the quality and reduce the costs of our health care system. With the Supreme Court recently upholding the tenets of PPACA, hospital readmissions will be further scrutinized: first, payments from the Centers for Medicare and Medicaid Services will be restricted for 3 conditions (pneumonia, heart failure, and myocardial infarction), and later, these restrictions will be broadened to all readmissions that are deemed to be avoidable. Liver transplantation, a high-cost service prone to readmissions in the first year after transplantation, is a likely target. In this issue of Liver Transplantation, Pereira et al. examine the clinical factors predicting readmission after liver transplantation. They report the largest single-center experience to date and assess readmissions for 766 patients who underwent transplantation between 2003 and 2010. The authors have identified a 45% 30-day readmission rate and disease-specific predictors: portal vein thrombosis before transplantation, hospitalization within 90 days before liver transplantation, renal insufficiency (creatinine > 1.9 mg/dL), and hypoalbuminemia (albumin 60 years old), higher Model for End-Stage Liver Disease scores (>19), preoperative encephalopathy, and marked muscle wasting are associated with a higher requirement for institutional care (eg, a skilled nursing facility) after discharge. These observations, gleaned from a large, single-center cohort, add important knowledge about factors associated with higher readmission rates after liver transplantation. Notwithstanding the laudable intentions behind PPACA provisions and the threat of future penalties imposed by the Centers for Medicare and Medicaid Services on the basis of those provisions, it is important to note that there are subtle but important confounding issues that may affect the present and future recording and reporting of readmission rates. For example, it is intuitive that shortening the original length of stay (LOS) after a procedure without the establishment of safety nets akin to medical homes will result in a higher readmission rate simply because if the LOS is longer, complications after transplantation will be managed during the original admission instead of requiring readmission within a few days of discharge. In addition, there is a recent trend showing a sharp rise in observation status for Medicare beneficiaries associated with a sharp decline in admission status. Although observation is expected to last <48 hours, there is no Medicare rule for how long patients can remain in this status, so observation status can be used to avoid any penalty associated with readmissions. Finally, for non-Medicare beneficiaries, payments for transplant services are already bundled so that case rates include certain readmissions and especially those related to transplant episodes. These contractual agreements include the sharing of financial risk with the provider: both LOS and readmission costs