How important is it to identify avoidable hospital readmissions with certainty?

• Published in: Canadian Medical Association journal (CMAJ) 2011-04, Vol.183 (7), p.E368-E369
• Main Author: Goldfield, Norbert
• Format: Article
• Language: English
• Subjects: Admission and discharge; Central service department; Hospitals; Humans; Medicine, Preventive; Patient admissions; Patient Readmission - standards; Patient Readmission - statistics & numerical data; Preventive health services; Quality Indicators, Health Care - standards; Quality of care; Quality of Health Care - standards; United States
• ISSN: 0820-3946; 1488-2329
• DOI: 10.1503/cmaj.110448

I find the premise of their article problematic. The authors say, "Readmissions to hospital are in creasingly being used as an indicator of quality of care. However, this approach is valid only when we know what proportion of readmissions are avoidable." With expert clinical judgment and by identifying excess readmissions, we can know the approximate proportion of readmissions that are preventable.3 In addition, well-done observational and randomized studies have clearly shown that the proportion of readmissions can be reduced.4,5 If we combine this knowledge with a comparison of readmission rates, we can use differences in readmission rates among institutions and health care professionals to improve quality of care, for public reporting and for appropriate payment incentives, without knowing precisely how many readmissions are avoidable. We should be debating two fundamental issues pertaining to preventable readmissions: the methods used to identify those that are potentially preventable and the policy levers we should consider as incentives for providers to reduce the proportion of preventable readmissions. There is a debate in the United States about the meaning of the words "preventable" and "avoidable." The National Committee for Quality Assurance has announced a draft allcause approach that makes the strange assertion that all readmissions are potentially preventable.7 The National Quality Forum has also certified a measure developed by UnitedHealthcare, the largest insurance company in the United States, that considers virtually all readmissions to be potentially preventable.8 As a researcher, I find myself somewhere between this patently problematic approach that has been developed and the approach used by van [Van Walraven] and colleagues, which asserts that we need to know a great deal more about which readmissions are potentially preventable. As the co-developer of the method that uses claims data, I disagree with the assertion by van Walraven that, "given the large variation in the proportion of avoidable readmissions between studies using primary data, 'avoidability' cannot accurately be inferred based on diagnostic codes for the index admission and the readmission. Instead, it needs to be determined through a peer-review process in which readmissions are classified as avoidable or not based on expert opinion." The method based on claims data uses several other variables that are present on a claims form in addition to diagnoses. The method sh