Few Readmissions After CAP Hospitalization Are Avoidable -

An analysis of hospital readmissions for community-acquired pneumonia (CAP) in France found that few readmissions were avoidable, supporting criticism that the measure could lead to unfair penalties in pay-for-performance schemes.
Few readmissions are avoidable after hospitalization for community-acquired pneumonia, a new study in France has found, suggesting that this indicator may not be an appropriate measure for hospital pay-for-performance programs.
The retrospective observational cohort study published in JAMA Network Open included 1150 patients with community-acquired pneumonia who were hospitalized in Grenoble University Hospital and Annecy General Hospital in France in 2014.
Bastien Boussat, MD, of the Department of Epidemiology at the Grenoble University Hospital in Grenoble, France, told Contagion: "Only a small percentage of readmissions after hospitalization for pneumonia are preventable (less than one in 10 readmissions). ."
The study included 651 (56.6%) men with a median age of 77.8 years, 98 patients (8.5%) died in hospital, 184 patients were readmitted within 30 days, and 108 (9.4%) were readmitted unexpectedly.
Data collected included comorbidities, pneumonia severity index risk class, physical examination and laboratory findings, X-ray or CT scan results and microbiological findings, as well as treatment and complications.
The study included a review of clinical records by medical experts who assessed the unplanned nature, avoidable nature and reasons for readmissions.Each case was reviewed by 4 specialists from a panel of 9 board-certified physicians, including 3 infectious disease specialists, 3 pulmonologists, and 3 clinical epidemiologists.The likelihood of avoidable readmission was quantified using latent class analysis, and a Bayesian posterior probability score greater than 50% was considered avoidable.
Fifteen of the 108 unplanned readmissions had a posterior probability score greater than 50% (13.9% of 108 unplanned readmissions; 95% CI, 8.0%-21.9%).Patients who avoided readmission for 4 days had significantly shorter time between discharge and readmission compared with 12 days (p=.02).
Boussat said he was surprised by the difficulty experts had in agreeing on whether readmissions were preventable and the low rate of preventable readmissions.
Of the 108 unplanned readmissions, only 51 (47.2%) were in full agreement among the four independent reviewers, including one patient classified as avoidable.
"Using 30-day readmissions after a CAP hospitalization to determine expedite payments and public reporting may unfairly penalize hospitals," Boussat said, stressing that "when the judging criteria involve reviewer subjectivity, multiple independent Review. These multiple independent reviews can be easily analyzed using latent category analysis models."
The Centers for Medicaid and Medicare Services launched a pay-for-performance program in 2008, linking Medicare reimbursement to hospital quality metrics.Pneumonia readmissions within 30 days were included in the Hospital Readmission Reduction Program (HRRP) in 2012, based on the concept that readmissions are generally avoidable.Since then, Europe, the UK, Germany, Denmark and France have introduced similar pay-for-performance schemes, the authors say, noting that they have been criticised for not adequately taking into account medical complexities and the inevitability of some readmissions.
"Policymakers can build national reporting systems around the general approach used in this study, consensus-based expert review of readmissions," Boussat said."The rollout of hospital-level digital health records and the development of artificial intelligence algorithms applied to electronic medical records may in the near future open the way for automated clinical predictive models that better account for readmissions than simple medicine Complexity. - Administrative Data."