Readmission rates reflect how well whole health and social care systems functionBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1150 (Published 29 January 2014) Cite this as: BMJ 2014;348:g1150
- David Oliver, visiting professor of medicine for older people1
These articles on readmission are based on a flawed premise—that readmissions are a marker of the quality of care in acute hospitals.1 2 3 Of course, patients are sometimes sent home unwell and prematurely, or with complications caused by hospital admission. But readmissions usually occur because4:
A new illness occurs, unrelated to the first admission
The patient has a long term condition, such as cardiac failure or chronic obstructive pulmonary disease, which relapses
The hospital, wanting to respect the patient’s wishes to go home, rightly accepts a degree of risk (remaining in a hospital bed isn’t risk free after all)
Even carefully made plans for discharge can be ignored, bypassed, or subverted, often by care staff or understandably worried relatives.
The notion that hospitals are responsible for most readmissions is untrue and the way readmissions are framed in these BMJ articles is a result of the US health insurance industry in which providers can be penalised for “never events” (which readmissions can never be). They are in reality a feature of how well whole health and social care systems function, the quality of primary care, and the help seeking behaviour of the public.
Although readmission rates vary considerably,5 they are as much determined by population health and deprivation as by quality of care, with the evidence for interventions to prevent readmission being patchy outside specific conditions such as heart failure.6 It is also not a “zero sum game,” with hospital being a place of safety and home being “risky.” Being in hospital can lead to a range of harms, especially for vulnerable older people, who should remain in a hospital bed only so long as it is genuinely adding value to their care. With hospital beds having been lost at a staggering rate over the past two decades, we need to use beds as the precious resource they are and not hang on to patients for fear of readmission, so long as discharge planning has been properly considered.7
The US, however, spends twice what the UK does as a proportion of gross domestic product on healthcare, for lower life expectancy, lower equity, higher rates of preventable death, higher health inequality, and worse continuity and access to primary care.8 So what these papers have to teach us is not clear.
Cite this as: BMJ 2014;348:g1150
Competing interests: None declared.