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Hospital readmissions are not monolithic, and Medicare should change its readmissions penalty program time frame from 30 days to 7 days, researchers said.

The researchers from multiple U.S. institutions stated that the Medicare Hospital Readmissions Reduction Program (HRRP) often penalizes hospitals for patient outcomes that are out of their control.

"We found that readmissions within the first 7 days after hospital discharge were more likely to be preventable than those within a late period of 8 to 30 days," they wrote in the . "Early readmissions were more likely to be amenable to interventions within the hospital and to be caused by factors for which the hospital is directly accountable, such as problems with physician decision making."

Outpatient facilities and home caregivers were more likely to be accountable for readmissions from 8 to 30 days, the researchers wrote.

"Late readmissions were more likely to be amenable to interventions outside the hospital and to be caused by factors over which the hospital has less direct control, such as appropriate monitoring and managing of symptoms after discharge by the primary care team," they stated.

The study covered 10 academic medical centers from April 201 2 through March 2013 and included 822 adult patients. Of those, 301 patients (36.6%) were readmitted within 7 days after discharge;521 (63.4%) were readmitted eight to 30 days after discharge; and 36.2% of early readmissions versus 23.0% of late readmissions were deemed preventable.

The researchers found that faulty physician decision-making was the number one cause of early readmissions, associated with 28.9% of the cases.

Three primary variants of errant decision making were identified:

• Premature discharge: 16.3% of cases
• Inadequate treatment during hospital stay: 14.3%
• Missed diagnoses: 10.6%

Difficulty monitoring and managing symptoms was the number one cause of late readmissions, associated with 33.2% of cases. The researchers identified three primary variants of monitoring and managing difficulties:

• Lack of disease monitoring: 12.7% of cases
• Overly long wait times for follow-up appointments: 10.0%
• Inability to make follow-up appointments: 10.9%

The researchers said their data indicate several reasons why the HRRP time-frame should be switched from 30 days to 7 days.

First, they found a significant difference in the preventability of early and late readmissions in the 30-day time-frame after discharge. "Early readmissions were associated with double the odds of preventability compared with late readmissions," they noted.

Second, a pair of physician adjudicators who reviewed the readmissions cases found hospitals were the best site to intervene and prevent early readmissions. The physician educators found outpatient clinics and home were the best settings to prevent late readmissions.

Third, the researchers found that erroneous physician decision-making and premature discharge were leading causes of early readmissions.

"Taken together, these findings suggest that readmissions in the week after discharge are more preventable and more likely to be caused by factors over which the hospital has direct control than those later in the 30-day window," they wrote.

Beyond narrowing HRRP's 30-day readmissions window to 7 days, the researchers also offer five recommendations to promote readmissions prevention:

• Hospitals should try to decrease cognitive errors that impact diagnosis and treatment
• The impact of hospital efforts to increase throughput on premature discharge should be examined
• Outpatient facilities should boost multidisciplinary care management for post-discharge monitoring of patients after discharge
• Access to primary care clinicians should be expanded
• Accountability for readmissions 30 days after discharge should be shared between outpatient and inpatient facilities

"Shared accountability over the 30 days, possibly with weighted penalties by readmission timing, would engage outpatient practices in readmission reduction efforts and reduce unfair financial penalties on hospitals."

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