Harlan Krumholz, MD, SM

With US hospital readmission rates within 30 days of discharge approaching 20%,[1] reducing readmissions has become a national priority. Hospitalists are frequently involved in quality improvement efforts to improve transitions from hospital to home,[2, 3] and they play critical roles in implementing recommended strategies to support effective discharge transitions.[4, 5] Initiatives such as Better Outcomes for Older Adults through Safe Transitions[6] and the adaptable Transitions Tool[7] from the Society of Hospital Medicine provide important approaches and checklists for helping hospitals improve strategies.[8]

In addition to these initiatives, multiple quality collaboratives and campaigns are underway to help hospitals reduce their readmission rates. Two of the more prominent efforts are the STAAR (STate Action on Avoidable Rehospitalization) initiative,[9] a learning collaborative launched in the fall of 2009 and led by the Institute for Healthcare Improvement (IHI) and funded in part by The Commonwealth Fund, and H2H (Hospital‐to‐Home), a national quality campaign led by the American College of Cardiology and IHI with support from several professional associations and partners. Together, these serve more than 1000 hospitals nationally. The STAAR initiative is a state‐based collaborative that partnered with more than 500 community groups across 4 states selected for their diverse readmissions performance and support for improvement efforts, including Massachusetts, Michigan, and Washington. After July 2011, efforts expanded to include Ohio. STAAR was designed to work with leadership at the state level including representatives from hospital associations, government payers, private payers, state governments, provider organizations, employers, and business groups. H2H, in contrast, employs a national quality campaign model and focuses on the care of patients with heart failure or acute myocardial infarction. H2H hospitals are encouraged to participate in a set of H2H Challenges, which provide hospitals with recommended strategies and tools for reducing unnecessary readmission and improve transitions of care. Each Challenge project is 6 to 8 months and consists of success metrics, 3 webinars, and 1 tool kit.

Although previous research has examined strategies used by hospitals enrolled in H2H,¹⁰ we know little about strategies used by STAAR hospitals within 1 year of enrollment. Such data across these 2 prominent initiatives at baseline can provide a snapshot of strategies used prior to the major efforts to reduce readmission rates nationally and identify gaps in practice to target for improvement. Furthermore, given the distinct designs of STAAR (a state‐based learning collaborative in selected regions) and H2H (an open, national campaign), future evaluations will likely compare the effectiveness of these alternative approaches for reducing readmissions.

Accordingly, we sought to describe and compare the reported use of recommended strategies to reduce readmission strategies among STAAR and H2H hospitals. Our findings provide a contemporary view of a large set of hospitals working to reduce readmissions. Findings from this study can provide insight into the strategies used by hospitals that enrolled in a state‐based learning collaborative versus a national campaign as well as document a baseline against which future improvements can be measured and evaluated.

METHODS

RESULTS

DISCUSSION

We found that many hospitals enrolled in the STAAR or the H2H initiative were not implementing strategies commonly recommended to reduce readmission in 2010 to 2011, indicating substantial opportunities for improvement. The gaps were apparent among both the STAAR and the H2H hospitals. Previous literature has shown that discharged patients often do not have timely posthospitalization follow‐up visits, and that discharge summaries are infrequently completed prior to the follow‐up visit.[4, 19, 31] Studies have also demonstrated weaknesses in the medication reconciliation process[32] and overall communication between hospital‐based and primary care physicians.[33, 34] Our survey adds to this existing literature by employing a more comprehensive survey of hospital strategies and reporting results for a larger, national sample of hospitals.

Encouraging the use of strategies recommended by quality initiatives is difficult for several reasons. First, the evidence base for their effectiveness is not yet solid, making it difficult for institutions to prioritize and select interventions and to foster enthusiasm for change. Second, the organizational challenges of these interventions are often substantial, requiring coordination across disciplines, departments, and settings (hospital, home, nursing facility). Third, some literature suggests[3] that multipronged strategies may be most effective, increasing the complexity of readmission reduction activities. Last, important financial barriers must be overcome, including the cost of interventions as well as lost revenue from reduced readmissions. Input from hospitalists who are often critical links among inpatient and outpatient care and between patients and their families is strongly needed to ensure hospitals focus on what strategies are most effective for successful transitions from hospital to home.

The prevalence of several strategies differed between STAAR and H2H hospitals; however, these differences were largely attenuated by geographic region. The finding that significant differences among hospitals in strategies was explained in large part by geographical region is consistent with previous research that has documented substantial regional differences in many kinds of practice patterns[35, 36, 37] as well as geographic differences in readmission rates.[38, 39, 40] The results suggest regionally focused initiatives may be most effective in tailoring interventions to practice needs and norms within specific areas.

Among the strategies that differed significantly between the hospitals in STAAR compared with H2H, the variation may be attributable in part to the focus of the initiatives themselves. For instance, 1 strategy that was significantly more prevalent among H2H compared with STAAR hospitals is central to the quality of care for patients with heart failure and acute myocardial infarction, the focus of H2H: referral patterns to cardiac rehabilitation services after discharge. H2H hospitals may have been particularly attuned to this practice, as H2H focused on cardiovascular‐related readmissions, whereas STAAR focused on all readmissions.

The study has several limitations. First, data were self‐reported, and we did not have the resources to verify these reports with onsite evaluations. Nevertheless, the methods for obtaining the data were the same for H2H and STAAR hospitals, and therefore measurement errors are unlikely to have varied systematically between the 2 groups of hospitals. Second, a single respondent at each hospital completed the survey; however, we did instruct respondents to attain information from a broad range of relevant staff to reflect a more comprehensive perspective in the survey. Third, the sample size of STAAR hospitals was modest and therefore may have lacked statistical power to detect important differences; however, we did include all hospitals that had enrolled in STAAR by the study date. Fourth, hospitals that enrolled in STAAR and H2H initiatives represent a selected group, and results may differ among nonenrolled hospitals. Last, we have data on strategies used during the 2010 to 2011 time frame and therefore cannot evaluate the impact of the quality initiatives from these baseline data. Studies that examine the associations between changes in the use of strategies and subsequent changes in readmission rates would be valuable. Nevertheless, this study establishes a baseline against which future progress can be evaluated.

In sum, we found that many STAAR and H2H hospitals were not implementing many of the recommended strategies for reducing readmissions as of 2010 to 2011, suggesting continued opportunities for improvement. Hospitalists will have opportunities to play leadership roles as hospitals look for meaningful ways to reduce readmissions. At the same time, although hospitalists have a key role in implementing hospital‐based programs, much of the care transitions work must also engage teams across the continuum of care. Furthermore, priority should be given to augmenting the evidence base about which strategies are most effective in reducing readmissions, as this evidence is currently underdeveloped.

With US hospital readmission rates within 30 days of discharge approaching 20%,[1] reducing readmissions has become a national priority. Hospitalists are frequently involved in quality improvement efforts to improve transitions from hospital to home,[2, 3] and they play critical roles in implementing recommended strategies to support effective discharge transitions.[4, 5] Initiatives such as Better Outcomes for Older Adults through Safe Transitions[6] and the adaptable Transitions Tool[7] from the Society of Hospital Medicine provide important approaches and checklists for helping hospitals improve strategies.[8]

In addition to these initiatives, multiple quality collaboratives and campaigns are underway to help hospitals reduce their readmission rates. Two of the more prominent efforts are the STAAR (STate Action on Avoidable Rehospitalization) initiative,[9] a learning collaborative launched in the fall of 2009 and led by the Institute for Healthcare Improvement (IHI) and funded in part by The Commonwealth Fund, and H2H (Hospital‐to‐Home), a national quality campaign led by the American College of Cardiology and IHI with support from several professional associations and partners. Together, these serve more than 1000 hospitals nationally. The STAAR initiative is a state‐based collaborative that partnered with more than 500 community groups across 4 states selected for their diverse readmissions performance and support for improvement efforts, including Massachusetts, Michigan, and Washington. After July 2011, efforts expanded to include Ohio. STAAR was designed to work with leadership at the state level including representatives from hospital associations, government payers, private payers, state governments, provider organizations, employers, and business groups. H2H, in contrast, employs a national quality campaign model and focuses on the care of patients with heart failure or acute myocardial infarction. H2H hospitals are encouraged to participate in a set of H2H Challenges, which provide hospitals with recommended strategies and tools for reducing unnecessary readmission and improve transitions of care. Each Challenge project is 6 to 8 months and consists of success metrics, 3 webinars, and 1 tool kit.

Although previous research has examined strategies used by hospitals enrolled in H2H,¹⁰ we know little about strategies used by STAAR hospitals within 1 year of enrollment. Such data across these 2 prominent initiatives at baseline can provide a snapshot of strategies used prior to the major efforts to reduce readmission rates nationally and identify gaps in practice to target for improvement. Furthermore, given the distinct designs of STAAR (a state‐based learning collaborative in selected regions) and H2H (an open, national campaign), future evaluations will likely compare the effectiveness of these alternative approaches for reducing readmissions.

Accordingly, we sought to describe and compare the reported use of recommended strategies to reduce readmission strategies among STAAR and H2H hospitals. Our findings provide a contemporary view of a large set of hospitals working to reduce readmissions. Findings from this study can provide insight into the strategies used by hospitals that enrolled in a state‐based learning collaborative versus a national campaign as well as document a baseline against which future improvements can be measured and evaluated.

METHODS

RESULTS

DISCUSSION

We found that many hospitals enrolled in the STAAR or the H2H initiative were not implementing strategies commonly recommended to reduce readmission in 2010 to 2011, indicating substantial opportunities for improvement. The gaps were apparent among both the STAAR and the H2H hospitals. Previous literature has shown that discharged patients often do not have timely posthospitalization follow‐up visits, and that discharge summaries are infrequently completed prior to the follow‐up visit.[4, 19, 31] Studies have also demonstrated weaknesses in the medication reconciliation process[32] and overall communication between hospital‐based and primary care physicians.[33, 34] Our survey adds to this existing literature by employing a more comprehensive survey of hospital strategies and reporting results for a larger, national sample of hospitals.

Encouraging the use of strategies recommended by quality initiatives is difficult for several reasons. First, the evidence base for their effectiveness is not yet solid, making it difficult for institutions to prioritize and select interventions and to foster enthusiasm for change. Second, the organizational challenges of these interventions are often substantial, requiring coordination across disciplines, departments, and settings (hospital, home, nursing facility). Third, some literature suggests[3] that multipronged strategies may be most effective, increasing the complexity of readmission reduction activities. Last, important financial barriers must be overcome, including the cost of interventions as well as lost revenue from reduced readmissions. Input from hospitalists who are often critical links among inpatient and outpatient care and between patients and their families is strongly needed to ensure hospitals focus on what strategies are most effective for successful transitions from hospital to home.

The prevalence of several strategies differed between STAAR and H2H hospitals; however, these differences were largely attenuated by geographic region. The finding that significant differences among hospitals in strategies was explained in large part by geographical region is consistent with previous research that has documented substantial regional differences in many kinds of practice patterns[35, 36, 37] as well as geographic differences in readmission rates.[38, 39, 40] The results suggest regionally focused initiatives may be most effective in tailoring interventions to practice needs and norms within specific areas.

Among the strategies that differed significantly between the hospitals in STAAR compared with H2H, the variation may be attributable in part to the focus of the initiatives themselves. For instance, 1 strategy that was significantly more prevalent among H2H compared with STAAR hospitals is central to the quality of care for patients with heart failure and acute myocardial infarction, the focus of H2H: referral patterns to cardiac rehabilitation services after discharge. H2H hospitals may have been particularly attuned to this practice, as H2H focused on cardiovascular‐related readmissions, whereas STAAR focused on all readmissions.

The study has several limitations. First, data were self‐reported, and we did not have the resources to verify these reports with onsite evaluations. Nevertheless, the methods for obtaining the data were the same for H2H and STAAR hospitals, and therefore measurement errors are unlikely to have varied systematically between the 2 groups of hospitals. Second, a single respondent at each hospital completed the survey; however, we did instruct respondents to attain information from a broad range of relevant staff to reflect a more comprehensive perspective in the survey. Third, the sample size of STAAR hospitals was modest and therefore may have lacked statistical power to detect important differences; however, we did include all hospitals that had enrolled in STAAR by the study date. Fourth, hospitals that enrolled in STAAR and H2H initiatives represent a selected group, and results may differ among nonenrolled hospitals. Last, we have data on strategies used during the 2010 to 2011 time frame and therefore cannot evaluate the impact of the quality initiatives from these baseline data. Studies that examine the associations between changes in the use of strategies and subsequent changes in readmission rates would be valuable. Nevertheless, this study establishes a baseline against which future progress can be evaluated.

In sum, we found that many STAAR and H2H hospitals were not implementing many of the recommended strategies for reducing readmissions as of 2010 to 2011, suggesting continued opportunities for improvement. Hospitalists will have opportunities to play leadership roles as hospitals look for meaningful ways to reduce readmissions. At the same time, although hospitalists have a key role in implementing hospital‐based programs, much of the care transitions work must also engage teams across the continuum of care. Furthermore, priority should be given to augmenting the evidence base about which strategies are most effective in reducing readmissions, as this evidence is currently underdeveloped.

With US hospital readmission rates within 30 days of discharge approaching 20%,[1] reducing readmissions has become a national priority. Hospitalists are frequently involved in quality improvement efforts to improve transitions from hospital to home,[2, 3] and they play critical roles in implementing recommended strategies to support effective discharge transitions.[4, 5] Initiatives such as Better Outcomes for Older Adults through Safe Transitions[6] and the adaptable Transitions Tool[7] from the Society of Hospital Medicine provide important approaches and checklists for helping hospitals improve strategies.[8]

In addition to these initiatives, multiple quality collaboratives and campaigns are underway to help hospitals reduce their readmission rates. Two of the more prominent efforts are the STAAR (STate Action on Avoidable Rehospitalization) initiative,[9] a learning collaborative launched in the fall of 2009 and led by the Institute for Healthcare Improvement (IHI) and funded in part by The Commonwealth Fund, and H2H (Hospital‐to‐Home), a national quality campaign led by the American College of Cardiology and IHI with support from several professional associations and partners. Together, these serve more than 1000 hospitals nationally. The STAAR initiative is a state‐based collaborative that partnered with more than 500 community groups across 4 states selected for their diverse readmissions performance and support for improvement efforts, including Massachusetts, Michigan, and Washington. After July 2011, efforts expanded to include Ohio. STAAR was designed to work with leadership at the state level including representatives from hospital associations, government payers, private payers, state governments, provider organizations, employers, and business groups. H2H, in contrast, employs a national quality campaign model and focuses on the care of patients with heart failure or acute myocardial infarction. H2H hospitals are encouraged to participate in a set of H2H Challenges, which provide hospitals with recommended strategies and tools for reducing unnecessary readmission and improve transitions of care. Each Challenge project is 6 to 8 months and consists of success metrics, 3 webinars, and 1 tool kit.

Although previous research has examined strategies used by hospitals enrolled in H2H,¹⁰ we know little about strategies used by STAAR hospitals within 1 year of enrollment. Such data across these 2 prominent initiatives at baseline can provide a snapshot of strategies used prior to the major efforts to reduce readmission rates nationally and identify gaps in practice to target for improvement. Furthermore, given the distinct designs of STAAR (a state‐based learning collaborative in selected regions) and H2H (an open, national campaign), future evaluations will likely compare the effectiveness of these alternative approaches for reducing readmissions.

Accordingly, we sought to describe and compare the reported use of recommended strategies to reduce readmission strategies among STAAR and H2H hospitals. Our findings provide a contemporary view of a large set of hospitals working to reduce readmissions. Findings from this study can provide insight into the strategies used by hospitals that enrolled in a state‐based learning collaborative versus a national campaign as well as document a baseline against which future improvements can be measured and evaluated.

METHODS

RESULTS

DISCUSSION

We found that many hospitals enrolled in the STAAR or the H2H initiative were not implementing strategies commonly recommended to reduce readmission in 2010 to 2011, indicating substantial opportunities for improvement. The gaps were apparent among both the STAAR and the H2H hospitals. Previous literature has shown that discharged patients often do not have timely posthospitalization follow‐up visits, and that discharge summaries are infrequently completed prior to the follow‐up visit.[4, 19, 31] Studies have also demonstrated weaknesses in the medication reconciliation process[32] and overall communication between hospital‐based and primary care physicians.[33, 34] Our survey adds to this existing literature by employing a more comprehensive survey of hospital strategies and reporting results for a larger, national sample of hospitals.

Encouraging the use of strategies recommended by quality initiatives is difficult for several reasons. First, the evidence base for their effectiveness is not yet solid, making it difficult for institutions to prioritize and select interventions and to foster enthusiasm for change. Second, the organizational challenges of these interventions are often substantial, requiring coordination across disciplines, departments, and settings (hospital, home, nursing facility). Third, some literature suggests[3] that multipronged strategies may be most effective, increasing the complexity of readmission reduction activities. Last, important financial barriers must be overcome, including the cost of interventions as well as lost revenue from reduced readmissions. Input from hospitalists who are often critical links among inpatient and outpatient care and between patients and their families is strongly needed to ensure hospitals focus on what strategies are most effective for successful transitions from hospital to home.

The prevalence of several strategies differed between STAAR and H2H hospitals; however, these differences were largely attenuated by geographic region. The finding that significant differences among hospitals in strategies was explained in large part by geographical region is consistent with previous research that has documented substantial regional differences in many kinds of practice patterns[35, 36, 37] as well as geographic differences in readmission rates.[38, 39, 40] The results suggest regionally focused initiatives may be most effective in tailoring interventions to practice needs and norms within specific areas.

Among the strategies that differed significantly between the hospitals in STAAR compared with H2H, the variation may be attributable in part to the focus of the initiatives themselves. For instance, 1 strategy that was significantly more prevalent among H2H compared with STAAR hospitals is central to the quality of care for patients with heart failure and acute myocardial infarction, the focus of H2H: referral patterns to cardiac rehabilitation services after discharge. H2H hospitals may have been particularly attuned to this practice, as H2H focused on cardiovascular‐related readmissions, whereas STAAR focused on all readmissions.

The study has several limitations. First, data were self‐reported, and we did not have the resources to verify these reports with onsite evaluations. Nevertheless, the methods for obtaining the data were the same for H2H and STAAR hospitals, and therefore measurement errors are unlikely to have varied systematically between the 2 groups of hospitals. Second, a single respondent at each hospital completed the survey; however, we did instruct respondents to attain information from a broad range of relevant staff to reflect a more comprehensive perspective in the survey. Third, the sample size of STAAR hospitals was modest and therefore may have lacked statistical power to detect important differences; however, we did include all hospitals that had enrolled in STAAR by the study date. Fourth, hospitals that enrolled in STAAR and H2H initiatives represent a selected group, and results may differ among nonenrolled hospitals. Last, we have data on strategies used during the 2010 to 2011 time frame and therefore cannot evaluate the impact of the quality initiatives from these baseline data. Studies that examine the associations between changes in the use of strategies and subsequent changes in readmission rates would be valuable. Nevertheless, this study establishes a baseline against which future progress can be evaluated.

In sum, we found that many STAAR and H2H hospitals were not implementing many of the recommended strategies for reducing readmissions as of 2010 to 2011, suggesting continued opportunities for improvement. Hospitalists will have opportunities to play leadership roles as hospitals look for meaningful ways to reduce readmissions. At the same time, although hospitalists have a key role in implementing hospital‐based programs, much of the care transitions work must also engage teams across the continuum of care. Furthermore, priority should be given to augmenting the evidence base about which strategies are most effective in reducing readmissions, as this evidence is currently underdeveloped.