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Hospital Readmissions and Quality of Care

Weissman, Joel S. PhD*†; Ayanian, John Z. MD, MPP†‡; Chasan-Taber, Scott PhD§; Sherwood, Marjorie J. MD; Roth, Carol RN, MPH; Epstein, Arnold M. MD, MA#†‡

Original Articles

Background. Readmission rates are often proposed as markers for quality of care. However, a consistent link between readmissions and quality has not been established.

Objective. To test the relation of readmission to quality and the utility of readmissions as hospital quality measures.

Subjects. One thousand, seven hundred and fifty-eight Medicare patients hospitalized in four states between 1991 to 1992 with pneumonia or congestive heart failure (CHF).

Design. Case control.

Measures. Related adverse readmissions (RARs), defined as readmissions that indicate potentially sub-optimal care during initial hospitalization, were identified from administrative data using readmission diagnoses and intervening time periods designated by physician panels. We used linear regression to estimate the association between implicit and explicit quality measures and readmission status (RARs, non-RAR readmissions, and nonreadmissions), adjusting for severity. We tested whether RARs were associated with inferior care and performed simulations to determine whether RARs discriminated between hospitals on the basis of quality.

Results. Compared with nonreadmitted pneumonia patients, patients with RARs had lower adjusted quality measured both by explicit (0.25 standardized units, P = 0.004) and implicit methods (0.17, P = 0.047). Adjusted differences for CHF patients were 0.17 (P = 0.048) and 0.20 (P = 0.017), respectively. In some analyses, patients with non-RAR readmissions also experienced lower quality. However, rates of inferior quality care did not differ significantly by readmission status, and simulations identified no meaningful relationship between RARs and hospital quality of care.

Conclusions. RARs are statistically associated with lower quality of care. However, neither RARs nor other readmissions appear to be useful tools for identifying patients who experience inferior care or for comparing quality among hospitals.

*From the Department of Medicine, Massachusetts General Hospital, Institute for Health Policy, Boston, Massachussetts.

From the Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.

From the Division of General Medicine (Section on Health Services and Policy Research), Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.

§From Boston Biostatistics, Inc., Framingham, Massachusetts.

¶From Value Health Sciences, Inc., Santa Monica, California.

#From the Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts.

Dr. Ayanian is a Generalist Physician Faculty Scholar of the Robert Wood Johnson Foundation.

This work was supported by Grant No. HS06331 from the Agency for Health Care Policy and Research.

A version of this paper was presented at the Annual Meeting of the American Public Health Association, Medical Care Section.

Address correspondence to: Joel S. Weissman, PhD, Massachusetts General Hospital, Institute for Health Policy, 50 Staniford Street, 9th floor, Boston, MA 02114. E-mail:

Received June 30, 1998; initial review completed August 21, 1998; accepted November 6, 1998.

© 1999 Lippincott Williams & Wilkins, Inc.