International Journal for Quality in Health Care 2001; Volume 13, Number 3: pp.
177–179
Counterpoint
‘Counterpoint’ is an occasional feature presenting discussion of a topic that is currently under debate in quality of care circles. We
invite readers to submit Letters to the Editor adding their opinion to the topic.
Readmission of patients to hospital: still ill
defined and poorly understood
The need to improve our understanding of readmission of
patients to hospitals after discharge is becoming increasingly
recognised. Hospital admission and readmission rates have
increased over the last few decades [1–5]. It is reported that
readmissions may be responsible for up to half of all hospital
admissions [6]. The rise in readmission rates is not unique
to western countries, as studies from the developing world
indicate a similar trend [7]. While the increases in readmission
rates are not directly related to age, older individuals make a
major contribution [8].
The cost of readmissions to a nation’s health service is high.
It is estimated that repeated admissions may be responsible for
up to 60% of hospital expenditure [6]. The cost of multiple
admissions to the patients and their relatives, in terms of
distress, morbidity and mortality, is immeasurable. It has
been reported that hospital admission, particularly of elderly
patients is associated with an increase in both morbidity and
mortality [8,9]. It has also been suggested that repeated
hospital admissions may promote dependency and lead to a
self-perpetuating cycle often described as the ‘revolving door
syndrome’ of readmissions [8].
Readmission rates have received considerable attention in
the literature for a number of reasons. Economic concerns
resulted in publications designed to monitor the impact of
changes in health care systems, including the effect of various
payment/reimbursement schemes on readmission rates [3,
10,11], while several studies examined the use of readmission
as a measure of outcome of the quality of care delivered in
hospital [12–14].
It is claimed that a significant number of readmissions are
avoidable and potentially preventable [5,15]. The interest in
readmission is driven by the assumption that improvement
in hospital care can result in a reduction in readmissions and
medical care costs [16]. This editorial aims to provide an
overview of the major issues raised by the literature on
readmission, to stimulate further debate and to identify areas
for future research.
Readmission rates – how big is the
problem?
The published data on readmission of patients to hospitals
report a wide variation in the rates and patterns of readmission.
 2001 International Society for Quality in Health Care and Oxford University Press
Overall, the readmission rates in the adult population vary
from 5% to 29% [1,17–19]. Although the evidence to explain
this variation is limited, these discrepancies appear to be due
to a lack of uniformity in defining readmission and the absence
of precision in the measurements used. The definitions of
a readmission varied from readmission within 2 weeks, 1
month, 3 months, 6 months or 1 year from the time of the
index admission [8].
A number of other factors account for these disparities
including variation in the types of readmissions (whether
planned or unplanned) investigated, in the settings used and
in the specialities involved in different studies [1]. Also, the
age of the population studied differed from study to study.
While no association of readmission with age has been found
[13], the elderly were the focus of study in many papers
published on readmission.
Readmissions – the causes
A review of the literature on readmission of adults reveals a
considerable variation in the probable causes for the increase
in readmission rates. Previous studies have identified factors
which might lead to repeated admissions such as hospital
admission during the most recent year, premature discharge,
poor patient compliance, age of the patient, male sex, chronic
disability, patient living alone, unavoidable relapse, inadequate
medical management, poor self-rated general health, in-
adequate rehabilitation and poor discharge planning [1,17,18,
20]. In addition, patients with specific diagnostic categories
such as chronic heart failure and chronic obstructive pul-
monary disease are said to be at greater risk of readmission [8].
However, there is no general agreement about the underlying
causes of readmission. Although some conditions occur
repeatedly, in many cases diagnostic subgroups may be a
marker for other factors associated with readmission including
the organisation and quality of care [8].
Attention has also focused on the association between the
rates of readmission and the length of the initial hospital
stay. It has been proposed that the increased readmission
rates are perhaps the inevitable price of early discharge [21].
Although premature discharge has been recognised as an
important factor responsible for unplanned readmission [18],
a positive relationship between the two has not yet been
177
Counterpoint: M. Hasan
established [1]. Moreover, it has been suggested that multiple
admissions may be a better strategy, being more acceptable
than permanent admission both to patients and to the health
service [18].
Are readmissions avoidable?
Several studies have examined ways to prevent readmissions
in the high-risk group of patients [22]. The strategies employed
include improved hospital in-patient care, robust discharge
planning, increased access to outpatient services, improved
community support, or a combination of these measures.
Previous studies have shown that, by achieving a true
integration between inpatient and outpatient care, both the
use of services after discharge and the costs of health care
among patients at the highest risk of readmission can be
reduced [23]. Another study that examined the role of a
nurse-led multidisciplinary intervention in preventing the
readmission of elderly patients with heart failure, dem-
onstrated a reduction in the rate of readmission, an im-
provement in the quality of life and a decrease in the overall
cost of medical care over a period of 3 months [24].
However, it is not clear whether the tide of readmission can
be stemmed [8]. Data from a recently conducted investigation
indicate that the majority of unplanned readmissions are
not avoidable and probably reflect a highly dependent and
medically unstable patient population [25]. Although intensive
discharge planning [13] and home-based intervention [26]
may reduce hospital readmissions in the short term, no long-
term effect was demonstrated [27]. Indeed, a greater access
to primary care resulted in an increase rather than a decrease
in the rate of rehospitalisation [6].
Do readmissions indicate poor quality
hospital care?
Recently, there has been a growing interest in the application
of avoidable readmission as a marker for poor quality of
hospital care [12–14]. Readmissions are not only common
but also pose a tremendous challenge to the health service to
determine cost-effective strategies for resource management
[22]. Although it is possible to measure readmissions using
the hospital information systems [28], there are a number of
limitations which need to be considered.
Firstly, the readmission rate is not a direct measure of
outcome but only a proxy for avoidable adverse events [12].
Secondly, as the readmission rates can be changed by varying
the threshold for readmission, the reliability and validity of
readmission as a measure of the quality of care are ques-
tionable [12]. Thirdly, the readmission rates are only likely to
predict outcome precisely if the differences are considerable
and if unmeasured case-mix variations account for a small
proportion of the inter-hospital difference in readmission
rates [29]. Finally, the errors in and incompleteness of data
in hospital information systems are likely to compromise the
178
value of readmission rates as a marker for monitoring the
quality of hospital care [30].
Many factors including the quality of hospital care influence
the readmission rates [16]. The strength of the apparent
association between the quality of hospital care and re-
admission is said to be dependent upon the accuracy of
assessment of the process of care, upon a careful char-
acterisation of the readmission and upon a comprehensive
identification of the confounding variables [13]. While some
studies have demonstrated a process-outcome link between
substandard care and the likelihood of readmission [13,18],
the association is not strong enough to be a valid and useful
quality indicator [14,16].
Conclusions
Although excessive readmission rates and repeated unplanned
admissions in the adult population are well documented, the
subject of readmission of patients to hospital remains poorly
understood. Not only there is a lack of clarity in defining
readmission but also the variation in the readmission rates
has not been adequately explained. There is no agreement
about the causes of readmission or the likelihood of its
prevention [1]. The reliability and validity of readmission
rates as an indicator of the standard of hospital care also
remain to be established.
It is essential, in view of the cost and quality implications,
that the readmission phenomenon be further investigated [8].
A thorough understanding will help in the development of
strategies to prevent the likelihood of repeated unplanned
admissions resulting in better resource utilisation and cost
savings. Clearly, we need more data and we need better
quality data.
In particular we need to address a number of method-
ological issues including the definition of a readmission, the
target population, and methods of measuring and classifying
readmission. Therefore, commissioning studies designed to
solve the question of instrumentation leading to precise
methodological recommendations should be a priority. This
may take the form of a systematic review of the publications
to date. A consensus meeting of the experts may also be of
immense value in facilitating this process.
Mujtaba Hasan
Academic Centre,
Llandough Hospital,
Penarth, UK
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