Preventable hospitalizations are one of healthcare’s most widely adopted quality measures, which is exactly why they ended up in the crosshairs of a new opinion piece in Health Affairs.
Rates of preventable hospital admissions were first developed as an indicator of access to timely ambulatory care over 30 years ago, yet they’re now used to judge the performance of hospitals, health plans, and even individual providers (MSSP is an easy example).
- These measures are typically based on inpatient admissions or ED visits for conditions like hypertension or asthma, where hospitalizations can potentially be avoided if patients have access to effective ambulatory care.
The authors argue that the metamorphosis of preventable hospitalizations from an access measure to a quality indicator was a serious misstep, and incorporate nearly a dozen studies to help make their case.
- One of the most rigorous studies was from the Agency for Healthcare Research and Quality, which found that differences in socioeconomic status explain “a substantial part – perhaps most” of the variation in preventable admissions for many conditions, and recommended against using the metric as a standalone way to assess provider quality.
Those findings prompted the director of the AHRQ to publish an editorial outlining the “persistent challenge of avoidable hospitalizations,” which referenced a VA trial suggesting that high-quality ambulatory care might result in more, not fewer, admissions.
- The VA analyzed 1,400 veterans hospitalized with potentially avoidable admissions for congestive heart failure, diabetes, and COPD. Veterans that received intensive primary care were hospitalized more frequently than those in the usual care group, but were also more satisfied with their care despite the additional hospitalizations.
Other evidence suggests that using preventable hospitalizations as a measure of provider quality can actually decrease care quality by discouraging necessary admissions.
- This study linked reduced readmissions to increased mortality for heart failure patients, unexpected results that might be explained by the fact that “incentives to avoid readmissions may lead to potentially inappropriate management of higher-risk patients… in the outpatient rather than inpatient setting.”
The Takeaway
Whether or not preventable hospitalizations are a flawed quality measure, this article is a solid reminder that “strong beliefs should be loosely held,” and that widely adopted views are often the most important ones to stress-test.
