Skip to main content

Main menu

  • Home
  • Content
    • Published Ahead of Print
    • Current Issue
    • Article Collections
    • JASN Podcasts
    • Archives
    • Saved Searches
    • ASN Meeting Abstracts
  • Authors
    • Submit a Manuscript
    • Author Resources
  • Editorial Team
  • Subscriptions
  • More
    • About JASN
    • Alerts
    • Advertising
    • Editorial Fellowship Team
    • Feedback
    • Reprints
    • Impact Factor
    • Editorial Fellowship Application Process
  • ASN Kidney News
  • Other
    • CJASN
    • Kidney360
    • Kidney News Online
    • American Society of Nephrology

User menu

  • Subscribe
  • My alerts
  • Log in
  • My Cart

Search

  • Advanced search
American Society of Nephrology
  • Other
    • CJASN
    • Kidney360
    • Kidney News Online
    • American Society of Nephrology
  • Subscribe
  • My alerts
  • Log in
  • My Cart
Advertisement
American Society of Nephrology

Advanced Search

  • Home
  • Content
    • Published Ahead of Print
    • Current Issue
    • Article Collections
    • JASN Podcasts
    • Archives
    • Saved Searches
    • ASN Meeting Abstracts
  • Authors
    • Submit a Manuscript
    • Author Resources
  • Editorial Team
  • Subscriptions
  • More
    • About JASN
    • Alerts
    • Advertising
    • Editorial Fellowship Team
    • Feedback
    • Reprints
    • Impact Factor
    • Editorial Fellowship Application Process
  • ASN Kidney News
  • Follow JASN on Twitter
  • Visit ASN on Facebook
  • Follow JASN on RSS
  • Community Forum
Up Front MattersEditorials
You have accessRestricted Access

Readmissions Metrics in Hemodialysis: Do the Specifics Matter?

Taimur Dad and Daniel E. Weiner
JASN February 2019, 30 (2) 184-186; DOI: https://doi.org/10.1681/ASN.2018101033
Taimur Dad
William B. Schwartz Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Daniel E. Weiner
William B. Schwartz Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data Supps
  • Info & Metrics
  • View PDF
Loading
  • hemodialysis
  • ESRD
  • hospitalization
  • payment
  • policy
  • Medicare

The 2010 Affordable Care Act required establishment of the Hospital Readmissions Reduction Program by 2012 in the United States. Under this mandate, which aimed to improve quality by reducing hospital readmissions, the Centers for Medicare and Medicaid Services (CMS; the largest single payer in the United States) developed payment adjustment factors to reduce hospital reimbursement for unplanned readmissions that occurred within 30 days of an index discharge for a set of diagnoses. Endorsed by the National Quality Forum, a quality metric clearinghouse, these measures subsequently were adopted by most other payers in the United States. However, although clearly undesirable for patient experience and quality of life, whether 30-day readmission rates truly reflect the quality of care delivered by a hospital remains controversial.1

Readmissions among Medicare beneficiaries are costly and are particularly common among patients on hemodialysis in the United States, with 35% of index discharges followed by an unplanned readmission within 30 days.2 These readmissions are often for causes not related to the initial admission (Figure 1). This readmission rate exceeds readmission rates for other chronic conditions, such as congestive heart failure or chronic obstructive pulmonary disease.2 Multiple factors are associated with an increased likelihood of readmission, only some of which may be modifiable by hospitals and dialysis facilities. These risk factors include extremes of age, the presence and severity of both medical and psychologic comorbid conditions, longer index hospitalization and need for mechanical ventilation during the index hospitalization, and more admissions over the preceding 6 months.3,4 Limited data suggest that early evaluation and intervention in the dialysis facility may reduce the overall risk of readmission.5,6

Figure 1.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 1.

Causes of rehospitalization within 30 days as a function of the cause of the index hospitalization, demonstrating that index hospitalizations and readmissions are often for unrelated causes. Derived from data contained in the US Renal Data System 2017 Annual Data Report.2 CVD, cardiovascular disease; Rehosp, rehospitalization; VA, vascular access.

Unplanned hospital readmission rates were incorporated into the ESRD Quality Incentive Program in the United States in 2015, such that worse performance on the standardized readmission ratio (SRR) metric could place a dialysis facility at increased risk of financial penalties of up to 2% of Medicare income in subsequent years. The SRR reflects the number of unplanned readmissions per facility during a calendar year that occurs between 4 and 30 days after an index discharge, divided by the expected number of unplanned 30-day readmissions.7 The latter number is derived from a model designed to account for patient characteristics, the dialysis facility, and the discharging hospital. The SRR excludes certain unplanned readmissions, including those primarily for cancer, mental health, or rehabilitation.7 Importantly, this measure focuses on the number of readmissions rather than the number of patients who have a readmission. As a result, a small minority of patients within a facility who have high readmission rates could have a marked effect on a facility’s SRR. The SRR has been criticized for several shortcomings, including that some readmissions are unavoidable, potentially reflecting patient morbidity and illnesses that are not specifically related to the index discharge.8,9

In this issue of the Journal of the American Society of Nephrology, Lin et al.10 evaluate the relationship between prior hospitalizations and the probability of related and unrelated 30-day readmissions among prevalent patients on hemodialysis in the United States. To assess relatedness of the index hospitalization and readmission, principal diagnoses for each hospitalization were categorized by organ system. Readmissions with a principal diagnosis within the same organ system as the index hospitalization were classified as related. Among 651,386 index hospitalizations in the US Renal Data System database in 2013–2014, roughly 45% occurred in individuals with up to one hospitalization in the year before the index hospitalization, 35% had two to four hospitalizations, and 20% had five or more hospitalizations. In adjusted analyses, having more hospitalizations in the preceding year was associated with a significantly higher probability of both related and unrelated 30-day readmissions; however, for all index discharges, readmission was more often for an unrelated than for a related cause. Related 30-day readmissions were more common after hospitalizations categorized within cardiovascular, pulmonary, digestive, and injury or poisoning organ systems. On the basis of these results, the authors asserted that CMS should consider refining 30-day readmission metrics to account for clinical relatedness and prior hospitalization burden.

Although there is room for improvement in the SRR, accounting for relatedness may not optimize this metric. Lin et al. worked hard to create an algorithm for relatedness that could be scalable to the policy level, but further assessment of validity is required to know if related versus unrelated readmissions are being classified correctly and in such a way that appropriately identifies quality care. Consider the following two patients: patient 1 was admitted with new onset atrial fibrillation during dialysis (organ system: cardiovascular) and readmitted within 30 days for exertional chest pain to rule out a myocardial infarction while in sinus rhythm (organ system: cardiovascular); patient 2 was admitted with influenza and required a prolonged intensive care unit stay (organ system: infection), during which she lost 6 kg of weight, and after discharge the dialysis target weight was not updated, and she was readmitted 5 days later with a diagnosis of heart failure (organ system: cardiovascular). Although, clinically, the readmission for patient 1 likely is unrelated to the index hospitalization, the algorithm classifies this as related. In contrast, although the readmission for patient 2 is both related to the index hospitalization and is modifiable at the dialysis facility, the current algorithm classifies this as unrelated. These examples highlight how difficult it is to transform administrative billing data into practical assessments of quality. Ultimately, in designing a metric, the trade-off is whether to be more restrictive, as proposed by Lin et al., increasing the risk of misclassification and gaming, or broader, as operationalized in the current metric, increasing the risk that quality becomes defined by nonmodifiable events. In designing the SRR, CMS elected for the latter. Regardless of the approach, both require rigorous adjustment for patient factors that are associated with an increased risk of hospitalization.

Despite there being few proven strategies to prevent readmissions in this population, we put forth the following recommendations on the basis of our own experience: (1) have a regular discussion of hospitalized patients on dialysis between the inpatient and outpatient teams, including a conversation at the time of discharge; (2) ensure that discharge paperwork is sent to the patient’s dialysis facility (and not just to the primary care physician); (3) scrutinize admission and discharge medication lists (especially in the era of electronic medical records); (4) reassess the patient’s target weight after discharge; (5) reconcile medications (ideally with review of pill bottles) as soon as possible after discharge; (6) have the nephrologist see the patient during the initial treatment (or as soon as possible) after discharge; and (7) coordinate visits to other providers/specialists as soon as possible after discharge. We suspect that, regardless of the measure specifications incorporated into a rehospitalization metric, these interventions will result in better performance on any metric that exists, and, far more importantly, will make a meaningful difference in the quality of care.

Disclosures

D.E.W. receives salary support from Dialysis Clinic Inc. He is the chair of the Quality Committee for the American Society of Nephrology.

Footnotes

  • Published online ahead of print. Publication date available at www.jasn.org.

  • See related article, “Prior Hospitalization Burden and the Relatedness of 30-Day Readmissions in Patients Receiving Hemodialysis,” on pages 323–335.

  • Copyright © 2019 by the American Society of Nephrology

References

  1. ↵
    1. Joynt KE,
    2. Jha AK
    : Thirty-day readmissions--truth and consequences. N Engl J Med 366: 1366–1369, 2012
    OpenUrlCrossRefPubMed
  2. ↵
    1. Saran R,
    2. Robinson B,
    3. Abbott KC,
    4. Agodoa LYC,
    5. Bhave N,
    6. Bragg-Gresham J, et al
    .: US renal data system 2017 annual data report: Epidemiology of kidney disease in the United States. Am J Kidney Dis 71(3S1): A7, 2018
    OpenUrlCrossRefPubMed
  3. ↵
    1. Chan L,
    2. Chauhan K,
    3. Poojary P,
    4. Saha A,
    5. Hammer E,
    6. Vassalotti JA, et al
    .: National estimates of 30-day unplanned readmissions of patients on maintenance hemodialysis. Clin J Am Soc Nephrol 12: 1652–1662, 2017
    OpenUrlAbstract/FREE Full Text
  4. ↵
    1. Harel Z,
    2. Wald R,
    3. McArthur E,
    4. Chertow GM,
    5. Harel S,
    6. Gruneir A, et al
    .: Rehospitalizations and emergency department visits after hospital discharge in patients receiving maintenance hemodialysis. J Am Soc Nephrol 26: 3141–3150, 2015
    OpenUrlAbstract/FREE Full Text
  5. ↵
    1. Chan KE,
    2. Lazarus JM,
    3. Wingard RL,
    4. Hakim RM
    : Association between repeat hospitalization and early intervention in dialysis patients following hospital discharge. Kidney Int 76: 331–341, 2009
    OpenUrlCrossRefPubMed
  6. ↵
    1. Erickson KF,
    2. Winkelmayer WC,
    3. Chertow GM,
    4. Bhattacharya J
    : Physician visits and 30-day hospital readmissions in patients receiving hemodialysis. J Am Soc Nephrol 25: 2079–2087, 2014
    OpenUrlAbstract/FREE Full Text
  7. ↵
    Centers for Medicare & Medicaid Services (CMS) End-Stage Renal Disease: (ESRD) Quality Incentive Program (QIP) Payment Year (PY) 2018 Final Measure Technical Specifications. Standardized Readmission Ratio (SRR) Clinical Measure, 2016. Available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ESRDQIP/Downloads/PY-2018-Technical-Measure-Specifications.pdf. Accessed November 15, 2018
  8. ↵
    1. Fishbane S,
    2. Wish JB
    : Quality measurement in wonderland: The curious case of a dialysis readmissions measure. Clin J Am Soc Nephrol 11: 190–194, 2016
    OpenUrlAbstract/FREE Full Text
  9. ↵
    1. Brunelli SM,
    2. Walker AG
    : The precision of standardized hospitalization, readmission, and mortality ratios for dialysis facilities. Am J Kidney Dis 71: 291–294, 2018
    OpenUrl
  10. ↵
    1. Lin E,
    2. Bhattacharya J,
    3. Chertow G
    : Prior hospitalization burden and the relatedness of 30-day readmissions in patients receiving hemodialysis. J Am Soc Nephrol 30: 323–335, 2019
    OpenUrlAbstract/FREE Full Text
PreviousNext
Back to top

In this issue

Journal of the American Society of Nephrology: 30 (2)
Journal of the American Society of Nephrology
Vol. 30, Issue 2
February 2019
  • Table of Contents
  • Table of Contents (PDF)
  • About the Cover
  • Index by author
View Selected Citations (0)
Print
Download PDF
Sign up for Alerts
Email Article
Thank you for your help in sharing the high-quality science in JASN.
Enter multiple addresses on separate lines or separate them with commas.
Readmissions Metrics in Hemodialysis: Do the Specifics Matter?
(Your Name) has sent you a message from American Society of Nephrology
(Your Name) thought you would like to see the American Society of Nephrology web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Readmissions Metrics in Hemodialysis: Do the Specifics Matter?
Taimur Dad, Daniel E. Weiner
JASN Feb 2019, 30 (2) 184-186; DOI: 10.1681/ASN.2018101033

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Request Permissions
Share
Readmissions Metrics in Hemodialysis: Do the Specifics Matter?
Taimur Dad, Daniel E. Weiner
JASN Feb 2019, 30 (2) 184-186; DOI: 10.1681/ASN.2018101033
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like

Jump to section

  • Article
    • Disclosures
    • Footnotes
    • References
  • Figures & Data Supps
  • Info & Metrics
  • View PDF

More in this TOC Section

Up Front Matters

  • The Mineralocorticoid Receptor in Salt-Sensitive Hypertension and Renal Injury
  • Missing Self and DSA—Synergy of Two NK Cell Activation Pathways in Kidney Transplantation
  • The Road Ahead for Research on Air Pollution and Kidney Disease
Show more Up Front Matters

Editorials

  • The Mineralocorticoid Receptor in Salt-Sensitive Hypertension and Renal Injury
  • Missing Self and DSA—Synergy of Two NK Cell Activation Pathways in Kidney Transplantation
  • The Road Ahead for Research on Air Pollution and Kidney Disease
Show more Editorials

Cited By...

  • No citing articles found.
  • Google Scholar

Similar Articles

Related Articles

  • Prior Hospitalization Burden and the Relatedness of 30-Day Readmissions in Patients Receiving Hemodialysis
  • PubMed
  • Google Scholar

Keywords

  • hemodialysis
  • ESRD
  • hospitalization
  • payment
  • policy
  • Medicare

Articles

  • Current Issue
  • Early Access
  • Subject Collections
  • Article Archive
  • ASN Annual Meeting Abstracts

Information for Authors

  • Submit a Manuscript
  • Author Resources
  • Editorial Fellowship Program
  • ASN Journal Policies
  • Reuse/Reprint Policy

About

  • JASN
  • ASN
  • ASN Journals
  • ASN Kidney News

Journal Information

  • About JASN
  • JASN Email Alerts
  • JASN Key Impact Information
  • JASN Podcasts
  • JASN RSS Feeds
  • Editorial Board

More Information

  • Advertise
  • ASN Podcasts
  • ASN Publications
  • Become an ASN Member
  • Feedback
  • Follow on Twitter
  • Password/Email Address Changes
  • Subscribe

© 2021 American Society of Nephrology

Print ISSN - 1046-6673 Online ISSN - 1533-3450

Powered by HighWire