Economic Evaluation of Quality Improvement Interventions Designed to Prevent Hospital Readmission

A Systematic Review and Meta-analysis

Published in: JAMA Internal Medicine, 2017;177(7):975-985. doi: 10.1001/jamainternmed.2017.1136

Posted on on July 12, 2017

by Teryl K. Nuckols, Emmett B. Keeler, Sally C. Morton, Laura Anderson, Brian Doyle, Joshua M. Pevnick, Marika Booth, Roberta M. Shanman, Aziza Arifkhanova, Paul G. Shekelle

Read More

Access further information on this document at JAMA Internal Medicine

This article was published outside of RAND. The full text of the article can be found at the link above.


Quality improvement (QI) interventions can reduce hospital readmission, but little is known about their economic value.


To systematically review economic evaluations of QI interventions designed to reduce readmissions.

Data Sources

Databases searched included PubMed, Econlit, the Centre for Reviews & Dissemination Economic Evaluations, New York Academy of Medicine's Grey Literature Report, and Worldcat (January 2004 to July 2016).

Study Selection

Dual reviewers selected English-language studies from high-income countries that evaluated organizational or structural changes to reduce hospital readmission, and that reported program and readmission-related costs.

Data Extraction and Synthesis

Dual reviewers extracted intervention characteristics, study design, clinical effectiveness, study quality, economic perspective, and costs. We calculated the risk difference and net costs to the health system in 2015 US dollars. Weighted least-squares regression analyses tested predictors of the risk difference and net costs.

Main Outcomes and Measures

Main outcomes measures included the risk difference in readmission rates and incremental net cost. This systematic review and data analysis is reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.


Of 5205 articles, 50 unique studies were eligible, including 25 studies in populations limited to heart failure (HF) that included 5768 patients, 21 in general populations that included 10,445 patients, and 4 in unique populations. Fifteen studies lasted up to 30 days while most others lasted 6 to 24 months. Based on regression analyses, readmissions declined by an average of 12.1% among patients with HF (95% CI, 8.3%-15.9%; P<.001; based on 22 studies with complete data) and by 6.3% among general populations (95% CI, 4.0%-8.7%; P<.001; 18 studies). The mean net savings to the health system per patient was $972 among patients with HF (95% CI, -$642 to $2586; P=.23; 24 studies), and the mean net loss was $169 among general populations (95% CI, -$2610 to $2949; P=.90; 21 studies), reflecting nonsignificant differences. Among general populations, interventions that engaged patients and caregivers were associated with greater net savings ($1714 vs -$6568; P=.006).

Conclusions and Relevance

Multicomponent QI interventions can be effective at reducing readmissions relative to the status quo, but net costs vary. Interventions that engage general populations of patients and their caregivers may offer greater value to the health system, but the implications for patients and caregivers are unknown.

This report is part of the RAND Corporation External publication series. Many RAND studies are published in peer-reviewed scholarly journals, as chapters in commercial books, or as documents published by other organizations.

Our mission to help improve policy and decisionmaking through research and analysis is enabled through our core values of quality and objectivity and our unwavering commitment to the highest level of integrity and ethical behavior. To help ensure our research and analysis are rigorous, objective, and nonpartisan, we subject our research publications to a robust and exacting quality-assurance process; avoid both the appearance and reality of financial and other conflicts of interest through staff training, project screening, and a policy of mandatory disclosure; and pursue transparency in our research engagements through our commitment to the open publication of our research findings and recommendations, disclosure of the source of funding of published research, and policies to ensure intellectual independence. For more information, visit

The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.